Elsevier

Sleep Medicine

Volume 46, June 2018, Pages 98-106
Sleep Medicine

Original Article
An open trial of bedtime fading for sleep disturbances in preschool children: a parent group education approach

https://doi.org/10.1016/j.sleep.2018.03.003Get rights and content

Highlights

  • Bedtime fading was delivered to parents of children aged 1–4 years.

  • Bedtime fading reduced sleep onset latency and wake after sleep onset.

  • Bedtime tantrums were reduced following treatment.

  • Treatment gains were maintained at two year follow-up.

Abstract

Study Objectives

To evaluate the efficacy of bedtime fading to reduce sleep disturbances in preschool aged children by using a group parent education format.

Design

A repeated-measures design (pretreatment, treatment, post-treatment and two year follow-up).

Setting

Flinders University Child and Adolescent Sleep Clinic, Adelaide, South Australia.

Participants

Participants comprised 21 children (M age = 3.0 ± 0.80 years, range = 1.5–4.0 years; 60% girls) identified as having difficulty initiating sleep, night waking, or a combination of both, and their mothers (M age = 36.1 ± 4.2 years).

Interventions

Mothers attended two group sessions that included basic sleep education (sleep needs, sleep architecture, and sleep homeostasis) and bedtime fading instruction.

Measurements and Results

Primary outcome variables were sleep onset latency (SOL), wake after sleep onset (WASO), and bedtime tantrums, and these variables were measured using two week maternal report sleep diaries. Immediate improvements were observed over pretreatment to treatment in average SOL per night (M = 23.2 ± 11.3 min vs. M = 13.0 ± 7.3 min, d = 0.91), average WASO per night (M = 32.4 ± 23.1 min vs. M = 24.0 ± 18.3 min, d = 0.41), and number of bedtime tantrums per week (M = 1.7 ± 3.0 vs. M = 0.4 ± 0.7, d = 0.43). Treatment gains were maintained at two year follow-up. Mothers rated bedtime fading high in terms of usefulness and satisfaction, and they reported that could successfully reimplement the treatment when needed.

Conclusions

Bedtime fading is a brief and promising intervention for pre-schoolers’ sleep difficulties. This simple intervention can be easily implemented by parents at home with little instructions, resulting in improvements in sleep and bedtime tantrums.

Introduction

Sleep problems affect many young children. Studies show that between 20% and 67% of preschoolers aged 18 months to 4 years take more than 30 min to fall asleep, whereas between 4% and 18% take longer than 1 h [1], [2], [3], [4]. Problematic night-time waking is also prevalent among preschool children [5], with children frequently requiring the presence of a parent to initiate or reinitiate sleep. Sleep disturbances result in insufficient and fragmented sleep for both children and parents, as well as negative daytime sequelae (Gelman & King, 2011).

Ferber [6] reported that frustrated and tired parents are often “at the end of [their] tether” by the time they seek professional help. Parents commonly try a variety of treatments and strategies to resolve their children's sleep problems, with some resorting to physical punishment or medication [6], [7]. However, concerns have been raised about the use of sleep medications for preschoolers [8], [9]. Consensus statements for pharmacological treatment of children's sleep problems recommend that medication should only be used after the failure of non-pharmacological treatments, such as behavioral interventions [5], [10], [11].

Bedtime fading involves delaying the child's bedtime to a time at which rapid sleep onset is probable (ie, slightly later than their natural sleep onset time) while maintaining a regular wake up time and age-appropriate naps [5], [12]. This is based on the sleep restriction therapy for adult insomnia [13]. The mechanism of action is through the sleep homeostatic system, with sleep pressure heightened by increasing the length of time that children are awake before bed and restricting their opportunity to dissipate this sleep pressure overnight (Borbely, 1982). Bedtime fading is argued to reduce SOL, night time awakenings, and WASO because of higher sleep efficiency following restricted sleep. The benefit of bedtime fading to sleep parameters has been shown in two small samples including four atypically developing children with severe intellectual disabilities who were referred to an inpatient unit for the treatment of self-injurious behavior [14] and in infants aged less than 16 months [15]. Bedtime fading has the advantage of being a gentler alternative to “extinction” methods, which can be distressing for children and parents owing to long bouts of crying [16], [17], [18]. Despite its therapeutic promise, and the stated need for this type of research, there remains a paucity of research in evaluating the efficacy of bedtime fading in typically developing preschool-aged children [19].

