J. ChiU PtycM. Psychiat. Vol. 30, No. 6. pp. 913-918, 1989 0021-9630/89 3.00 + 0.

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Primed in Great Britain. Pergamon Press pic
1989 Association for Child Psychology and Psychiatry

Reducing Sleep Disruptions in

Young Children: Evaluation of
Therapist-guided and Written Information
Approaches: A Brief Report
Frederick W. Seymour,* Phyllis Brock,t Mary During,^ and
Gary Poole*
AbstractRegular night waking of young children is one of the most common problems
encountered by parents. This study compared a standardized night waking programme
that involved organized bedtime routines, procedures for settling the child and for the
handling of crying, calling out and getting out of bed, with a group which received written
information only and a waiting list control group. The children receiving the standard
programme and those receiving written information only showed significant improvement
over children in the waiting list group. This result supports the use of written parent
instructions with or without therapist support

Keywords: Young children, night waking, bedtime settling, parent manuals

Introduction

Probably the most common problem parents have with young children is the
management of bedtime and night waking. It has been estimated from surveys that
between a quarter and a third of all 1-2 yr olds wake on most nights (Bernal, 1973;
Fergusson, Shannon & Harwood, 1981; Jenkins, Bax & Hart, 1980; Moore & Ucko,
1957; Richman, 1981; Werry & Carlielle, 1981). Typically, children who wake at
night are also difficult to get to bed and to settle (Jenkins et al., 1980; Ragins &
Schachter, 1971; Richman, 1981; Roberts & Schoellkopf, 1951). Until recently, the
most common response to parents seeking help was the prescription of sedatives and/or
advice that the child would soon outgrow the problem (Werry & Carlielle, 1981).
However, survey results show that sleep problems often persist (Jenkins et al., 1980;
Richman, Stevenson & Craham, 1975) and that medication is ineffective (Rapoport,
Mikkelsen & Werry, 1978; Richman, 1985).

Accepted manuscript received 28 February 1989

'University of Auckland, New Zealand.

^Auckland, New Zealand.
*Whangarei, New Zealand.
Requestsfor reprints to: Dr Frederick W. Seymour, Psychology Department, University of Auckland, Private
Bag, Auckland, New Zealand.

913
 Frederick W. Seymour et al.

Recendy, attention has turned to parent management of sleep disruptions. In a

study of 208 night waking children, Seymour, Bayfield, Brock and During (1983)
found that the families typically had no regular bedtime routine, children were difficult
to manage approaching bedtime, and had much of the control over when and how
they went to bed. Parents either remained with their child until asleep (often feeding
them) or they attended to the child repeatedly in response to calling out or crying.
Other parents allowed the child to fall asleep in the living area, transferring them
to bed when asleep. When the child awoke during the night, parents again either
stayed with their child until asleep (often repeating feedings) or took them to their bed.
Consistent with these observations, behavioural interventions have included parent
removal of attention from bedtime or night disruption (Bergman, 1976; Rapoff,
Christopherson & Rapoff; 1982), consistent bedtime routines (Milan, Mitchell, Berger
& Pierson, 1981) and systematic reward of bedtime behaviours such as setding into
bed quickly and sleeping through the night (Kellerman, 1980). Four studies have
utilized combinations of these procedures with larger groups of children Qones &
Verduyn, 1983; Richman, Douglas, Hunt, Lansdown & Levere, 1985; Seymour et
al., 1983). All report a high level of parent implementation of procedures and rapid
sustained change in sleep difficulties with the majority of families.
This study was conducted with two objectives. Firstly, to experimentally evaluate
the standardized sleep programme that had been employed by the authors over a
5-year period and, secondly, to investigate the effectiveness of a written parent guide
that could be given to parents without the intensive therapist support that had been
typical ofthe standardized approach. Parent guides have been proven effective with
a wide range of common problems other than sleep (McMahon & Forehand, 1981).

