Services and Programs Proven to be Effective in Managing Pediatric Sleep Disturbances and Disorders, and Their Impact on the Social and Emotional Development of Young Children

Introduction

During the preschool years dramatic changes take place in a typical child’s sleep, while enormous changes in physical, linguistic, cognitive and social development occur which profoundly alter both waking activities and sleep regulation. Establishing sleep habits which meet a child’s individual needs and are adapted to his culture and family circumstances is vital to individual and family well-being. Within a broad range of individual, familial and cultural variations¹ by the end of the preschool period a child who is a “good” sleeper will have a regular but not ritualized, emotionally and socially positive, pre-bed routine, free of resistance and coercion. The chid will be put to bed awake, without difficulty, by a variety of caregivers, and sleep independently wherever appropriate to family culture and circumstances. Sleep onset will be rapid both initially and after later wakings, without crying, calling-out or adult attention, unless he is ill or needs care, so that sleep is of age-appropriate duration and quality.^2,3,4

Achieving this outcome requires continuous, dynamic, learned adjustments affecting every aspect of sleep and involving all parents, caregivers, siblings and other family members. This is influenced by child temperament; parental adjustment; resources and practices; maternal health and well-being, and family/community circumstances.³ Careful assessment of family circumstances and environment and child development is necessary in diagnosing pediatric sleep disturbances (PSDs).^5,6 Sleep may be measured by parental diaries,⁷ activity monitoring,⁸ videosomonography⁹ and clinic-based, multi-channel physiological recording (polysomnography).¹⁰ Questionnaires for assessing children’s sleep have recently been comprehensively reviewed^11,12,13 and while the psychometric quality of many is poor there are a few that meet required standards.¹¹

Subject

PSDs are a common reason for attending family health services^14,15 and may broadly be differentiated into a psycho-social group focussed on parent-child interaction, and a group (henceforth referred to as the bio-maturational group) in which atypical biological, especially neural, maturation appears to be critical.^16,17

Psycho-social PSDs include:

1. Problems of bed resistance and sleep location. Children may resist/delay being prepared for and placed into bed (with tantrums, escape/avoidance, and demands for pre-bed rituals) and/or may sleep often in locations other than where parents desire (e.g., co-sleeping with parents or siblings) because the child moves or is moved from their own cot or bed to stop or prevent them crying and obtain sleep.
2. Problems of sleep-onset delay and recurrent night waking, where the infant or child needs parental attendance and attention to initially go to sleep or to resume sleep after later wakings.
3. Fears and anxieties associated with bedtime, night-time, and sleep.

Bio-maturational PSDs include:

1. Parasomnias, which are undesirable behaviour occurring during sleep or sleep wake transitions, including sleepwalking/talking, sleep terrors, and rhythmic movement disorders such as head banging and body rocking and also nocturnal enuresis (bedwetting), and
2. Circadian rhythm disorders, in which the individual’s sleep-wake phases are not in synchrony with those of the family or community.

Psycho-social PSDs commonly co-occur, and may affect 15 – 35% of families.^18,19 Bio-maturational PSDs are much less common, chronically affecting 1- 3% of families,²⁰ but children with parasomnias often also exhibit psycho-social PSDs.²⁰ Little evidence links PSDs to family demographic variables, but more boys than girls may be affected by parasomnias.²¹

Obstructive sleep apnea and other breathing difficulties are primarily problems of airway functioning and respiratory control during sleep.²² Any infant or child with symptoms of sleep apnea (noisy breathing and profuse sweating) or anoxia (lack of oxygen) needs urgent medical evaluation. Some infants experience episodes of anoxia (lack of oxygen) while asleep, often resulting in death in infants aged > 12 months (Sudden Infant Death Syndrome; SIDS). Risk of SIDS is reduced by placing infants on their back to sleep²³ and by breastfeeding, and avoiding exposure to cigarette smoke and co-sleeping.²⁴

