Behavioural methods in the treatment of sleep disorders--a pilot study

The Impact of Anxiety on Behavioral Sleep Difficulties and Treatment in Young Children: A Review of the Literature

Sleep difficulties are a common pediatric complaint, and the majority of these sleep difficulties are behavioral in nature (e.g., difficulties initiating or maintaining sleep). Although research supports behavioral interventions to improve sleep in young children with behavioral sleep difficulties, anxiety and child distress are common in this age range and these factors can impact treatment outcomes directly (e.g., increased distress and resistance at bedtime) and indirectly (e.g., poor parental compliance with behavioral strategies). Anxiety is an important aspect of treatment in adolescents and adults with behavioral sleep difficulties, but this factor is rarely considered in the literature for younger children. Thus, this manuscript reviews the literature on anxiety as it relates to behavioral sleep difficulties in young children (i.e., the preschool and surrounding age range), provides an overview of empirically supported behavioral intervention and research incorporating anxiety into behavioral sleep treatments, and provides recommendations and future directions for continuing to advance the literature and treatment in this area.

Seeing the Whole Elephant: a scoping review of behavioral treatments for pediatric insomnia

Pediatric insomnia is common, impacting up to a third of typically-developing, healthy children, and over 80% of children with neurodevelopmental disorders or chronic medical conditions. Previous reviews of behavioral interventions for pediatric insomnia have had a limited focus on a single age group, a specific population, and/or only randomized controlled trials. Furthermore, few reviews have considered non-sleep outcomes of both children and their parents. This scoping review provides a broader context, including studies regardless of research design or population, along with sleep and non-sleep study outcomes. Clear gaps in the literature were identified, highlighting the need for additional research in different populations, including school-age children and adolescents, racial/ethnic groups around the world, as well as youth with medical or psychiatric disorders. In addition, more research is needed on different features of treatment, including the delivery mode, involvement of all family members, non-sleep outcomes, and long-term follow-up.

Benefits of a bedtime routine in young children: Sleep, development, and beyond

This paper presents a conceptual model and reviews the empirical evidence to support a nightly bedtime routine as a key factor in the promotion of not only healthy sleep, but also of broad development and wellbeing in early childhood. A bedtime routine embodies the characteristics of nurturing care and early child stimulation, which are deemed to be essential for positive outcomes, especially for at-risk children. Furthermore, common, adaptive components of a bedtime routine can contribute to an array of positive developmental outcomes beyond improved sleep, inclusive of language development, literacy, child emotional and behavioral regulation, parent-child attachment, and family functioning, among other outcomes. These bedtime routine components include activities in the broad domains of nutrition (e.g., feeding, healthy snack), hygiene (e.g., bathing, oral care), communication (e.g., reading, singing/lullabies) and physical contact (e.g., massage, cuddling/rocking). A bedtime routine can provide multiple benefits to child and family functioning at a time of day that many parents are present with their children. Although additional research on hypothesized routine-related child outcomes and mechanisms of action are needed, promoting a bedtime routine may be a feasible and cost-effective method to promote positive early childhood development worldwide, particularly for socioeconomically disadvantaged and other at-risk young children.

Case Series

OBJECTIVE

To assess the effectiveness and feasibility of behavioral sleep intervention for medicated children with ADHD.

METHOD

Six medicated children (five boys, one girl; aged 6-12 years) with ADHD participated in a 4-week sleep intervention program. The main behavioral strategies used were Faded Bedtime With Response Cost (FBRC) and positive reinforcement. Within a case-series design, objective measure (Sleep Disturbance Scale for Children [SDSC]) and subjective measure (sleep diaries) were used to record changes in children's sleep.

RESULTS

For all six children, significant decrease was found in the severity of children's sleep problems (based on SDSC data). Bedtime resistance and mean sleep onset latency were reduced following the 4-week intervention program according to sleep diaries data. Gains were generally maintained at the follow-up. Parents perceived the intervention as being helpful.

CONCLUSION

Based on the initial data, this intervention shows promise as an effective and feasible treatment.