Method
Experimental design
An experimental group design was used in which 45 children were randomly allocated between three
groups. In one group, parents received the standardized sleep programme. This included an 8-page
Parent Guide plus an hour long interview to establish the programme, followed by telephone calls each
day at first and as needed thereafter. In total this took 2-3 hrs per family. This treatment procedure
has been described in detail elsewhere (Seymour et al., 1983; Seymour, 1987). In the second group,
the Parent Guide was given to parents to read and any questions were answered before parents departed!
There was no telephone contact. Total staff attention was 5-10 mins. In the third group, parents were
told that they could not be seen immediately and were given an appointment in 4 weeks time. All
treatments were administered by one ofthe authors (P.B.) The basic comparison for analysis of outcome
was between 7 days of records kept by parents pre-treatment and records taken after a 4-week post-
treatment interview.
At the post-treatment interview, parents who had not been successful in the Written Information
group and all parents in the Waiting List group were offered the standard sleep programme, again
with the same staff member. One week of records was then collected for all 45 families at 1-mnth and
3-mnth follow-ups. Thus, for ethical reasons all families were eventually offered fiill treatment and follow-
up comparisons between groups on the basis of their original group allocation could not be made.
However, those records were able to reveal maintenance of treatment.

Subjects
Subjects were 45 children and their families who attended Leslie Gentre, a community-oriented, family
counselling agency situated in Auckland. Relevant criteria for inclusion in the study were that the child
 Sleep disruptions in children y 1D

was between 9 mnths and 5 yrs of age with the primary problem being sleep, and that parents gave
approval for participation in "research". All consecutive referrals meeting these criteria were included.
Most referrals were by community-based paediatric nurses.
The 45 children were randomly allocated 15 to each ofthe three treatment groups. The mean age
ofthe children was 18 mnths, 28 (62%) were male and 42 (93%) lived within a two-parent family.
ANOVA revealed no significant difference for age across groups [F(2,42) = 0.03, /)> 0.05]. There was
no difference in the distribution of males versus females [x (2) = 1.3, /> > 0.05] or two-parent versus
single parent families [x^ (2) = 0.0, /> > 0.05].

Measures
Two methods of data collection were used: mothers' report via an Assessment Schedule for Sleep
Problems administered in a standardized interview, and Sleep Diaries maintained by mothers. The
Sleep Diary required mothers to record the time that their child was put to bed, the time until they
settled, times they awoke during the night and time to resettle, and the time they finally awoke next
morning. These records were collected at the end of each week and analysed to reveal average time
children were put to bed, average time at which they were settled, number of night wakings per week
and average time awake at night.
The Assessment Schedule contained questions about child sleep-related behaviours and about parent
behaviours in response to sleep disruptions. The interviewer marked the Assessment Schedule according
to categories of child behaviour and parent response listed in the schedule.
Reliability of the Sleep Diaries was assessed by comparison with mother report on the Assessment
Schedule for Sleep Problems for the same week. Pearson product-moment correlations were significant
for both of the variables assessedaverage time to bed (r = 0.87,/)<0.05) and number of night wakings
(r = 0.92,/I < 0.01).

Results
Time awake nights
Analysis of covariance in which the pre-treatment scores served as the covariate
revealed significant differences [F(2,41) = 10.79, /)< O.OOl]. Follow-up Tukey's
Studentized Range Tests revealed significant difference {p < 0.05) in time awake nights
between the Sleep Programme group and the Waiting List groups. No other significant
differences emerged.
The pre-treatment and post-treatment group means are shown in Table 1. Total
time awake nights showed an average decrease of 23 mins per night for the Sleep
Programme group and 12 mins per night for the Written Information group but an
increase of 12 mins for the Waiting List group
The results reported in Table 1 reveal a very large variance within groups as well
as between groups. This variance is the outcome of a few very serious cases, the extreme
of which was a child in the Sleep Programme group who was awake on average 3
hrs per night. Improvement in the Sleep Programme group was rapid, with the average
decrease of 23 mins awake per night being achieved within the first week. Improvement
in the Written Information group was gradual across the 4 weeks to the post-treatment
period.

Number of night wakings

The average number of wakings per week decreased by 8.7 for the Sleep Programme
group and by 7.4 for the Written Information group, and also decreased slightly by
916 Frederick W. Seymour et al.

