By Associate Professor Sarah Blunden MAPS, Head of Paediatric Sleep Research, Sophia Rainbird and Hayley Etherton, Central Queensland University, and Yvonne Hauck, Curtin University

Afirst baby in the household brings with it many challenges, the most common being that of parental sleep disruption due to the child’s night waking (France & Blampied, 1999). Whilst typically developing infants (under six months old) need to be fed overnight, the challenge for some parents may be either that the infant is unable to resettle after a feed, or if no longer feeding during the night, that they cannot resettle unassisted after waking from their normal sleep cycle. Indeed, around 30 per cent of new parents of infants (defined as aged 6-18 months) report their child as having a sleep ‘problem’ of this nature (Mindell, Kuhn, Lewin, Meltzer, & Sadeh, 2006).

These sleep problems, resulting in secondary sleep disturbance and significant stress for parents, are called behavioural sleep disorders and classified as 'behavioural insomnia of childhood' (BIC; American Academy of Sleep Medicine [AASM], 2005). Characteristics of BIC include difficulty initiating sleep, with frequent night wakings that require significant time and effort to resettle. In infants over six months old, and for those no longer feeding, difficulty initiating sleep without the assistance of another individual or object is a sub-type of BIC called 'sleep onset association disorder'. In Australia, as in many Western industrialised cultures (where infants sleep either in their own bed or in a separate room), these behavioural sleep problems are a common complaint. The problem becomes not only sleep disturbance, but the crying from an infant in need of assistance to resettle. This signalling or crying is the single largest contributor to the stress of sleep problems in new parents (Bayer, Hiscock, Hampton, & Wake, 2007).

Why do infants cry?

Night time waking is a normal occurrence and most infants can reinitiate sleep after a night waking or a feed. For those who cannot, crying for assistance is, according to etiological models, a natural, interactive and communicative process by an infant in need (Bowlby, 2005) matching parental provision of that need. As suggested in developmental theory (Singer & Revenson, 1997), infants are unable to regulate their crying responses or initiate at will their problem solving capacities, so it is hard to see overnight crying as anything other than a call for parental assistance. Indeed, of all primates, human infants are born the most immature neurologically and develop independent survival skills more slowly (McKenna, et al., 1993).

Impact of infant crying on parents

As the primary caregivers, parents’ need for rest must be recognised. Parents who suffer fatigue from sleep disturbance caused by infant waking and crying are at significant risk of depression, stress and anxiety (Hiscock, Bayer, Hampton, Ukoumunne, & Wake, 2008). Poor coping strategies (Nezu, 2004), increased risk of parenting and parent/infant attachment dysfunctions (McKenna et al., 2007), early cessation of breastfeeding (McKenna, et al, 2007), increased risk of traffic accidents (Gnardellis, 2008), parental and marital discord (Kerr & Jowett, 1994) and even increased incidence of child abuse have been directly related to secondary parental sleep disturbance (El-Sheikh , Buckhalt, Mize, & Acebo 2006). Recent Australian data (Price et al., 2012) show 68 per cent of mothers of seven-month-old sleep disturbed infants have increased depression scores, similar to fathers (Tikotzky & Sadeh, 2009). These parents represent an identifiable ‘at-risk’ subgroup. The increasing incidence of dual working families in need of their own sleep to perform and function at work confirms the needs for assistance for sleep-deprived parents.

Sleep training methods

Not surprisingly, parents who have an infant with problematic sleep seek intervention assistance. The most common sleep training methods for parents, generally undertaken after the infant is six months old,  are based on ‘extinction’ and can be positioned along a spectrum of interaction. Extinction methods use the principles of operant conditioning (Skinner, 1933) and change behaviour by ‘extinguishing’ (ignoring) the undesirable behaviours of disruptive sleep and crying, and eliminating the ‘reward’ component (parental attention).

The least interactive sleep training method is the ‘extinction method’ (the ‘cry-it-out method’) which instructs parents to leave their infant alone at sleep time, completely ignoring their cries. Second is the ‘graduated extinction method’ (‘controlled crying’), which instructs parents to leave their infant alone at sleep time and alternate between minimal attending and unattended crying at increasingly longer intervals. The most interactive extinction method allows parents to stay in the infant’s room at sleep time and gradually withdraw their presence, eventually leaving the room altogether but still periodically ignoring the crying (the ‘camping out method’; Mindell et al., 2006).