Treatment of Sleep Disorders in Children with Developmental Disabilities

Sleep disorders in children with developmental disabilities are a common and frequently disruptive behavioral concern. In the present study, four children with developmental disabilities (two of the children exhibited frequent night wakings and two had bedtime disturbances) were treated using a multiple baseline across subjects design. Sleep diaries were used to monitor changes in each child's sleep throughout treatment. Establishment of a consistent bedtime routine combined with a graduated extinction procedure for nighttime behavior problems resulted in a decrease in night wakings for two children (a 7-year-old girl and an 11-year-old boy) and a decrease in bedtime disturbances for two children (a 2-year-old girl and a 12-year-old boy). This series of interventions highlights the heterogeneity of maintaining variables in sleep disorders and the effectiveness of relatively simple behavioral interventions for the treatment of night wakings and bedtime disturbances in children with autism and other developmental disabilities.

Non-pharmacological management of problematic sleeping in children with developmental disabilities

AIM

Sleep is important for underlying neural plasticity, and children with developmental disabilities suffer behavioural, emotional, cognitive, and sensory-motor issues that affect their wake and sleep states. Problematic sleeping can be hypothesized to have adverse effects on both of these areas in children with developmental disabilities. With this review, we aim to provide a benchmark in managing problematic sleeping in children with developmental disabilities.

METHOD

A literature search was conducted and data on the study descriptives, patient characteristics, study design, study-related factors, criteria applied to operationalize sleep and developmental disability, and sleep 'management' were collected. Each management strategy was tabulated and analysed.

RESULTS

We identified 90 studies involving 1460 children with developmental disabilities, of whom 61.6% were male. The highest proportion of studies, almost half, were in children with syndromes (44.4%), followed by studies in children with intellectual disabilities (18.9%). Non-pharmacological sleep management was primarily aimed at improving sleep quality (86.7%), followed by sleep-wake schedules and, to a certain extent, sleep regularity (42.2%). About 56.7% of the studies reported more than one approach. Studies mostly focused on disorders of initiating and maintaining sleep through a diversity of strategies and relied heavily on subjective measures to identify and monitor problematic sleeping. Sleep management approaches were primarily delivered at the level of the individual in the home setting. The number of management approaches per study was unrelated to the number of sleep problems discussed.

INTERPRETATION

Modifying sleep management strategies to meet the specific needs of children with developmental disabilities is encouraged, and studies that look beyond sleep quality or sleep quantity are required. It is also advocated that modifications to sleep hygiene, sleep regularity, and sleep ecology in a population with developmental disabilities are rigorously investigated. Finally, daytime somnolence should not be overlooked when aiming to optimize sleep in children with developmental disabilities across the ages and stages of their lives. There were several limitations in the research findings of problematic sleep in children with developmental disabilities. In general, the sleep problems and the developmental disabilities investigated were multicomponent in nature. It is likely that management approaches impacted those problems on multiple levels or through diverse 'therapeutic' pathways. There is a need for randomized controlled trials and more objective measures that quantify improved sleep or wake states.

Parent Management of Sleep Difficulties in Young Children

Difficulties in settling children to sleep and night waking are common problems faced by parents with young children. The effectiveness of parent-managed behavioural intervention is examined in this study of four children which employs a multiple-baseline-design across subjects. Components of the intervention included: establishing regular bedtime routines; paying attention to the children before bed in the living areas and staying with the children only briefly when settling them in bed; adopting procedures for ignoring disruptive bedtime behaviour and night waking; and giving praise for appropriate behaviour. Complete success in settling the three children who were difficult at bedtime was achieved in five to fourteen days. Persistent night waking in all four children was eliminated in five to thirteen nights.

Assessment of sleep problems in preschool aged children: an adaptation of the children's sleep habits questionnaire

The purpose of the present study was to evaluate the factor structure of the children's sleep habits questionnaire (CSHQ) when used with preschool and toddler age children. Mothers of 105 children ages 2-5 completed the CSHQ, the child behavior checklist (CBCL), and a sleep diary. Internal consistency for the original subscales on the CSHQ ranged from .55 to .82 and factor analysis resulted in four factors that tap into critical aspects of sleep. The concurrent validity of the revised scales of the CSHQ was adequate. Overall the results from this study suggest a revised factor structure may be more appropriate for use with preschool and toddler age children.

Clinical management of behavioral insomnia of childhood

Behavioral insomnia is highly prevalent, affecting approximately 25% of children. It involves difficulties initiating and maintaining sleep and frequently results in inadequate sleep, leading to an array of negative effects for both the child and the child's family. In this paper, we describe a variety of empirically supported behavioral interventions for insomnia from infancy through adolescence. We explore how biological, cognitive, and psychosocial developmental changes contribute to behavioral insomnia and how these changes may affect sleep and behavioral interventions. We also discuss barriers that prevent families from accessing interventions, including why many empirically-supported behavioral interventions are overlooked by health care providers.

