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aSchool of Psychology, and cDepartment of Nutrition and Dietetics, Flinders University, Adelaide, South Australia, WHATS KNOWN ON THIS SUBJECT: Recommended
Australia; bPublic Health and Health Promotion, SA Health, South Australia, Australia; dDepartment of Psychiatry, guidelines exist for the treatment of nocturnal
and fSchool of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, South Australia, Australia;
wakefulness for infants, including graduated
and eWomens and Childrens Health Network, Adelaide, South Australia, Australia
extinction and bedtime fading. Such interventions
Dr Gradisar provided co-conception and design of the study, supervision of most of the analyses have a solid evidence base for improving infant sleep,
and conducted the rest of analyses, signicant contribution to the interpretation of analyses, yet little is known about their contraindications.
and was main contributor to writing of manuscript; Dr Jackson provided co-conception and
design of the study, collected most of the data (pretreatment to 3 months), conducted most of the WHAT THIS STUDY ADDS: Sustained improvements in
analyses, provided signicant input to the literature reviewed, was a minor contributor to writing sleep latency were found for both treatment groups,
of the manuscript, and provided critical evaluation of manuscript drafts; Dr Spurrier provided but not controls, yet no signicant differences
co-conception and design of the study, critical evaluation of manuscript drafts, and interpretation occurred in the infant salivary cortisol, parental
of ndings; Ms Gibson provided input into study design, collected most of the 12-month follow-up stress and mood, and attachment proles between
data, and provided interpretation of ndings and critical evaluation of manuscript drafts; all groups.
Dr Whitham provided input into the study design, conducted data scoring and analyses of 12-month
To cite: Gradisar M, Jackson K, Spurrier NJ, et al. Behavioral Interventions
for Infant Sleep Problems: A Randomized Controlled Trial. Pediatrics.
2016;137(6):e20151486
RESULTS
Figure 1 presents the flow of
participants through each stage of
the study.
Infant Sleep
Figure 2 presents descriptive
statistics for infants sleep over the
3-month treatment and follow-up
period. Linear mixed model
regression analyses of sleep diaries
showed significant interactions for
sleep latency, P < .05, wake after
sleep onset, P < .0001, number of
awakenings, P = .01, and total night
sleep time, P < .01. From pretreatment
to the 3-month follow-up, sleep
latency showed large declines
for infants in both the graduated
extinction (12.7 minutes; d = 0.87)
and bedtime fading (10 minutes;
d = 1.04) groups, but no change for
the control group (+2.0 minutes; d =
0.11). There was a very large decline
FIGURE 1
Participant ow through the randomized controlled trial. in the number of awakenings for
infants in the graduated extinction
group (d = 1.98), yet no changes for
to gold standard criteria. Recordings demonstrate changes within each
infants in both the bedtime fading (d
of each child-parent dyad were coded intervention. A time-of-day effect
= 0.10) and control (d = 0.13) groups.
as either secure, insecure (avoidant), was found between morning
Large improvements in wake after
insecure (resistant), and insecure and afternoon cortisol values
sleep onset were found for infants in
(disorganized). (pretreatment, P < .01), thus morning
the control (31.7 minutes; d = 0.93)
and afternoon cortisol values are and bedtime fading (24.6 minutes;
Analysis analyzed separately. Fishers exact d = 0.99) groups, with a very large
Linear mixed-model regressions test was used to assess differences in improvement found for the graduated
were used to test for significant attachment styles between groups. extinction group (44.4 minutes;
interactions on primary (sleep diary) A series of 1-way analyses of variance d = 2.02). Finally, total sleep time
and secondary (infant cortisol; assessed between-group differences showed a moderate increase in the
maternal stress/mood) outcome on the Child Behavior Checklist. graduated extinction condition (+0.32
variables. Within-group Cohens No effect sizes were available for hour), little change in the bedtime
d effect sizes were calculated to using bedtime fading on typically fading condition (+0.09 hour), and
a moderate increase in the control Afternoon cortisol showed a large and a large reduction in mothers
condition (+0.36 hour). Actigraphy decline in the graduated extinction stress in the bedtime fading group
showed no significant interactions for group (d = 0.89), a moderate decline (d = 0.86). Analysis of maternal
wake after sleep onset, P > .05, and in the bedtime fading group (d = mood demonstrated no significant
total sleep time, P > .05. 0.61) and a small decline in the interaction, P > .05. Mothers mood
control group (d = 0.39). improved from pretreatment to the
Infant and Parental Stress 12-month follow-up in all conditions,
Morning and afternoon infant cortisol A significant interaction was found with small effects found for those in
values for each group over time are for maternal stress, P < .01 (Fig 3). the graduated extinction (d = 0.34)
presented in Fig 3. No significant There were moderate improvements and control (d = 0.39) conditions,
interactions occurred for morning in all groups from pretreatment to yet a large effect for mothers in the
cortisol, P > .05, yet there was for 12-month follow-up (graduated bedtime fading group (d = 0.83).