Table 1. Pre-treatment and post-treatment means for each experimental group

Sleep Written Waiting
Programme Information List
Minutes awake each night
Pre-treatment means 38.7 21.4 29.7
(43.9) (14.5) (20.6)
Post-treatment means 15.2 8.9 41.5
(15.2) (9.5) (32.9)
No. of wakings per week
Pre-treatment means 15.6 12.3 12.8
(8.8) (8.3) (7.8)
Post-treatment means 6.9 4.9 11.7
(7.1) (4.8) (6.7)
Bedtime setthng time
Pre-treatment means 7.52pm 7.51 pm 7.47pm
(40.8 mins) (46.8 mins) (43.2 mins)
Post-treatment means 7.24 7.23 7.50
(28.4) (48.2) (28.7)
Standard deviations are shown in brackets.

1.1 times in the Waiting List group. ANCOVA in which pre-treatment scores served
as the covariate revealed significant differences [i^(2,41) = 9.37,/?<0.00l]. Follow-
up Tukey's tests showed significant differences between the Sleep Programme group
and the Waiting List group (p < 0.05) and between the Written Information group
and the Waiting List group (p < 0.05). No significant difference was found between
the Sleep Progrzimme group and Written Information group.

Bedtime settling to sleep

The average time children settled to sleep pre-treatment averaged around 7.50pm
in all three groups. At post-treatment setding time had fallen by 28 mins in both
the Sleep Programme and Written Information groups, but had become later by 3
mins in the Waiting List group. ANCOVA in which pre-treatment scores served
as the covariate revealed significant differences [i^(2,41) = 5.97, p < O.Ol]. Follow-up
Tukey's tests showed significant differences between the Sleep Programme group and
Waiting List group (p < 0.05) and between the Written Information group and the
Waiting List group (p<0.05). There was no significant difference between the Sleep
Programme group and Written Information group.

Maintenance of treatment effects

Peirents in both the Written Information group and Waiting List group were offered
the standard sleep programme following the post-assessment. The measures taken
at 1 mnth and 3 mnths after the post-treatment assessment revealed that the original
Written Information group maintained changes and that intervention with the original
Waiting List group was a successful replication ofthe sleep programme. Maintenance
 Sleep disruptions in children 917

of treatment effects appeared strongly for the Sleep Programme group. At the 1-mnth
follow up assessment, time awake nights was 28 mins less than pre-treatment and
at the 3-mnth follow-up it was 32 mins less. The average number of times children
woke at nights during the week was 10.0 fewer at the 1-mnth follow-up and 11.2
fewer at 3 mnths. Settling to sleep time was on average 37 mins earlier than pre-
treatment times at 1-mnth follow-up. At 3-mnths follow-up settling time was only
17 mins earlier which may be accounted for in maturation, for as children grow older
they normjilly go to bed later.

Discussion
This study shows that a behaviour management programme administered by parents
can have a strong impact on their child's night waking. Most parents will implement
the procedures and children will wake during the night less frequently, and when
they do wake, they will settle more quickly and with less need of parent attention.
Furthermore these improvements will be maintained over a 3-mnth period.
Comparisons between groups showed the Sleep Programme group to have significant
improvement over the Waiting List control on all three variables. The Written
Information group showed significant improvement over the Waiting List group on
the variables of number of night wakings and bedtime settling to sleep.
The written information given to parents was identical in both the Sleep Programme
and Written Information groups, thus affording a test ofthe impact ofa therapist's
presence. Records for the first 2 weeks of programme implementation revealed that
parents in the Sleep Programme group achieved rapid improvement in their children's
sleep behaviours compared to more gradued improvement by parents in the Written
Information group. Thus the effect of a therapist may be to produce a more immediate
commitment to programme implementation than can be achieved by parents reading
material only. However, at 4 weeks the two groups could not be distinguished from
one another by the statistical ansdyses ofthe three measures of child behaviour. This
result then can be regarded as justifying the provision of written parent manuals for
use without a therapist's involvement, at least where the problem of child night waking
is concerned. Thus staff at the Leslie Centre went on to produce such a manuad
(Macdonald/Leslie Centre, 1985). Richman and colleagues have followed a similar
progression from experimental analysis of a therapist directed programme (Richman
et al., 1985) to parent manual (Douglas & Richman, 1984).

AcknowledgementsThis research was supported by funds from Presbyterian Support Services Association
and by the encouragement and co-operation of other staff at Leslie Centre. We are grateful to John
Gribben for his assistance with the statistical analyses.

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