Problems

PSDs predict sleep disturbances and behavioural difficulties later in childhood^25,26,27 and potentially throughout life,^28,29 and sleep quality is linked to intellectual, emotional and social development.³⁰ If chronic or severe, PSDs are stressful for the child, siblings and parents, contributing to attachment difficulties, disruptions of learning, depression, family conflict and marital breakdown^15,26 and to overmedication with prescription and non-prescription drugs.¹⁸

Research Context

Considerable research has investigated the developmental neurophysiology of sleep from infancy onwards. Over the first months of life sleep is coordinated into a day-night pattern and consolidated.^4,31 Cycles of rapid-eye-movement sleep (REM) and non-REM sleep shift from rapid cycling and 1:1distribution at birth to a 1:2 distribution at 8 months, and deep, non-REM sleep (associated with parasomnias) predominates early in sleep, while REM (associated with awakenings, dreams and nightmares) occurs more later.²¹ Research into factors predictive of PSDs reveal associations with first-born status, colic, difficult infant temperament, maternal depression and insecure adult attachment, and diversity in parenting strategies.³ There is more treatment research for psycho-social than for bio-maturational PSDs, and this has shifted from mostly case studies to well-controlled investigations. Some treatments have achieved empirically validated status as well-established, probably efficacious [i.e., effective] or promising^{32,33,34,35,36} using criteria from Chambless and Hollon.³⁷

Key Research Questions

Research has focussed on how to facilitate the development of infants’ ability to self-soothe so that sleep initiation is under child- rather than other-related cues. Understanding the behavioural trap² by which parent-child interactions shape and maintain sleep disruptions has stimulated development of behavioural treatments and adaptations thereof, with concerns as to their effectiveness, acceptability, impact on attachment, adjustment and family well-being, and cultural appropriateness.

Recent Research Results

As noted above, family interventions for PSDs need to begin with careful functional assessment and analysis that considers the well-being of the whole family, not just the target child,^38,39 from a developmental perspective. Parent education, at about birth or later, on infant sleep management^40,41 and in regulating breastfeeding to optimize night sleep duration⁴² facilitates sleep development and may prevent PSDs developing.⁴³

Systematically structuring pre-bed routines using quiet, pleasant activities and praise for compliance (termed Positive Routines) reduces pre-bed tantrums and resistance.⁴⁴ Crying and calling out etc during initial settling time or following later night wakings is reduced or eliminated by a range of interventions [variously called Extinction, Graduated Extinction, and (Graduated) Planned Ignoring³⁴]. All involve the immediate or progressive (graduated) delay/withdrawal of parental attention for sleep-disruptive behaviour, thereby (in principle) removing the reinforcer for the behaviour, a process termed behavioural extinction.² In older, more verbal children, this withdrawal of attention can be supplemented by adding shaping and positive reinforcement (praise, tangible rewards) for achieving appropriate sleep^45,46 and/or by using strategies such as the Bedtime Pass⁴⁷ and Social Stories⁴⁸ (modelling combined with rewards). For infants over 6 months, modifying the withdrawal of adult attention by adding Parental Presence, in which the parent lies near the child but does not interact with them until the child goes to sleep^49,50 reduces distress to low levels, and is now regarded as best practice for children 6 to 24 months of age.⁴⁹ Positive Routines may be supplemented by adjusting bedtime later or earlier depending on sleep latency (Bedtime Fading) and by removal from bed and being kept awake when not sleeping (Response Cost).⁵¹ Combining reducing doses of a sedative drug with planned ignoring also reduces distress,^52,53 but sedative drugs used alone have at best short-term effects.^33,54