afternoon cortisol values, P < .01. extinction: d = 0.51; bedtime fading:
From pretreatment to the 12-month d = 0.62; control: d = 0.64). However, Twelve-Month Follow-up: Child
follow-up, morning cortisol showed over the initial month of treatment, Attachment and Emotional-
Behavioral Problems
a small decline in the graduated mothers stress in the control group
extinction group (d = 0.23), a remained somewhat unchanged (d = Table 3 presents the percentage
moderate drop in the bedtime fading 0.16), whereas there was a moderate of parent-child attachment
group (d = 0.62), yet no change stress reduction for mothers in the classifications in each group. No
for the control group (d = 0.17). graduated extinction group (d = 0.67) significant differences were found
between secure and insecure fading produced large decreases in a central research question in the
attachment styles between groups, sleep latency compared with the current study was: Do extinction-
P > .05. There were no significant control group. The control groups based techniques produce
differences between groups for any sleep did show improvements in psychophysiological stress that leads
emotional or behavioral problems on nocturnal wakefulness and total to later problematic emotions and
the Child Behavior Checklist (all P > sleep, suggesting developmental behavior, and thus insecure parent-
.05; Table 3). maturity and/or improvements from child attachment?
sleep education.35 No significant
sleep changes were found by using Child-Parent Stress, Emotions,
DISCUSSION objective actigraphy, suggesting Behaviors, and Attachment
Compared with controls, graduated sleep diaries and actigraphy measure Relatively minor stressors (eg, brief
extinction produced large decreases different phenomena (eg, infants parental separation) elevate cortisol
in nocturnal wakefulness (time taken absence of crying by parents vs levels in newborn infants38; however,
to fall asleep, number of awakenings, infants movements, respectively), the cortisol stress response diminishes
minutes awake after sleep onset), further suggesting infants may from 4 months of age.30,38,39
yet a novel aspect of this trial was still experience wakefulness but This may explain the lack of
evaluating bedtime fading, about do not signal to parents.36 We significant cortisol elevation in the
which there has been relatively little do not interpret these data as graduated extinction condition in
research,22 especially in typically the infant giving up,25,37 but the current study, especially as our
developing infants.33,34 Bedtime instead self-soothing.36 However, sample was older than 4 months of
(n = 1).
age (range 616 months; mean 10.8 behaviors comparable across groups. those of Price et al.41 are the only
months). We cannot conclude no This lack of findings concur with a studies that now form a preliminary
cortisol response occurred, as we did recent 6-year follow-up assessment evidence base that suggests brief
not collect real-time cortisol data (ie, of a large randomized controlled trial, behavioral sleep treatments may help
plasma) during nocturnal treatment where no differences in problematic young children sleep, yet do not lead
implementation. Our diurnal cortisol behaviors and mental health were to later emotional and behavioral
data indicate the active treatments found between children who received problems, or later parent-child
did not result in chronically elevated behavioral sleep interventions and insecure attachment.25
levels over time (ie, values were those in the control group.41
within normative limits),40 which is Limitations and Future Research
necessary for hypothalamic-pituitary- The final argument against using Directions
adrenocortical dysregulation.38 extinction-based methods for infant
sleep problems is the potential for Although the generalizability of
This is a crucial point when insecure child-parent attachment.25 our findings to the population is
considering the chain of arguments No significant differences were reduced with a small sample size,
forming the hypothesis that found in attachment styles between they nevertheless support those of a
graduated extinction may lead to groups, which suggests a lack of larger follow-up study of behavioral
problematic emotions and behaviors evidence between infants sleep and sleep interventions for infants (n =
in later child development.25 This attachment.5 For parental stress, 326).41 Although stress was measured
hypothesis requires a significant and mothers in both intervention groups at different time points across
chronic cortisol elevation resulting reported less stress than mothers interventions, we did not measure
from graduated extinction, yet is in the control group. The lack of acute stress during interventions.
further disconfirmed by examining support for dysfunctional child- Changes in attachment across the
our long-term emotional and parent relationships (ie, disinhibited study would also have been interesting,
behavioral findings. No significant attachment, child-parent closeness yet we note that 12 months of age is
difference in childrens emotions and and conflict, global relationship) after the prime age for the strange situation
behaviors could be found between behavioral sleep interventions has also procedure.32 The current study
groups 12 months after intervention, been found in a recent 6-year follow-up contrasted only 2 behavioral sleep
with internalizing and externalizing study.41 Altogether, our findings and interventions. Future trials are needed
follow-up data and the minority of analyses under supervision, provided some input to the literature reviewed and was a minor contributor to writing of
manuscript, and provided critical evaluation of manuscript drafts; Dr Sved Williams provided assistance with design of the study, interpretation of ndings, and
critical evaluation of manuscript drafts; Dr Powell-Davies provided input into the study design, scored the infant-parent attachment, and provided interpretation
of ndings and critical evaluation of manuscript drafts; Dr Kennaway provided input into study design, expert input into salivary cortisol data collection, scoring
of salivary cortisol, interpretation of ndings, and critical evaluation of manuscript drafts; and all authors approved the nal manuscript as submitted.
This trial has been registered at the Australian New Zealand Clinical Trials Registry (identier ACTRN12612000813886)
DOI: 10.1542/peds.2015-1486
Accepted for publication Mar 21, 2016
Address correspondence to Michael Gradisar, PhD, c/o Flinders University, School of Psychology, GPO Box 2100, Adelaide, SA, 5001, Australia. E-mail: grad0011@
inders.edu.au
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright 2016 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no nancial relationships relevant to this article to disclose.
FUNDING: Supported by Australian Rotary Health Fund, Channel 7 Childrens Research Fund, Faculty of Social and Behavioral Sciences.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conicts of interest to disclose.
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