Elsevier

Sleep Medicine

Volume 84, August 2021, Pages 244-252
Sleep Medicine

Review Article
Parents matter: barriers and solutions when implementing behavioural sleep interventions for infant sleep problems

https://doi.org/10.1016/j.sleep.2021.05.042Get rights and content

Highlights

  • Many barriers exist for parents implementing behavioural sleep interventions.

  • A model of barriers and solutions is proposed.

  • Socio-cultural barriers, parent barriers and infant barriers may reduce intervention success.

  • Motivational interviewing or emotional regulation may increase intervention success.

Abstract

Behavioural sleep interventions (eg, 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.

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.

References (121)

  • K.G. France

    Extinction with parental presence

  • A. Sadeh et al.

    Parenting and infant sleep

    Sleep Med Rev

    (2010)
  • L. Tikotzky et al.

    The role of cognitive-behavioral therapy in behavioral childhood insomnia

    Sleep Med

    (2010)
  • O.G. Jenni et al.

    Cultural issues in children's sleep: a model for clinical practice

    Pediatr Clin

    (2011)
  • J.A. Mindell et al.

    Cross-cultural differences in infant and toddler sleep

    Sleep Med

    (2010)
  • L.J. Meltzer et al.

    Sleep in the family

    Pediatr Clin

    (2011)
  • D. Sinai et al.

    Infant sleep, parental sleep and parenting stress in families of mothers on maternity leave and in families of working mothers

    Infant Behav Dev

    (2012)
  • S.M. Coyne et al.

    “Do you dare to compare?” Associations between maternal social comparisons on social networking sites and parenting, mental health, and romantic relationship outcomes

    Comput Hum Behav

    (2017)
  • C. Richardson et al.

    Paediatric sleep literacy in australian health professionals

    Sleep Med

    (2021)
  • M. Galbally et al.

    Perinatal maternal depression, antidepressant use and infant sleep outcomes: exploring cross-lagged associations in a pregnancy cohort study

    J Affect Disord

    (2018)
  • T. Del Vecchio et al.

    Affective and physiological factors predicting maternal response to infant crying

    Infant Behav Dev

    (2009)
  • M. Kahn et al.

    Links between infant sleep and parental tolerance for infant crying: longitudinal assessment from pregnancy through six months postpartum

    Sleep Med

    (2018)
  • B.M. Sorondo et al.

    Associations between infant temperament, maternal stress, and infants' sleep across the first year of life

    Infant Behav Dev

    (2015)
  • M.C. Lovejoy et al.

    Maternal depression and parenting behavior: a meta-analytic review

    Clin Psychol Rev

    (2000)
  • K.G. France et al.

    Infant sleep disturbance: description of a problem behaviour process

    Sleep Med Rev

    (1999)
  • K. Spruyt et al.

    Relationship between sleep/wake patterns, temperament and overall development in term infants over the first year of life

    Early Hum Dev

    (2008)
  • G. Moran et al.

    Proneness to distress and ambivalent relationships

    Infant Behav Dev

    (1998)
  • S.M. Honaker et al.

    Real-world implementation of infant behavioral sleep interventions: results of a parental survey

    J Pediatr

    (2018)
  • G. Micic et al.

    Readiness to change and commitment as predictors of therapy compliance in adolescents with Delayed Sleep-Wake Phase Disorder

    Sleep Med

    (2019)
  • M. Gradisar et al.

    Behavioral interventions for infant sleep problems: a randomized controlled trial

    Pediatrics

    (2016)
  • J.A. Mindell et al.

    Behavioral treatment of bedtime problems and night wakings in infants and young children

    Sleep

    (2006)
  • V.I. Rickert et al.

    Reducing nocturnal awakening and crying episodes in infants and young children: a comparison between scheduled awakenings and systematic ignoring

    Pediatrics

    (1988)
  • L.J. Meltzer et al.

    Systematic review and meta-analysis of behavioral interventions for pediatric insomnia

    J Pediatr Psychol

    (2014)
  • B. Eckerberg

    Treatment of sleep problems in families with young children: effects of treatment on family well-being

    Acta Paediatr

    (2004)
  • H. Hiscock et al.

    Randomised controlled trial of behavioural infant sleep intervention to improve infant sleep and maternal mood

    BMJ

    (2002)
  • L. Bartels et al.

    Mothers who kill: the forensic use and judicial reception of evidence of postnatal depression and other psychiatric disorders in Australian filicide cases

    Melb UL Rev

    (2013)
  • X. Chen et al.

    Is sleep duration associated with childhood obesity? A systematic review and meta-analysis

    Obesity

    (2008)
  • M.H. Hemmi et al.

    Associations between problems with crying, sleeping and/or feeding in infancy and long-term behavioural outcomes in childhood: a meta-analysis

    Arch Dis Child

    (2011)
  • A.M. Price et al.

    Five-year follow-up of harms and benefits of behavioral infant sleep intervention: randomized trial

    Pediatrics

    (2012)
  • A. Bilgin et al.

    Parental use of ‘cry it out’in infants: no adverse effects on attachment and behavioural development at 18 months

    JCPP (J Child Psychol Psychiatry)

    (2020)
  • L. Tse et al.

    A qualitative study of parents' perceptions of a behavioural sleep intervention

    Child Care Health Dev

    (2008)
  • H.L. Ball et al.

    Toward an integrated anthropology of infant sleep

    Am Anthropol

    (2019)
  • I. Iglowstein et al.

    Sleep duration from infancy to adolescence: reference values and generational trends

    Pediatrics

    (2003)
  • T.I. Morgenthaler et al.

    Practice parameters for behavioral treatment of bedtime problems and night wakings in infants and young children

    Sleep

    (2006)
  • A. Sadeh et al.

    Infant sleep and parental sleep-related cognitions

    J Fam Psychol

    (2007)
  • A. Sadeh

    Evaluating night wakings in sleep-disturbed infants: a methodological study of parental reports and actigraphy

    Sleep

    (1996)
  • Rudzik AEF, Ball HL. Biologically normal sleep in the mother-infant dyad. Am J Hum Biol...
  • A. Sadeh et al.

    Infant sleep problems: origins, assessment, interventions

    Infant Ment Health J

    (1993)
  • L.J. Meltzer et al.

    Prevalence of diagnosed sleep disorders in pediatric primary care practices

    Pediatrics

    (2010)
  • J.A. Owens

    The practice of pediatric sleep medicine: results of a community survey

    Pediatrics

    (2001)
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