First effects of a multicomponent treatment for sleep disorders in children

Insomnia in children is a common disorder, yet only few child-specific treatment modalities exist so far. The goal of this study was to investigate the effectiveness of a multicomponent intervention program for children with insomnia at 5-10 years of age and their parents. The program was a structured six-session behavioral and hypnotherapeutic group treatment with three sessions for the children and three for their parents. Thirty-eight children (5.1-10.9 years) were randomly assigned to the specific treatment condition or waiting list plus sleep diary control condition. Twenty-two children participated in the treatment group and 16 in the control group. All children suffered from insomnia according to the International Classification of Sleep Disorders criteria. Sleep symptoms were assessed with a sleep diary and the German version of the Children Sleep Habit Questionnaire (CSHQ) and the Sleep Disturbance Scale for Children (SDSC). Although both conditions showed a significant decrease in several sleep symptoms, the treatment group exhibited a significantly greater improvement with regard to CSHQ and SDSC total scores as well as in several sleep parameters, reflecting the most important features of the intervention program, such as bedtime, sleep-related anxiety, night waking, and sleeping in parents' bed. By contrast, the control group's data revealed only unspecific effects. These pilot data suggest that insomnia in childhood can be treated effectively with this child-specific multicomponent group treatment.

JuSt - a multimodal program for treatment of insomnia in adolescents: a pilot study

Insomnia is the most prevalent sleep disorder in adolescents. A number of studies have evaluated the efficacy of the management of chronic insomnia in adults. Behavioral therapy for insomnia is the treatment of first choice, encompassing education about sleep and sleep hygiene, stimulus control, relaxation techniques, and cognitive strategies to combat nocturnal ruminations. Special programs for adolescents are lacking. In this study an age-oriented treatment program for adolescents (JuSt) was developed and evaluated. Eighteen adolescents and their parents participated in a psychological short-term treatment comprising six sessions. First results show that the treatment was well accepted by the adolescents and their parents and led to a significant reduction in sleep problems, such as sleep onset, sleep efficacy, sleep duration, and feeling rested as well as in cognitive parameters, such as ruminations and mental health. Randomized controlled studies are needed to evaluate the efficacy of this new approach to treat insomnia in adolescents.

A brief parental education for shaping sleep habits in 4-month-old infants

OBJECTIVE

To examine the effectiveness of a simple behavioral intervention with an educational booklet on the modification of parenting behaviors and the prevention of sleep disturbance in 4-month-old infants.

DESIGN

A prospective cohort design with cluster sampling controls in a primary care setting.

PARTICIPANTS

A total of 136 mothers with 4-month-old infants who visited a local health check-up clinic and responded to the 3-month follow-up survey.

METHODS

At the health check-up, an intervention group was provided with 10 minutes of group guidance and a simple educational booklet designed to encourage parents to promote favorable sleep patterns in their infants. A control group was provided with standard education alone. The two groups were questioned 3 months later through a survey sent by mail. Main measurements were parenting behaviors of parents and night waking of infants.

RESULTS

Two undesirable maternal behaviors that reinforce night waking in infants exhibited a significantly greater improvement in the intervention group than in the control group. "Feed or check diaper promptly" behavior and "hold and soothe immediately" behavior after "night waking" in the infant were significantly decreased in the intervention group.

CONCLUSIONS

Our findings suggest that increased night waking in infants was prevented in the intervention group. Our results indicate that the proportion of infant night waking was significantly higher in the control group, and there was also a tendency toward an increase in the proportion of infants who woke frequently and cried. These infant behaviors were not changed in the intervention group at the 3-month follow-up stage.