Parents need to be carefully prepared for any intervention, supported during it,⁵⁵ and warned of the possibility of both initial brief increases in the frequency or intensity of behaviour following the removal of reinforcers (post-extinction response bursts), which may exacerbate sleep disturbance briefly upon treatment initiation,⁵² and the possibility of spontaneous recovery of PSD following illness or changes in routine.⁵⁵ Whether unmodified or modified, procedures involving withdrawing parental attention are largely non-stressful for parents and positive for the family^56,57,58,59 and, importantly, have no reported adverse effects on child well-being or development.^60,61 Night-time fears/anxieties are reduced by treatments involving relaxation, modelling coping, positive thoughts/imagery, and positive rewards for “bravery.”^62,63

There is comparatively little controlled research into treatments for bio-maturational PSDs.³⁵ Scheduled awakenings, in which parents use baseline information to predict the time of a parasomnia event and wake the child 15-30 min beforehand has successfully treated sleepwalking and sleep terrors.⁶⁴ Waking (via a urine alarm) is also an effective treatment for nocturnal enuresis,^65,66 though this is generally used only for older children. Infants and children with chronic illness, disabilities and special needs may experience high rates of PSDs. There is little systematic research on treatment for such children⁶⁷ but considerable research interest is evident in recent systematic reviews.^68,69

Conclusions

The neuro-development of sleep and its importance to development is relatively well-understood. PSDs are systematically described and diagnosed, and the psycho-social versus bio-maturational distinction is well-established, however the causes of and risk-factors for PSDs are less well specified. Development of good sleep habits in the first year of life depends on the infant learning to self-soothe and on the parents avoiding inadvertently reinforcing sleep-disruptive behaviours. Teaching parents how to structure their bed-time and sleep-related interactions with their infant/child so that self-soothing occurs and sleep-disruptive behaviour is not reinforced may prevent as well as treat PSDs. These treatments may be tailored, by gradual adjustment of parental attention, parental presence, and/or brief use of sedatives, so as to reduce stress, apprehension and infant distress, with parental presence being most strongly recommended as contemporary best practice.⁴⁹ Effective interventions promote family well-being and do not adversely affect chid development. More research is needed into bio-maturational PSDs, into services for families facing chronic child illness and disabilities, and into cultural factors.

Implications

• Staff working in pediatric/family services settings need regular training in empirically-based best-practice for the both functional analysis and diagnosis and the treatment of PSDs.
• PSDs need to be understood and treated within an ecological perspective on the child and the family.
• Parental and staff expectations that interventions will be stressful or distressing, or that they will have long-term ill-effects on the child or the family, can be countered by substantial evidence to the contrary where well-designed and properly supported interventions are used.
• Untreated, chronic PSDs, especially if severe and/or disruptive have the potential for long-term negative consequences for the child and his/her family and should be treated promptly and effectively.
• While interventions (other than for children who are ill, disabled, or have special needs) are typically brief, parents need good preparation for and support during the critical time.
• Interventions which employ best-practice procedures should have relatively rapid positive effects and these should be maintained long-term. If positive effects are not observed reasonably rapidly procedures should be checked for fidelity to the implemented program.
• Research needs to focus on improving and extending preventive interventions; matching treatments to families; improving the range and quality of services for children who are ill, disabled, or have special needs; and assessing long-term impacts on the target child and her/his family.

