Review ArticleParents matter: barriers and solutions when implementing behavioural sleep interventions for infant sleep problems
Introduction
For at least three decades, scientists have been researching the efficacy of a number of behavioural treatments for childhood insomnia [[1], [2], [3], [4]]. Expert consensus, based on the available empirical research, suggests that extinction-based methods (EBM) are an effective way to improve infant sleep [2,5] and the well-being of the parent [6,7]. There is also potential to reverse a host of negative consequences linked to poor infant sleep (ie, behavioural problems, maternal depression, later childhood obesity, physical abuse, marital distress, filicide; [8, [9], [10], [11], [12]]). Studies that have measured possible side effects of these interventions, have thus far failed to demonstrate any observable negative consequences on infant sleep, cortisol levels, attachment, or separation anxiety [1,12,13].
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. First, we provide readers with a brief background of the development of typical and atypical infant sleep so as to indicate ‘when’ and for whom extinction methods are best introduced in order to be effective. We then address potential barriers to implementing extinction methods, and finish with relevant solutions that can be implemented by parents or caregivers. It is important to consider that most infant sleep research is conducted within a western socio-cultural paradigm [16], thus narrowing the focus of research into EBM. We recommend that these EBMs are only used when (i) other causes for infant crying have been ruled out (eg, medical cause), (ii) when infants are aged 6 months and above, and (iii) when parents express a desire to utilise an EBM (eg, fits within their broader cultural context or belief system, and is consistent with their goals).
Section snippets
Development of infant sleep
In an attempt to answer ‘when’ it is best to introduce extinction methods, it is important to discuss the development of infant sleep. Infant sleep patterns rapidly change in the first months of life [[17], [18], [19]]. Newborns have a free-running circadian rhythm that may develop and stabilise as early as 1 month of age, and periods of sleep and wakefulness consolidate into a circadian pattern from approximately 12 weeks of age [19,20]. The National Sleep Foundation recommend 14–17 h of sleep
Treatments for infant sleep problems
There are a number of interventions used to treat sleep problems in infants and toddlers. A review by Mindell and colleagues [2] reported that behavioural interventions improved infant sleep in 94% of studies, with over 80% of children demonstrating clinically significant improvement. Interventions with the most support were based on learning theory (eg, operant conditioning; where the infant's behaviour changed depending on the type of response provided by the parent). They highlighted that
Barriers
Despite the evidence of positive treatment gains for both the infant and mother, there is emerging evidence to suggest some parents struggle to successfully implement EBM [3,36], and others are critical of the methods [42,43]. Some previous research has reported significant drop out ratios (10–30%; [3,38]), though this is often not clearly described or reported [38]. Thus, we suggest researchers provide more detailed reasons for attrition in future research. One recent study comparing graduated
Solutions: methods of increasing success
While barriers to intervention exist in a number of infant and broader socio-cultural contexts, we posit solutions for barriers that can be addressed by parents since any behavioural intervention for infant sleep needs to be implemented by the parent. As described earlier, there are certain conditions or contexts where the use of EBMs are more (or less) appropriate. Before outlining each solution, we first outline a framework for implementing solutions given the prevalence of infant sleep
Conclusion
Problematic sleep is a far-reaching problem for many parents of infants. As the evidence suggests, behavioural methods, in particular extinction-based methods, are some of the most efficacious treatments with quick gains, yet they are not always well tolerated by parents. In this review, a number of barriers were posited in the implementation of extinction-based methods. The proposed model highlighted several methods to address these barriers, some of which have been used successfully in other
Funding
This research did not receive any specific grant funding from agencies in the public, commercial, or non-for-profit sectors.
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