Risk factors and consequences of early childhood dyssomnias: New perspectives

Dyssomnias are largely under-diagnosed in infants and toddlers. This literature review proposes an integrative model based on empirical data on determinants and consequences of sleep disturbances occurring in early life. This model proposes that parental behaviors that impede the child's autonomy toward sleep periods are primary grounds for the development of dyssomnias, e.g., parental presence until the child falls asleep, and putting an already sleeping child to bed. The model also indicates the serious potential consequences of a modest but chronic loss of sleep in childhood. At least three developmental domains could be directly affected: behavioral/social competence, cognitive performance, and physical condition. Thus, children with short nocturnal sleep duration before age 3.5 years show increased risk of high hyperactivity-impulsivity scores and low cognitive performance at 6 years compared to children who sleep 11 h per night, after controlling for potentially confounding variables. Moreover, persistent short sleep duration in early infancy increased the risk of suffering of obesity at 6 years of age, after controlling for potentially confounding variables. Finally, the importance of allowing the child to sleep at least 10 h per night in early childhood is stressed, as the National Sleep Foundation Poll suggests, for optimal child development.

Maternal separation anxiety as a regulator of infants' sleep

BACKGROUND

The regulation of infants' sleep is determined not only by biological factors but by relational aspects too. This study focused on maternal separation anxiety and examined its association with sleep-wake regulation at 10 months of age.

METHOD

In a community sample comprising 52 infants and their mothers, sleep was measured objectively with an activity monitor, as well as through questionnaires. The mothers reported on their own separation anxiety and on the child's perceived distress.

RESULTS

The main finding was that maternal separation anxiety was linked to settling to sleep routines and to night-waking. The contribution of the mothers' own separation anxiety to their infants' night-waking remained significant after controlling for the child's fussiness.

CONCLUSIONS

Consistent with the transactional perspective, the current research documented an interplay between maternal separation anxiety and aspects of the child's sleep-wake transitions.

Sleep problems in children with neurological disorders

This review describes the complex and often reciprocal relationship between sleep problems, neurological disorders and/or intellectual disability in children. The causes of Intellectual disability (ID) discussed in this review include those conditions present from or around the time of birth, although it also considers traumatic brain injuries occurring later in development. This review discusses the patterns of sleep difficulty associated with specific disorders and summarizes the assessment and interventions, both behavioural and pharmacological, applicable to children. Many neurological disorders such as epilepsy, narcolepsy and neurorespiratory disorders vary considerably in terms of the degree of co-morbid problems and can present with a spectrum of effects on underlying cognitive or behavioural substrates including sleep function. These conditions are discussed as they provide useful insights into how disordered sleep can impact on cognitive development and behaviour. The review draws both on the literature in these areas and the extensive clinical experience of the authors.

Dyssomnias and parasomnias in early childhood

OBJECTIVES

Our aim for this study was to determine the prevalence of dyssomnias and various parasomnias in early childhood and to describe their temporal evolution, gender differences, and correlates.

METHODS

This research is part of a longitudinal study of child development. A randomized, 3-level, stratified survey design was used to study a representative sample of infants who were born in 1997-1998 in the province of Quebec (Canada). When the children were 2.5 years of age, 1997 families agreed to be interviewed. The presence of dyssomnias or parasomnias was obtained from a self-administered questionnaire that was completed by the mother at each round of measures.

RESULTS

The percentage of children with frequent night wakings decreased steadily from 36.3% at age 2.5 to 13.2% at age 6. Similarly, the percentage of children who had difficulty falling asleep at night decreased significantly from 16.0% at ages 3.5 and 4 to 10% at age 5 and to 7.4% at age 6. The overall prevalence of each parasomnia for the period studied was as follows: somnambulism, 14.5%; sleep terrors, 39.8%; somniloquy, 84.4%; enuresis, 25.0%; bruxism, 45.6%; and rhythmic movements, 9.2%. Persistent somnambulism at age 6 was significantly correlated with sleep terrors and somniloquy. Persistent sleep terrors at age 6 were also correlated with somniloquy. Finally, persistent sleep terrors at age 6 were correlated with frequent night wakings. Separation anxiety was associated with persistent night wakings and with somnambulism, bruxism, sleep terrors, and somniloquy.

CONCLUSIONS

There is a high prevalence of night wakings and sleep-onset difficulties in preschool children. Parasomnias are highly prevalent in early childhood and are associated with separation anxiety. However, they have little impact on sleep duration.