References

1. Kawasaki C, Nugent, JK, Miyshita H, Miyahara H, Brazelton TB. The cultural organization of infant’s sleep. Children’s Environments 1994; 11: 135-141.
2. Blampied NM, France KG. A behavioural model of infant sleep disturbance. J Appl Behav Anal 1993; 26: 477-492.
3. France KG, Blampied NM. Infant sleep disturbance: Description of a problem behaviour process. Sleep Med Rev 1999; 4: 265-280.
4. Henderson, JMT, France, KG, Blampied, NM. The consolidation of infants’ nocturnal sleep across the first year of life. Sleep Med Rev 2011; 15: 211-20.
5. France KG, Blampied NM, Henderson JMT. Infant sleep disturbance. Current Paediatrics 2003; 13: 241-246.
6. France KG, Henderson JMT, Hudson SM. Fact, act, tact: A three-stage approach to treating sleep problems of infants and young children. Child Adolesc Psychiat Clin N Am 1996; 5: 581-599.
7. France KG, Hudson SM. Behavior management of infant sleep disturbance. J Appl Behav Anal 1990; 23: 91-98.
8. So K, Adamson TM, Horne, RS. The use of actigraphy for assessment of the development of sleep/wake patterns in infants during the first 12 months of life. J Sleep Res 2007; 16: 181-87.
9. Anders TF, Sostek AM. The use of timelapse video recording of sleep-wake behaviour in human infants. Psychophysiology 1976; 13: 155-158.
10. Griebel ML, Moyer LK. Pediatric polysomonography. In T Lee-Chiong (Ed.). Sleep: A comprehensive handbook 2006; Hoboken, NJ: 987-97.
11. Lewandoski AS, Toliver-Sokol M, Palermo TM. Evidence-based review of subjective pediatric sleep measures. J Ped Psychol 2011; 36: 780-93.
12. Spruyt K, Gozal D. Development of pediatric sleep questionnaires as diagnostic or epidemiological tools: A brief review of Dos and Don’ts. Sleep Med Rev 2011; 15: 7 – 17.
13. Spruyt K, Gozal D. Pediatric sleep questionnaires as diagnostic or epidemiological tools: A review of currently available instruments. Sleep Med Rev 2011; 15: 19 – 32.
14. Keren M, Feldman R, Tyano S. Diagnoses and interactive patterns of infants referred to a community-based mental health clinic. J Am Acad Child Adol Psychiat 2001; 40: 27-35.
15. Mindell JA, Moline ML, Zendell SM, Brown LW, Fry JM Pediatrics and sleep disorders: Training and practice. Pediatrics 1994; 94: 194-200.
16. Anders TF, Eiben LA. Pediatric sleep disorders: A review of the past 10 years. J Am Acad Child Adolesc Psychiat 1997; 36: 9 – 20.
17. Thideke CC. Sleep disorders and sleep problems in childhood. Am Fam Physician 2001; 63: 277-284.
18. Armstrong KL, Quinn RA, Dadds MR. The sleep patterns of normal children. Med J Aust 1994: 161; 202-205.
19. Scott G, Richards MPM. Night waking in 1-year old children in England. Child Care Health Dev 1990; 16: 4-8.
20. Mehlenbeck R, Spirito A, Owens J, Boegers J. The clinical presentation of childhood partial arousal parasomnias. Sleep Med 2000; 1: 307-312.
21. Anders TF. Neurophysiological studies of sleep in infants and children. J Child Psychol Psychiat 1982; 23: 75-83.
22. Gaultier C. Sleep apnoea in infants. Current Paediatrics 2003; 13: 64-68.
23. Willinger M, Hoffman HJ, Hartford RB. Infant sleep position and risk for suddent infant death syndrome: Report of meeting held January 13 and 14, 1994, National Institutes of health, Bethesda, MD. Pediatrics 1994; 93: 841- 819.
24. Gunn AJ, Gunn TR, Mitchell EA. Is changing the sleep environment enough? Current recommendations for SIDS. Sleep Med Rev 2000; 4:453-469.
25. Goodnight JA, Bates JE, Pettit GS, Staples, AD, Dodge KA. Temperamental resistance to control increases the association between sleep problems and externalizing behavior development. J Fam Psychol 2007; 21; 39-48.
