Review of Sleep Interventions for Children

This assignment tasks you with critically analyzing a collection of research papers on sleep interventions for young children. The focus is on evaluating the effectiveness of these interventions, particularly behavioral approaches like extinction, and understanding the challenges parents may face when implementing them. You'll need to synthesize information from multiple sources to provide a comprehensive overview of this topic.

Running head: CRITICAL ANALYSIS USING CASP TOOL
CRITICAL ANALYSIS USING CASP TOOL
Name of the Student
Name of the University
Author note

1CRITICAL ANALYSIS USING CASP TOOL
Table of Contents
Introduction..........................................................................................................................2
Search strategy.....................................................................................................................3
Literature review..................................................................................................................4
Critical appraisal (using CASP tool)...................................................................................7
Section A (determination of validity of the result)..........................................................7
Section B (about the results)..........................................................................................10
Section C (local application of the result).....................................................................11
Conclusion.........................................................................................................................12
References for literature review.........................................................................................14
References..........................................................................................................................15

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Introduction
Nocturnal awakening and frequent crying is one of the major problems parents had to
suffer while taking care of their children. The episodes of bedtime problems and sleepless nights
affects nearly 20 to 30 % of infants and toddlers worldwide. Initially parents are unaware of
these problems of their children however, when the problems persists, they become intolerant
and distraught (Honaker and Meltzer 2014). This severe problem of infants often persists until
they grow up. The deleterious effect of nocturnal crying and night awakening in children are
mood swings, attention discrepancy, poor mental and social development and aggression. The
problems affects the mental growth of child and the quality of life is compromised (Hysing et al.
2014).
Due to these problems, there is a need for finding strategies or interventions of these
children issues. In a research of Rickert and Johnson (1988), they found an intervention of
nocturnal crying and night awakening. The intervention was scheduled awakening that was used
as an effective strategy to reduce and slow but sure elimination of crying and awakening
episodes in infants and toddlers. The research mainly evaluated the effectiveness of scheduled
awakening by comparing it with systematic ignoring procedure. The scheduled awakening
procedure is an intervention of waking up and consoling a kid at least 15 to 30 minutes before
nocturnal crying and awakening to assist them in sleep consolidation. Another group, having no-
treatment was included to analyze the maturation in sleep pattern.
This report critically analyzes the research done by Rickert and Johnson (1988), and
compares it with four recent literature on the same issue to evaluate whether such intervention

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are useful in treating children issues or not. Therefore, the decision of funding depends on the
critical analysis by the means of a relevant CASP tool.
Search strategy
There is a need to review recent research literatures, which are related to nocturnal crying
and night awakening to analyze the effectiveness of scheduled awakening. It is important to find
out whether same strategies or some other interventions have been used to address this problem.
The strategies to search other research articles related to this topic are:
 The main strategy to find research articles related to this topic was to include
those articles that has been published between 2012 and 2017.
 Second criteria was to include articles which are peer reviewed journal articles
written in English and must cover the strategies to manage nocturnal awakening
in kids.
 Databases used to search relevant and recent research articles were Cochrane,
PubMed, CINAHL and Google Scholar.
 Key terms used to search articles were ‘ interventions for nocturnal awakening
and crying’, ‘interventions for nocturnal awakening in children’, ‘crying episodes
in infants’, ‘strategies for night awakening and nocturnal crying in infants and
toddlers’.
These inclusion and exclusion criteria and key search terms helped to search recent
review articles and evaluate different current interventions to treat these issues in children.

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Literature review
The following table contains the literature review of five research articles on the topic
nocturnal crying and night awakening in infants.
Author year journal Intervention Key findings notes
Rickert and
Johnson
1988 American
academy of
pediatrics
(AAP)
Scheduled
awakening
and
systematic
ignorance
This
technique can
be used by
parents to
reduce the
night
awakening
issues of their
children
This
technique is
one of the
prime
intervention
that can be
used to treat
children with
sleep
disorders
Werner et al. 2015 Journal of
clinical sleep
medicine
(JCSM)
Zurich 3
concept was
used to
manage the
disorder. the
combination
of sleep
regulation,
Using this
technique,
night
awakening in
children
reduced and
sleep time
This
technique
can be used
as an
intervention
to treat
children with
night