Prenatal Cocaine Exposure and Infant Sleep at 7 Months of age: The Influence of the Caregiving Environment

The primary goal of this study was to examine sleep problems in a sample of cocaine-exposed 7-month-old infants and to determine if maternal psychopathology mediated any existing association between substance exposure and sleep behaviors. We also examined the differences in sleep behaviors of cocaine-exposed infants in parental custody and cocaine-exposed infants in nonparental custody. Participants were 65 cocaine-exposed and 53 nonexposed infants and their primary caregivers who were recruited at delivery and assessed at 7 months of infant age. As expected, women who used cocaine during pregnancy had more psychiatric symptoms than nonusers. Prenatal exposure to heavier amounts of cocaine was significantly related to more severe sleep difficulties, and maternal anxiety mediated this association. Approximately 28% of cocaine mothers lost custody of their infants by 7 months of age. Nonmaternal caregivers had significantly fewer symptoms of psychopathology than the cocaine-using women who retained custody of their children. Infants who were in nonparental care at 7 months of age also had less severe sleep problems than did infants who remained in parental care.

Cognitive–behavioral treatment for childhood sleep disorders

Sleep problems are very prevalent during childhood and may have adverse developmental impact. The efficacy of a number of cognitive-behavioral interventions for the most prevalent problems such as difficulty falling asleep and night-wakings has been repeatedly demonstrated with relatively rapid outcomes and high success rates. Preventive interventions in infancy have shown some promise in lowering the rates of sleep problems in infants of trained parents. Cognitive-behavioral interventions have also been proposed for childhood parasomnias (sleepwalking, night terrors, nightmares, and rhythmic behaviors), however, very limited research has been conducted to assess the efficacy of these interventions. Specific methodological issues, limitations and needs have been identified in the clinical literatures. These issues include: (a) integrating objective sleep assessment methods in clinical research; (b) identifying the specific curative factors of various effective interventions; (c) the absence of long-term follow-up studies for assessing relapse problems; (d) assessing the role of mode of delivery (i.e., professional consultation versus written information) in treatment efficacy; and (e) the need to expand the research on clinical interventions for the parasomnias.

Annotation: The use of psychotropic medications in children: a British view

BACKGROUND

Prescribing practices relating to the use of psychotropic medication with mentally disordered children have changed significantly in Britain over recent years.

METHODS

I conducted a review of the modest body of empirical data available relating to the prescribing practices of child psychiatrists, paediatricians and general practitioners (primary care physicians). The data were obtained primarily from postal questionnaire studies but also from British drug studies and a government-sponsored evaluation of the efficacy of stimulant medication. Postgraduate training guidelines for the three principal clinical disciplines are also discussed.

RESULTS

Systematic evaluation of prescribing practices has a relatively short history. All the studies reviewed demonstrated consistent methodological weaknesses, the most important of which was reliance upon retrospective reports of prescribing practices from clinicians with no analysis of actual prescription data. No studies relating to the general use of psychotropic medication by paediatricians were found. Child psychiatrists and general practitioners appear to be using a range of drugs for a range of conditions; however, there was evidence of intra- and interdisciplinary variations in practice. It was also evident from the general practitioner data that drug treatments were frequently used for conditions best managed with behavioural methods (e.g., common sleep problems and enuresis). Government prescription data relating to methylphenidate use in ADHD reveal a dramatic rise over the past ten years. Currently, most child psychiatrists use this treatment compared to approximately half the profession only seven years ago. The use of newer antipsychotic agents as well as the SSRI antidepressants appears to be growing in child psychiatric practice. A majority of clinicians surveyed believed that medication was an important treatment modality but also felt that they were relatively unskilled in the field and requested further training.

CONCLUSIONS

Overall, a picture of both a growing and better informed use of psychotropic medication is emerging in Britain despite shortcomings in postgraduate training. Future research needs to evaluate prescribing practice in a more objective manner in order to improve training and also service developments in the field.

Body movement, presence of parents, and the process of falling asleep in toddlers

A total of 30 toddlers were videotaped as they fell asleep and the kinematic properties of their movements were analysed employing a computerised system, based on the Kestenberg Movement Profile (KMP). We analysed the movements and their association to the length of the falling asleep phase and presence of parents. Results revealed that the movement variables had a significant contribution in explaining the length of the Falling Asleep Phase (FAP). Toddlers who fell asleep within 30 minutes of entering bed displayed movements characterised by low amplitude and gradual slopes, movements such as sucking and caressing. Toddlers who were awake for longer than 30 minutes before they fell asleep displayed movements characterised by high amplitude and abrupt changes, movements such as kicking, banging, and straining. The movement variables predicted the length of the falling asleep phase significantly better than other variables associated with the falling asleep phase, such as duration of music played, duration of using pacifiers/thumbs, and the presence of objects in the bed including bottles. A significant correlation was found between the presence of parents in the toddler’s room and the type of movement that was used; Parents who spent more time in the room had toddlers who revealed less soothing movements and more movements characterised by high amplitudes and abrupt slopes. Possible intervening variables including temperament, chronological age, mental age, sleep parameters, and demographic information did not explain the findings. Practical applications of the study in assisting young children in the falling asleep phase are discussed.