Parents’ use of sleep training methods

All of the extinction treatments outlined above have proven to reduce night time crying and parental interaction, but those that involve significant amounts of unattended crying are reportedly tolerated with difficulty by parents (Mindell et al., 2006). Indeed, these reports have been verified in a 2012 anonymous online, Australia-wide pilot study of 102 parents of infants, which assessed compliance and uptake of cry-intensive sleep interventions. Results showed 71 per cent of parents (n=73) would not use, or continue to use, extinction techniques (Blunden & Baills, 2013). These findings have been replicated in a larger 2014 study (Etherton, Blunden, Rainbird & Hauck, unpublished data, 2014), with preliminary results showing 63 per cent of parents (n=502) did not use or continue to use extinction methods primarily due to concern for excessive stress to the child and parents, as they dislike the intervention’s concept of leaving their child to cry unattended.

Based on these unprecedented studies, a large proportion of parents are unlikely to support extinction-based sleep interventions and will remain unassisted, sleep deprived and at risk. Furthermore, managing an infant’s crying by ignoring it contradicts the developmental theories which support the etiology of crying in infants as the communication of a need for parental attention. However, the needs of parents as the primary carers of infants cannot be dismissed. Parents are left with the invidious choice of improving their own sleep disturbance or letting their infant cry unattended.

When parents do seek assistance for secondary sleep disturbance, it is usually from their general practitioner, child health nurse or other allied health professional, who all receive little specific training in sleep intervention methods. Indeed, trainee doctors receive less than six hours medical training in paediatric sleep in total. Given this lack of sleep content in training, medical and allied health professionals presumably have to resort to information from the published literature to acquire their knowledge of interventions for infant sleep disturbance, which is extremely skewed towards extinction methods. For example, in two recent reviews, 76 per cent (Mindell et al., 2006) and 61 per cent (Ramos & Youngclarke, 2006) of sleep training methods utilised extinction techniques. Even parenting books for sleep training are skewed towards extinction techniques (Ramos & Youngclarke, 2006). Not surprisingly, health practitioners are better informed about extinction-based sleep training and predominantly offer these interventions to parents.

Non-extinction-based sleep training

Other ‘cue-based’ methods where crying is not ignored through extinction have been developed and are successful (Blunden, 2011; Douglas & Hill, 2011), but are less commonly offered and less well known (Mindell et al., 2006). Cue-based methods have as a common denominator responding to the infant cries overnight. They are guided by attachment theorists who consider that maternal availability and responding to infant cues at bedtime are necessary in young children (Teti, Kim, Mayer & Countermine, 2010). Responding to the child is coupled with the option of reducing the intensity of the response in order to gradually reduce the child’s dependence on a parent for sleep re-initiation. For instance, the reduction in interaction would move from cuddling a child to sleep, to patting the child to sleep, to eventually not touching the child at all while he or she falls asleep (Blunden 2011; see boxed example below).

Cue-based sleep intervention example 
Rocking a child to sleep
  • Child wakes and signals to parent
  • Parent response:
Step 1: Always call back to say you are coming
Step 2

Pick up child, rock almost to sleep, then place in sleep
space with a comfort object and pat child to sleep                     

  • Practice until child’s resistance and protest reaction is reduced and child settles with only patting
Step 3:  Continue to call back and go to child, but reduce patting to stop at the moment of sleep onset. The child is no longer touched at the moment of sleep and has the comfort object.
  • Practice until the child’s resistance and protest reaction is reduced
Step 4:

Continue to call back and go to child, but no longer pat, and replace with voice comfort. Offer replacement comfort object.

  • Practice until the child’s resistance and protest reaction is reduced
Step 5:

Continue to call back, attend but stand at the door and comfort verbally

  • Practice until the child’s resistance and protest reaction is reduced
Step 6:   Continue to call back and comfort verbally but move in and out of the room while child is still awake, calling to child when you are outside. Instruct child to find comfort object.
Step 7:  Eventually call back and instruct child to find comfort toy, and only provide verbal comfort

 

It has been shown that cue-based methods can be as effective as those using extinction with parental presence  (Blunden 2011) and other extinction settling interventions, although there is still a paucity of available literature and empirical evidence for this claim (Mindell et al.,  2006). Therefore, as suggested in the management protocol document from the AASM (Mindell et al., 2006),  it would seem that offering a range of techniques (including non-extinction-based techniques) would be beneficial and would meet parental demand.

Conclusions

To cry or not to cry? Why are parents not consistently offered other non-extinction-based sleep interventions, which exist, are published and successful? In no other area of health care delivery is there only one choice for a given health problem. Even for childhood vaccinations, parents have choice. Given what is at stake, parents need to be offered alternatives to cry-intensive extinction-based responses to infant crying. Psychologists need to be informed about other psychologically-based sleep interventions to assist struggling parents to cope with their infant’s crying.

The first author can be contacted at s.blunden@cqu.edu.au

References

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InPsych April 2014

 

Table of contents

Vol 36 | Issue 2