Research advocates behavioral interventions as first line treatment for young children's sleep problems [5], [11]. An American Academy of Sleep Medicine [AASM] review of behavioral treatments for young children’s sleep stated that 94% of studies showed clinically significant results regarding symptom reduction [5]. An accompanying AASM report on practice parameters for behavioral treatments of young children's sleep [20] reviewed the empirical evidence from 52 treatment studies that implemented behavioral interventions for bedtime problems and night wakings in infants and preschool children. Studies were graded on the quality of their evidence. Several treatments were recommended. Two treatments, unmodified extinction (which involves putting the child to bed at a set bedtime and then ignoring the child until a fixed time the next morning) and preventative parent education (which focuses on developing good sleep habits by providing education on bedtime routines, consistent sleep schedules, and managing parental involvement during sleep initiation and night-time awakenings), received a Standard recommendation (signifying a high level of clinical certainty). Four treatments were recommended as Guideline treatments, which indicated a moderate level of clinical evidence. These included graduated extinction (eg, “controlled crying,” whereby parents ignore bedtime crying and tantrums for specified periods before briefly comforting the child), scheduled awakenings (where parents wake and comfort their child 15 to 30 min before the child’s typical spontaneous awakening), positive bedtime routines (where parents implement a set bedtime routine involving quiet, pleasant activities), and bedtime fading with response cost. One possible contributor for the Guideline assignment (as opposed to Standard) for bedtime fading with response cost is the paucity of studies evaluating this strategy in typically developing children. Indeed, only one case study met inclusion criteria for the AASM report [21].

Bedtime fading is frequently coupled with an intervention called response cost. Response cost involves removing the child from their bed if sleep is not initiated within a prescribed time, and then re-attempting sleep after a set period (ie, 15–30 min; [5]). This treatment component is based upon stimulus control therapy for adult insomnia [22], and has its foundation in learning theory (ie, classical and operant conditioning), with the premise being that the child associates his or her bedroom with sleep and not wakefulness. Although both bedtime fading and response cost techniques result in a later bedtime and faster sleep onset [5], response cost is not recommended as a sole treatment for night time waking. Furthermore, there is some contention that response cost may be inappropriate for typically developing children as it reinforces the child's attempts to leave the bedroom environment [19]. Therefore, the present study examines the effect of bedtime fading as a single component therapy.

The present study adds to the limited evidence base for bedtime fading (without response cost) in a sample of typically developing preschoolers. On the basis of the results found in atypically developing children and infants, we hypothesize that SOL, WASO, and bedtime tantrums will decrease from pretreatment to post-treatment and, further, that treatment outcomes will be maintained at a two-year follow-up. Based on the AASM practice parameters report [23], possible predictors of treatment outcome, including maternal education, maternal affect [7], [24], [25], [26], [27], [28], [29], and family functioning [26], will be examined to discover for whom the treatment was most efficacious. Mothers’ perception of the usefulness of bedtime fading and satisfaction with the treatment will be measured post-treatment to evaluate treatment acceptability.

Section snippets

Participants

Participants comprised 21 children (M age = 3.0 years, SD = 0.8; 13 female and 8 male) who were identified as having a sleep problem, and their parents (M age = 36.1 years, SD = 4.2). Inclusion criteria included (a) difficulty falling asleep, frequent or prolonged night awakenings, or a combination of both, (b) aged between 18 months and 4 years, (c) no known or suspected medical reason for their sleep problem, (d) not taking medications known to affect sleep, and (e) identified as typically

Primary outcome measures

Descriptive statistics for sleep and bedtime tantrums at pretreatment, treatment, post-treatment and two year follow-up are given in Table 2.