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

OBJECTIVE

To assess knowledge, screening, evaluation, treatment practices, and attitudes regarding sleep disorders in children and adolescents in a large sample of community-based and academic pediatricians.

DESIGN

Cross-sectional survey.

PARTICIPANTS

Six hundred twenty-six pediatricians in Rhode Island, Massachusetts, and Connecticut. INTRUMENT: The Pediatric Sleep Survey, a 42-item questionnaire assessing general and specific sleep knowledge categories; clinical screening, diagnostic, and treatment practices for common pediatric sleep disorders; and practitioner attitudes regarding the impact of sleep disorders in the clinical setting and as a public health issue.

RESULTS

On the knowledge section, the mean Total Knowledge score for the respondents was 18.1 +/- 3.5 out of 30 items, with 23.5% of the sample responding correctly on half or less of the items. Pediatricians scored highest on items relating to developmental and behavioral aspects of sleep and parasomnias, whereas the mean percentage of correct responses was <50% for items relating to sleep disordered breathing, excessive daytime sleepiness, and sleep movement disorders. Although only 16.5% and 18.2% of the sample reported not screening routinely for sleep disorders in infants and toddlers, this percentage rose to 43.9% in adolescents. Furthermore, only 38.3% regularly question the adolescents themselves about their sleep. Only about one quarter of the respondents screen toddlers and school-aged children for snoring. In evaluating and treating pediatric sleep problems, 53.2% of the sample never or rarely order overnight sleep studies to assess for obstructive sleep apnea and few use alternative treatment strategies, such as continuous positive airway pressure. A quarter of the sample at least occasionally recommends diphenhydramine and almost half suggests a psychological evaluation for children with night terrors. Finally, the percent of pediatricians rating the impact on children of sleep problems in a variety of domains as important or very important ranged from 49.7% (nonintentional injuries) to 92.6% (academic performance). However, only 46% of the sample felt confident or very confident about their own ability to screen for sleep problems, whereas 34.2% and 25.3% similarly rated their ability to evaluate and treat sleep problems in children.

CONCLUSIONS

The results of this survey suggest that there are still significant gaps among practicing pediatricians both in basic knowledge about pediatric sleep disorders, and in the translation of that knowledge into clinical practice. Despite their acknowledgment of the importance of sleep problems, many pediatricians fail to screen adequately for them, especially in older children and adolescents. Additional educational efforts regarding pediatric sleep issues are warranted, and should be targeted at the medical school, postgraduate training, and continuing medical education levels.

The treatment of child and adolescent mental health problems in primary care: a systematic review

BACKGROUND

There is significant potential to increase the accessibility and effectiveness of child and adolescent mental health services through the involvement of primary care professionals and the delivery of interventions in the primary care setting. However, little is known about the actual clinical and cost-effectiveness of such service delivery.

OBJECTIVE

The aim of the study was to review systematically the evidence concerning the effectiveness of interventions for child and adolescent mental health problems in primary care, and interventions designed to improve the skills of primary care staff.

METHODS

Searches were made of The Cochrane Clinical Trials Register, MEDLINE, PSYCINFO, EMBASE and CINAHL, together with correspondence with subject experts and authors of studies, and checking of references in identified papers.

RESULTS AND CONCLUSIONS

There was some preliminary evidence that treatments by specialist staff working in primary care were effective, although the quality of included studies was variable and no data were available on the cost-effectiveness of interventions. Equally, some educational interventions show potential for increasing the skills and confidence of primary care staff, but controlled evaluations were rare and few studies reported actual changes in professional behaviour or patient health outcomes. A significant programme of research is required if the potential for child and adolescent mental health services in primary care is to be realized in an effective and efficient way.