5CRITICAL ANALYSIS USING CASP TOOL
regular
rhythm and
adjusted bed
time were
used as
behavioral
strategy
increased awakening
Meltzer and
Mindell
2014 Journal of
pediatric
psychology
Behavioral
strategies
such as
parental
education,
bedtime
fading,
graduated
extinction
was assessed
to regulate
their effect
in sleep
association
This
technique
resulted in
onset of sleep
tendency and
decrease in
awakening
frequency
The
intervention
lacked
studies on
factors
needed to
successfully
complete the
treatment
Gradiser et al. 2016 American
academy of
Graduated
extinction
Sleep latency
was decreased
These two
technique

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pediatrics
(AAP)
and bedtime
fading as
intervention
in graduated
extinction and
bedtime
fading group
whereas,
number of
awakening
decreased in
gradual
extinction
group
can also be
used to treat
children with
such disorder
Price et al. 2012 American
academy of
pediatrics
(AAP)
Behavioral
sleep
technique
This
technique has
no long term
effects and
parents can
use these
techniques
fearlessly to
reduce the
night
awakening
issues of their
Behavioral
sleep
technique
can be used
as an
intervention
to deal with
the problem.

7CRITICAL ANALYSIS USING CASP TOOL
children
Critical appraisal (using CASP tool)
The research study demonstrated by Rickert and Johnson (1988) was based on
Randomized Control Trial (RCT). Therefore, to critically appraise the research article, the CASP
tool for RCT has been used. This CASP tool for RCT is comprised of 11 questions divided into
three sections (Munn et al. 2014). The CASP for RCT has been demonstrated below:
Section A (determination of validity of the result)
1. Focus of the trial
According to the research article by (), a clear indication of the research topic can be
identified. They have clearly mentioned the focused issue and the main purpose of the research.
The prime aim of the research was to evaluate the effectiveness of the systematic ignoring and
scheduled awakening techniques as interventions to decrease the night awakening and nocturnal
crying episodes in infants and toddlers, used as the population of the study. The comparator
group in this study was group of children with no treatment/intervention. The considered
outcome was to evaluate the effects of used interventions.
2. Treatment was randomized or not
As per the norms of RCT studies, the trial group as well as the control group has to be
allocated randomly. Once this process is correct and completed, the biasness in the system
reduced drastically. Hence, the prime critical aspect of conducting RCT is developing random
categorization and screening of participants prior the commencement of the treatment (Ivers et

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al. 2012). In the examined research article, the participants of RCT included 33 children, having
an average age of 20 months. All these participants were recruited via local newspaper
advertisements. Even the assignment of children to one of the groups between treatment group
and Control group was done randomly and after that home visit was conducted. therefore, the
allocation of the children was screened by researchers as parents of those participating children
was unaware of the group they were in. they were informed after the 9 weeks of trial and once
the data was collected. The data was comprised of the daily schedule of the child such as feeding
time, sleep duration, night awakening and crying duration and so on.
3. Treatment of patients who entered the trial
The researchers, to evaluate the fact that whether all the members who entered the trial
were appropriately accounted for its assumption, carried out proper follow up of participants.
The researchers also analyzed the outcomes in children assigned to a specific group. However,
during the study differences in treatment has been found. At first, the children were assigned to
any one of the groups between trail and control. Furthermore, few children from each group
opted out from the trial. Hence, total 33 children were left out of 56. Finally, all the parents were
asked to report one week prior to treatment/trial, to ensure proper analysis of both the groups.
This process helped the researchers to maintain a baseline data of the study. Maintenance of
baseline data in such research is important as it helps to interpret the data effectively (Deke and
Puma 2013).
4. Patients, health and study personnel were blind to treatment
To conduct a successful RCT, blinding procedure is important. This process prevents the
participants and healthcare workers involved from understanding the kind of intervention they