Sleep onset latency

One-way ANOVA results revealed a significant main effect of time on SOL, F (3, 18) = 5.49, p < 0.011, Cohen's d = 0.99. SOL decreased significantly from pretreatment to treatment, t (20) = 3.87, p = 0.001, Cohen's d = 0.91, but not between treatment and post-treatment, t (20) = 0.85, p = 0.40, Cohen's d = 0.11, or between post-treatment and two year

The effect of bedtime fading on sleep and bedtime tantrums

The current study evaluated the effectiveness of bedtime fading to improve SOL, WASO, and bedtime tantrums in typically developing preschoolers. Consistent with the results of previous studies among atypically developing children and typically developing infants, the present study showed that bedtime fading led to rapid and significant decreases in SOL, WASO, and bedtime tantrums [12], [14], [15], [21], [42], [44]. The present study also extended on these findings by including a larger sample

Conclusions

The present study adds to the limited literature examining the efficacy of bedtime fading to help the sleep problems and bedtime tantrums of preschool-aged children. Bedtime fading was helpful as a single component treatment to reduce SOL, WASO, and bedtime tantrums, thus supporting the efficacy of bedtime fading without concurrent response cost. Given the relative stability of sleep problems across this developmental stage, providing a quick treatment that is easy to implement – and

Financial support

Faculty of Social and Behavioral Sciences, Flinders University.

Acknowledgments

The authors thank Laura Jarema for her work in scoring parent sleep diaries, the wonderful parents who participated in the present study, and Alexandra Jolly for the use of her rooms to conduct the group sessions. This project was funded by the Faculty of Social and Behavioural Sciences, Flinders University.

References (46)

  • B. Zuckerman et al.

    Sleep problems in early childhood: continuities, predictive factors and behavioral correlates

    Pediatrics

    (1987)
  • J.A. Mindell et al.

    Pharmacological management of insomnia in children and adolescents: consensus statement

    Pediatrics

    (2006)
  • R. Ferber

    Solve your child's sleep problems

    (1985)
  • K.L. Armstrong et al.

    Childhood sleep problems: association with prenatal factors and maternal distress/depression

    J Paediatr Child Health

    (1998)
  • J.A. Mindell et al.

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

    Sleep

    (2006)
  • J.A. Owens et al.

    Medication use in the treatment of pediatric insomnia: results of a survey of community-based pediatricians

    Pediatrics

    (2003)
  • J.A. Owens et al.

    The use of pharmacotherapy in the treatment of pediatric insomnia in primary care: rational approaches. A consensus meeting summary

    J Clin Sleep Med

    (2005)
  • A.J. Spielman et al.

    Treatment of chronic insomnia by restriction of time in bed

    Sleep

    (1987)
  • C.C. Piazza et al.

    A faded bedtime with response cost protocol for the treatment of multiple sleep problems in children

    J Appl Behav Anal

    (1991)
  • M. Gradisar et al.

    Behavioral interventions for infant sleep problems: a randomized controlled trial

    Pediatrics

    (Jun 2016)
  • M.A. Milan et al.

    Positive routines: a rapid alternative to extinction for elimination of bedtime tantrum behaviour

    Child Behavior Therapy

    (1981)
  • C. Ortiz et al.

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

    J Early Intensive Behav Interv (JEIBI)

    (2007)
  • V.I. Rickert et al.

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

    Pediatrics

    (1988)
  • Cited by (10)

    • Sleep Problems in Autism Spectrum Disorder

      2024, Pediatric Clinics of North America
    • Insomnia in young children

      2023, Encyclopedia of Sleep and Circadian Rhythms: Volume 1-6, Second Edition
    • “My stuffed animals help me”: the importance, barriers, and strategies for adequate sleep behaviors of school-age children and parents

      2019, Sleep Health
      Citation Excerpt :

      If the child does not fall asleep within 15 minutes, bedtime is delayed another 15 minutes. Bedtime is advanced in 15-minute increments until the usual bedtime is reinstated and the child falls asleep within 15 minutes.70–72). The parents and children also agreed that enforcing rules about technology use (ie, time and place) would encourage healthy sleep.

    View all citing articles on Scopus
    View full text