REVIEW ARTICLE: Behavioural and cognitive-behavioural interventions for sleep disorders in infants and children: A review

This review covers the literature on behavioural and cognitive-behavioural treatments for sleep disturbance in infants, pre-school, and school-age children. Treatment areas are dyssomnias (disorders of initiating, maintaining, or excessive sleep) and parasomnias (behaviours which occur predominantly during sleep). Interventions aimed at preventing sleep disorder through targeting infant sleep patterns are also examined. Controlled experimental studies are the main focus of this review but case studies and clinical reports are also included. It is concluded that, for families willing to undertake behavioural and cognitive-behavioural interventions, some treatments appear effective for some infant and child sleep problems, in the short term at least. The adequacy of current research is discussed, and suggestions for future research are given.

Treatment of young children's bedtime refusal and nighttime wakings: a comparison of "standard" and graduated ignoring procedures

Young children with sleep problems received either "standard" or graduated ignoring treatment. Both brief treatments were superior to a wait-list control condition and resulted in comparable improvements in bedtime and nighttime sleep problems. At bedtime, the treatments did not differ with respect to maternal compliance and stress. For nighttime wakings, mothers in the graduated ignoring group reported higher rates of compliance and less treatment-related stress. Maternal characteristics predicted treatment outcome in the standard ignoring condition. Following treatment, only positive side effects were observed. When compared to the wait-list group, mothers in the standard ignoring group reported less verbose discipline and decreased stress in parenting, while mothers in the graduated ignoring group reported improved parent-child relationships. Treatment gains were maintained over a 2-month follow-up period.

Functional assessment and treatment of sleeping problems with developmentally disabled children: six case studies

Sleeping problems are common among developmentally disabled children of young age and they may have adverse effects on the well-being of both child and parents. In the present study, results from functional assessment with four children suggested that sleeping problems were reinforced by parental attention whilst an undiagnosed seizure disorder was associated with nighttime crying with one child. Conditioned anxiety resulted in problems in settling to sleep with a sixth child. Behavioral (i.e., extinction, desensitization) and pharmacological (i.e., anticonvulsant) treatment resulted in a substantial reduction in sleeping problems with all children. Follow-up data indicate that effects were maintained.

The incidence of sleeping problems in preterm and fullterm infants discharged from neonatal special care units: an epidemiological longitudinal study

Anecdotal reports have suggested that sleeping problems are a frequent complaint from parents of preterm infants. This prospective epidemiological study examined the incidence and stability of sleeping problems of very preterm (< 32 weeks gestation at birth), preterm (32-36 weeks gestation) and fullterm infants, all admitted to special care baby units (SCBU) after birth, in comparison to healthy term infants over the first 5 years of life. Preterm infants were found to have fewer and shorter night-wakings at 5 months. No differences in sleeping behaviour compared with healthy term children were found at 20 and 56 months of age. Similar significant, and moderate, stability of nightwaking from one age to the next were found for exSCBU-graduates and healthy fullterm infants. Parental interventions such as staying with the child until sleep and taking the infant into bed af night were related to nightwaking problems and increased parental distress. It is concluded that prematurity, and thus neurological immaturity and special care experience are less important than caretaking behaviour in the development of sleeping problems in both preterm and fullterm infants.

Sleep difficulties and their management in preschoolers with atopic eczema

Sleep disruption is known to be common in preschool children. Those with atopic eczema (AE) would seem to be at particular risk because of itching. In this preliminary survey parents confirmed clinical impressions that sleep loss is a common feature when a child's atopic eczema is flaring. Sleep disturbance was reported by parents for 86% of the relevant nights with an average of 2.7 wakings per night and an average parental sleep loss of 2.6 h per night. Parents used a common core of strategies to help their children sleep at these times. Some of the strategies employed are likely to perpetuate sleep disturbance beyond the time of the flare. Parents gained most benefit from their own idiosyncratic approaches. For the majority of children (59%) sleep disruption is limited to times when their AE is flaring.

Sleep problems in pre-school children: a review of the literature

This paper reviews the literature on sleep problems in pre-school children, aiming to raise awareness of the current knowledge in this field. The article begins with a discussion of the prevalence of sleep problems in young children. Disorders of initiating and maintaining sleep are by far the most common type of sleep problem in this age group, and are therefore the focus of this review. The effects of sleep disturbance are examined, focusing on how parents often feel desperate and in need of support outside the family. The causes of sleep problems are considered and the complexity in identifying causal factors is highlighted. The article continues with an exploration of the treatment of sleep problems, suggesting that much of the advice given to parents is contradictory. The literature demonstrates that the use of medication is common, but it appears that this method of treatment is of limited benefit. It seems that behaviour modification or a psychodynamic approach may be much more successful, and the use of self-help manuals/booklets has been shown to be useful by some authors. Finally, preventative strategies are discussed highlighting the need for further research in this area.