9CRITICAL ANALYSIS USING CASP TOOL
were given. However, practically such process is impossible in clinical trials as to determine the
success of such research, complete engagement of the participant is important. According to the
examined study of Rickert and Johnson (1988), the trail group and the control group was
finalized randomly, that indicates to the fact that the treatment and intervention was obscured
from them. However, it is difficult to state that they were blind to the intervention as well. The
groups were informed about all the research scenario, once the data was collected. Therefore,
open labeling has been identified instead of blinding in this study, leading to biasness. In a RCT
conducted by Douglas and Hill (2013) to screen the effectiveness of behavioral sleep in kids,
selection of participants was based on the problems reported by their parents. While the
difference from the examine study was, researchers in case were blind to the group allocation,
instead of parents.
5. Groups were similar at the commencement of trial or not
Evaluation of the RCT study is done by assessing the similarity of trial groups. Similarity
is denoted by baseline factors such as sex, age, socio-economic status, health status and
educational status. Maintaining these baseline factors are critical as it influences study outcomes,
determines validity of the study and effects the intervention as well (Savović et al. 2014). Rickert
and Johnson (1988) maintained the similarity in their research as they took children in age group
of 6 to 54 months. However, there was biasness in the study, as social factor was not maintained.
There were children having single parents as well as double parent. Educational baseline was
also not maintained in the study.
6. The group was treated equally or not

10CRITICAL ANALYSIS USING CASP TOOL
Apart from equal appliance of trial intervention, other factors that can affect the results of
trial or performance of the participant need to treated equally. Rickert and Johnson (1988) also
treated their participants equally by using exclusion criteria to finalize the participants. The
researches eliminated all the other factors that can affect the prime interventions of the study;
systematic ignorance and scheduled awakening. Therefore, they excluded those parents who
were not concerned about one of this problems their child was facing. The children who were
resistant to sleep were excluded as well. Researchers also taken into account the number of
nights and time duration of night awakening of all the participants to provide equal treatment to
all of them (Almirall et al. 2012).
Section B (about the results)
7. Effect of the treatment
The effectiveness of the treatment was determined by comparing the outcomes in trail
group and control group. The prime aim was to determine the decreased amount of night
awakening and nocturnal crying in these groups. After comparison, it was found that participants
of systematic ignoring group showed positive outcomes in 8 weeks, which was the fastest among
all. Scheduled awakening was also found to be effective however; the Rate of improvement was
slow in this case. Hence, the period at which prime differences were noticed was observed in
week 3, 4, 5, 6 and 7. The pyramid of successful intervention can be stated as: systematic
ignoring scheduled awakening and at last the no treatment group. In a similar research done by
Halal and Nunes (2014) it was found that systematical ignorance to the demand of children to a
specific period could effectively improve their sleep pattern.
8. Estimation of the treatment effect

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Interval of confidence and size of effect determines the accuracy of the trial effect in
RCT. narrow confidence interval denotes accurate results as well as the wider confidence
interval denotes uncertain trial results. During the evaluation of the research of Rickert and
Johnson (), it can be said that wide confidence was present in the study because variability in
control group development trends were noticed. The group with no treatment also showed
improvement and that is a subject for research as well. In spite of such limitations, the research
was successful to introduce the intervention used to treat nocturnal crying and awakening in
children. In a study by Gregory and Sedah (2012), it was proved that systematic ignorance and
scheduled awakening was able to improve the condition of children.
Section C (local application of the result)
9. Application of the result
The valid and effective evidence of application of the intervention, used in the research
on local population successfully, can understand success of any research. The transferability and
efficacy of the research is high if it can be applied to a large population without any difficulty. In
this research article, systematic ignoring emerges, as the best intervention to treat the issues,
however, the chances of its application in local population is less. According to studies, several
parents are unable to ignore their children crying, which is a treatment process to reduce night
awakening. Many parents may not prefer ignoring their child’s cry as an appropriate treatment to
reduce night awakening period. There is evidence also which have showed that parents strongly
resist employing the systematic ignoring approach for their child (Etherton, Blunden and Hauck
2016). Therefore, it can be stated that scheduled awakening can be used in local population, as it
is easy to apply. There is a need to conduct more research on strategies to affect the sleep of the
children positively, using systematic ignorance technique.

