Behavioral parent-training approaches for the treatment of bedtime noncompliance in young children.

Abstract

Bedtime noncompliance is one of the most common and treatable types of child sleep problems. Children who are noncompliant at bedtime are more likely to exhibit daytime somnolescence, which may in turn lead children to exhibit daytime misbehavior, impaired social functioning and poorer school achievement. In addition, these bedtime problems can have a number of negative consequences for members of the child's family, including parental sleep deprivation and depression. Behavioral parent-training approaches are considered the treatments of choice for bedtime noncompliance in young children. In this paper, we describe the evidence supporting a number of such approaches. We highlight several gaps in the treatment literature and we make recommendations for future research. Keywords: Bedtime Noncompliance, Parent Training, Sleep Problems Bedtime noncompliance in preschool and elementary-school school aged children is typically characterized by stalling, whining, or tantruming when bedtime approaches. Almost all children will exhibit these behaviors at some point in their young lives. Most parents have the skills to handle milder forms of bedtime noncompliance. However, when the intensity, duration, or frequency of these behaviors leads to disruptions in a family's functioning, mental health professionals can offer substantial help. These bedtime behaviors are best classified diagnostically as Behavioral Insomnia of Childhood, Limitsetting Type (2005 revision of the International Classification of Sleep Disorders; American Academy of Sleep Medicine). In this paper we will use the less awkward term "bedtime noncompliance" to describe this set of behaviors. Although some of the studies we will mention include infants, we will focus primarily on preschool and school aged children. For an excellent review of the entire class of sleep problems in children, including parasomnias, fears, and nightmare disorders see Sadeh (2005).There is evidence that bedtime noncompliance is one of the most common childhood behavior problems. While many surveys of sleep problems in children lump sleep problems together, a few studies have examined prevalence rates of bedtime noncompliance. Estimates vary widely, but most studies suggest that 5-10% of school-aged children display significant bedtime noncompliance (e.g. Blader, Koplewics, Abikoff, & Foley, 1997, Mindell, 1993. Sleep problems as a class account for almost 10% of presenting concerns in child and adolescent outpatient mental health centers (Meisbov, Schroeder, & Wesson, 1993). There is no doubt that many other families experience these problems and do not seek professional help. Research on Effects of Sleep ProblemsThere is an increasing amount of clinical observation and research demonstrating that sleep problems, including bedtime noncompliance, can lead to insufficient sleep in children, which can, if chronic, lead to emotional, physical, behavioral, and cognitive problems (Dahl, 1996; Gais, Philal, Wagner, & Born, 2000;Kuhn, Mayfield & Kuhn, 1999;Lavigne, et al., 199...

Discussion of Extinction-Based Behavioral Sleep Interventions for Young Children and Reasons Why Parents May Find Them Difficult

“…Parental resistance remains the largest barrier to the implementation of extinction interventions, 30 and preliminary data 28 would suggest the majority of Australian parents find graduated extinction too difficult and stressful to implement. Despite being a known issue for decades, few researchers have explicitly addressed it.…”

“…Underlying extinction interventions is the premise that bedtime noncompliance has been trained by the behaviors of the parents. 30 But it would be unwise to assume all child sleep problems have been trained by the parents. Some data suggests maladaptive parenting behaviors can follow early infancy sleep difficulties, not the other way around.…”

“…30 Crying is inherent in extinction interventions; otherwise it would not be necessary as the child would simply fall asleep on their own. Crying increases when an extinction intervention begins and is called an "extinction burst."…”

“…In some cultures, leaving a child to sleep alone is considered "bad parenting," 78 which has significant implications for treatment, especially in relation to extinction interventions. 30 Most current pediatric H Etherton, S Blunden and Y Hauck. Parental Difficulty with Extinction sleep interventions and parent training models are based upon a stereotypical Western, middle-class family set-up, which sleeps children and adults in different rooms and beds and fosters independence in their children over social dependence.…”

Caretaker-Child Interactions At Bedtime: A Bidirectional Analysis of Noncompliant Bedtime Behavior

“…Many studies have found untreated sleep problems to be associated with childhood behavior problems (Adams & Rickert, 1989;Ortiz & McCormick, 2007;Wade, Ortiz, & Gorman, 2007). Developmental psychologists often categorize problem behaviors as being either externalizing or internalizing.…”