Sleep problems in toddlers: effects of treatment on their daytime behavior

OBJECTIVE

This study investigated the effects of a treatment program for severely sleep-disturbed children on their daytime interaction with their mothers.

METHOD

Twenty-eight children with serious sleep problems and 30 matched controls, aged 12 to 36 months, were compared on behavior rating scales, on sleep patterns, and during play and feeding interactions with their mothers before and after an intervention program.

RESULTS

After treatment the sleep-disturbed children improved in their behavior, in their sleep patterns, and during feeding interactions with their mothers. However, the behavior of the children but not that of their mothers improved.

CONCLUSIONS

The findings of this study indicate that a brief behavioral intervention program focused on helping families manage children with sleep disturbances can generalize to daytime mother-child interactions. This suggests that a compromised relationship in early life may be modified by rather simple interventions since changes of one behavioral system may modify the total relationship of young children with those caring for them.

Management of infant sleep problems in a residential unit

Torrens House provides a short residential programme for families with a baby (8-12 months of age) identified by parents as having a sleep problem such as waking frequently at night and being difficult to settle. The programme involves the promotion of infant self-settling by the use of a controlled crying technique, together with wrapping, cessation of night feeds and establishment of a day-time routine. Twenty families (with 23 babies) were followed through the programme and for 3 months afterwards. There were significant decreases in the number of times the babies woke, the number of night-feeds and the length of time awake at night at 1 month follow-up, with a reduction in depressive symptomatology of the parents and a perceived improvement in their infants' behaviour. Twenty of the 23 babies were sleeping well at 3 month follow-up.

Sleep management--the hidden agenda

The management of apparent sleep problems is often not straight-forward because of a proportion of clients attending with a 'hidden agenda', requiring more in-depth long-term treatment for psychological problems. This paper looks at a sample of 100 consecutive referrals to a community sleep clinic in the East End of London and attempts to address the question of who comes to the sleep clinic and why. A proportion of clients responded to brief intervention of a behavioural nature but 19% were referred on to other services for psycho-therapeutic help.

The evaluation and treatment of sleep disturbances in young children

This study examines the accuracy of parents' reports about their children's sleep behavior and their response to a behavioral treatment. Twenty-eight sleep-disordered and thirty control children aged 12-36 months were filmed during three nights using an infrared camera and their sleep behavior compared with parental reports. There were significant differences among the groups with parents of good sleepers being less accurate in reporting on their children's sleep behavior. Poor sleepers also had more behavior problems, a more difficult temperament and more adverse early medical histories. The good sleepers woke up as frequently as the poor sleepers. However, they managed to soothe themselves back to sleep without disturbing anyone. Virtually all poor sleepers showed significant improvement following treatment.

A behavioral model of infant sleep disturbance

Chronic sleep disturbance, such as bed refusal, sleep-onset delay, and night waking with crying, affects 15% to 35% of preschool children. Biological factors, particularly arousals associated with recurrent episodes of rapid-eye-movement sleep, render infants vulnerable to repeated awakenings. Parental failure to establish appropriate stimulus control of sleep-related behaviors and parent-mediated contingencies of reinforcement for sleep-incompatible behaviors may shape and maintain infant sleep disturbance. Treatment and prevention strategies are discussed, and research needs are identified.

Sleep clinics with health visitors: a 2-year evaluation

This study was undertaken to evaluate a service for sleep clinics over a time span of 2 years. The service was operated jointly by health visitors and clinical psychologists and based on a previous model run by the same team of psychologists and child development advisors. The outcome was not supportive of this type of service in terms of referral rates over a period of time, improvement rate, continued existence or cost-effectiveness of such a service. The reasons for the difficulties of such clinics are discussed.

Nightmares, life events and behaviour problems in preschool children

A postal survey was carried out to identify nursery school children with frequent nightmares in an English city. Of the 22 children reported as suffering from frequent nightmares, 14 came from families who were willing to be interviewed further. A control group with no nightmares, matched for age and sex, was selected from the returns. The mothers of the children in the two groups were interviewed using the Preschool Behaviour Checklist and a life events scale. The results showed that neither life events nor behaviour problems were more prevalent in the frequent nightmares group.