26. Hiscock H, Canterford L, Ukoumunne OC, Wake M. Adverse association of sleep problems in Australian preschoolers: A national population study. Pediatrics 2007; 119; 86-93.
27. Pollock JI. Night-waking at five years of age: Predictors and prognosis. J Child Psychol Psychiat 1994; 35: 699-708.
28. Gregory AM, caspi A, Eley TC, Moffit, TE, O’Connor TG, Poulton R. Prospective longitudinal associations between persistent sleep problems in childhood and anxiety and depression disorders in adulthood. J Abnorm Child Psychol 2005; 33: 157-63.
29. Wong MM, Brower KJ, Fitzgerald HE, Zucker RA. Sleep problems in early childhood and early onset of alcohol and other drug use in adolescence. Alcohol: Clin Exp Res 2004; 28: 578-87.
30. Dahl RE. The regulation of sleep and arousal: Development and psychopathology. Dev Psychopath 1996: 8:3-27.
31. Henderson JMT, France KG, Owens, JL, Blampied NM. Sleeping through the night: The consolidation of self-regulated sleep across the first year of life. Pediatrics 2010; 126; e1081-7.
32. Kuhn BR, Elliott AJ. Treatment efficacy in behavioural pediatric sleep medicine. J PsychosomRes 2003: 54: 587-597.
33. Kuhn BR, Weidinger D. Interventions for infant and toddler sleep disturbance: A review. Child Fam Behav Ther 2000; 22: 33- 50.
34. Mindell JA. Empirically supported treatments in pediatric psychology: Bedtime refusal and night wakings in young children. J Ped Psychol 1999; 24: 465-481.
35. Owens JL, France KG, Wiggs L. Behavioural and cognitive behavioural interventions for sleep disorders in infants and children: A review. Sleep Med Rev 1999; 3: 281-302.
36. Ramchandani P, Wiggs L, Webb V, Stores G. A systematic review of treatments for settling problems and night waking in young children. BMJ 2000; 320: 209-213.
37. Chambless DL, Hollon SD. Defining empirically supported therapies. J Consult Clin Psychol 1998; 66: 7-18.
38. Blampied, NM. Functional behavioral analysis and treatment of sleep in infants and children. In AR Wolfson, H Montgomery-Downs (Eds). Handbook of infant, child and adolescent sleep: Development and problems. In press: Oxford, UK: Oxford University Press.
39. Blampied, NM, Bootzin RR. Sleep: A behavioral account. In G Madden (Ed) APA Handbook of Behavior Analysis Vol 2;American Psychological Society, Washington, DC: 425-53.
40. Adair R, Zuckerman B, Bauchner H, Philipp, B, Levenson S. Reducing night waking in infancy: A primary care intervention. Pediatrics, 1992; 89: 585-588.
41. Wolfson A, Lacks P, Futterman A, Effects of parent training on infant sleeping patterns, parents’ stress and perceived parental competence. J Consult Clin Psychol 1992; 60: 41-48.
42. Pinilla T, Birch LL. Help me make it through the night: Behavioral entrainment of breast-fed infant’s sleep patterns. Pediatrics 1993; 91: 436- 444.
43. Kerr SM, Jowett SA, Smith, LN. Preventing sleep problems in infants: A randomized controlled trial. J Adv Nurs 1996; 24: 938-942.
44. Adams LA, Rickert VI. Reducing bedtime tantrums: Comparison between positive routines and graduated extinction. Pediatrics 1989; 84: 757-761.
45. Sanders MR, Bor B, Dadds MR. Modifying bedtime disruptions in children using stimulus control and contingency management techniques. Behav Psychother 1984; 12: 130-141.
46. Ronnen T. Intervention package for treating sleep disorders in a four-year-old girl. J Behav Ther Exp Psychiat 1991; 22: 141-148.
47. Schones CJ. The bedtime pass. In M Perlis, M Aolia, B Kuhn (Eds). Behavioral treatment for sleep disorders 2011; Amsterdam, Elsevier: 293-98.
48. Burke RV, Kuhn BR, Peterson JL. Brief report: A “storybook” ending to children’s bedtime problems – The use of a rewarding social story to reduce bedtime resistance and frequent night waking. J Ped Psychol 2004; 29: 389-96.
49. France KG. Extinction with parental presence. In M Perlis, M Aolia, B Kuhn (Eds). Behavioral treatment for sleep disorders 2011; Amsterdam, Elsevier: 275-83.
50. Sadeh A. Assessment of intervention for infant night waking: Parental reports and activity-based home monitoring. J Consult Clin Psychol 1994; 62: 63-68.
51. Kodak T, Piazza CC. Bedtime fading with response cost for children with multiple sleep problems. In M Perlis, M Aolia, B Kuhn (Eds). Behavioral treatment for sleep disorders 2011; Amsterdam, Elsevier: 285-92.
52. France KG, Blampied NM, Wilkinson P. Treatment of infant sleep disturbance by trimeprazine in combination with extinction. Dev Behav Ped 1991; 12: 308-314.
53. Selim CA, France KG, Blampied NM, Liberty KA. Treating treatment-resistant infant sleep disturbance with combination pharmacotherapy and behavioural family interventions. Austral Psychol 2006; 41: 193-204.
54. France KG, Blampied NM, Wilkinson P. A multiple-baseline, double-blind evaluation of the effects of trimeprazine tartrate on infant sleep disturbance. Exp Clin Psychopharm 1999; 7: 502-513.
55. France KG. Handling parents’ concerns regarding the behavioural treatment of infant sleep disturbance. Behav Change 1994; 11: 71-109.
56. Durand VM, Mindell JA. Behavioral treatment of multiple childhood sleep disorders: Effects on child and family. Behav Mod 1990; 14: 37-49.
57. Lam P, Hiscock H, Wake M. Outcomes of infant sleep problems: A longitudinal study of sleep, behavior, and maternal wellbeing. Pediatrics 2003; 111: e203-07.
58. Lawton C, France KG, Blampied NM. Treatment of infant sleep disturbance by graduated extinction. Child Fam Behav Ther 1991; 13: 39- 56.
59. Minde K, Faucon A, Falkner S. Sleep problems in toddlers: Effects of treatment on their daytime behavior. J Am Acad Child Adolesc Psychiat 1994; 33: 1114-1121.
60. France KG. Behavior characteristics and security in sleep-disturbed infants treated with extinction. J Ped Psychol 1992; 17: 467-475.
61. Price, AMH, Wake, M, Ukoumune, OC, Hiscock, H. Five-year follow-up of harms and benefits of behavioral infant sleep intervention: Randomised trial. Pediatrics, 2012, 130: 643 – 651.
62. Mikulas WL. Graduated exposure games to reduce children’s fear of the dark. In M Perlis, M Aolia, B Kuhn (Eds). Behavioral treatment for sleep disorders 2011; Amsterdam, Elsevier: 319-23.
63. Pincus DB, Weiner CL, Fried A. Differential efficacy of home monitoring and cognitive-behavioral treatment for decreasing children’s maladaptive nighttime fears. Child Fam Behav Ther 2012; 34: 1 – 19.
64. Byars K. Scheduled awakenings: A behavioral protocol for treating sleepwalking and sleep terrors in children. In M Perlis, M Aolia, B Kuhn (Eds). Behavioral treatment for sleep disorders 2011; Amsterdam, Elsevier: 325-32.
65. Brown ML, Pope AW, Brown EL. Treatment of primary nocturnal enuresis in children: A review. Child: Care Heal Devel 2011; 37: 153– 60.
66. Mellon MW, McGrath ML. Empirically supported treatments in pediatric psychology: Nocturnal enuresis. J Ped Psychol 2000; 25: 193-214.
67. Wiggs L, France KG. Behavioural treatments for sleep problems in children and adolescents with physical illness, psychological problems or intellectual disabilities. Sleep Med Rev 2000; 4: 299-314.
68. Richdale A, Johnson K. Advances in Autism Spectrum Disorders: Sleep disorders In press. North Carolina, Information Age Publishing.
69. Richdale A. Autism and other developmental disabilities. In AR Wolfson, H Montgomery-Downs (Eds). Handbook of infant, child and adolescent sleep: Development and problems. In press; Oxford, Oxford University Press.