12CRITICAL ANALYSIS USING CASP TOOL
10. Clinical outcome consideration
In case of nocturnal crying and night awakening, the clinically significant outcome was
decreasing the duration of nocturnal awakening and frequency of awakening in children. The
research of Rickert and Johnson (1988) proved the efficacy of systematic ignoring and scheduled
awakening by clinical outcomes as well. For example, after implementation of this intervention
on kinds, dramatic improvement in frequency of awakening was noticed. Therefore, clinical
outcome of this research for children was positive. However, for parents the stress level
enhanced even after the application of intervention (Meltzer et al. 2012).
11. Values of benefit
This RCT of research worth all the time and cost investment as at last successful
interventions was discovered. This research provided huge response as parent applied these
interventions on their children and get positive results. Hence, on ground level as well the
research become successful. However, the prime limitation of this experiment was slower effects
and identifying correct intervention for each children to get positive outcomes associated with it
(Moore 2012).
Conclusion
The report discussed the prime reasons of nocturnal crying and night awakening in
children and assessed its impact on the child as well as on the health of their parents. This report
critically appraised the research article of Rickert and Johnson (1988), compared it with four
similar research articles, and conducted a literature review on these papers. Finally, it was
revealed that systematic ignorance and scheduled awakening is beneficiary for children having
such issues. Literature review also points out the fact that scheduled awakening can be used on

13CRITICAL ANALYSIS USING CASP TOOL
local population as it shows faster and positive results on ground as well. Hence, it can be
recommended that more research should be conducted to successfully apply these interventions
in society. Proper research can figure out the loopholes that affects the implementation of these
interventions on children with such disorders in society.

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References for literature review
Gradisar, M., Jackson, K., Spurrier, N.J., Gibson, J., Whitham, J., Williams, A.S., Dolby,
R. and Kennaway, D.J., 2016. Behavioral interventions for infant sleep problems: A randomized
controlled trial. Pediatrics, p.e20151486.
Meltzer, L.J. and Mindell, J.A., 2014. Systematic review and meta-analysis of behavioral
interventions for pediatric insomnia. Journal of Pediatric Psychology, 39(8), pp.932-948.
Price, A.M., Wake, M., Ukoumunne, O.C. and Hiscock, H., 2012. Five-year follow-up of
harms and benefits of behavioral infant sleep intervention: randomized trial. Pediatrics, 130(4),
pp.643-651.
Rickert, V.I. and Johnson, C.M., 1988. Reducing nocturnal awakening and crying
episodes in infants and young children: a comparison between scheduled awakenings and
systematic ignoring. Pediatrics, 81(2), pp.203-212.
Werner, H., Hunkeler, P., Benz, C., Molinari, L., Guyer, C., Häfliger, F., Huber, R. and
Jenni, O.G., 2015. The Zurich 3-step concept for the management of behavioral sleep disorders
in children: a before-and-after study. Journal of clinical sleep medicine: JCSM: official
publication of the American Academy of Sleep Medicine, 11(3), p.241.

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References
Almirall, D., Compton, S.N., Gunlicks‐Stoessel, M., Duan, N. and Murphy, S.A., 2012.
Designing a pilot sequential multiple assignment randomized trial for developing an adaptive
treatment strategy. Statistics in medicine, 31(17), pp.1887-1902.
Calvert, M., Blazeby, J., Altman, D.G., Revicki, D.A., Moher, D., Brundage, M.D. and
CONSORT PRO Group, 2013. Reporting of patient-reported outcomes in randomized trials: the
CONSORT PRO extension. Jama, 309(8), pp.814-822.
Deke, J. and Puma, M., 2013. Coping with missing data in randomized controlled trials.
Mathematica Policy Research.
Douglas, P.S. and Hill, P.S., 2013. Behavioral sleep interventions in the first six months
of life do not improve outcomes for mothers or infants: a systematic review. Journal of
Developmental & Behavioral Pediatrics, 34(7), pp.497-507.
Etherton, H., Blunden, S. and Hauck, Y., 2016. Discussion of extinction-based behavioral
sleep interventions for young children and reasons why parents may find them difficult. Journal
of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep
Medicine, 12(11), p.1535.
Gregory, A.M. and Sadeh, A., 2012. Sleep, emotional and behavioral difficulties in
children and adolescents. Sleep medicine reviews, 16(2), pp.129-136.
Halal, C.S. and Nunes, M.L., 2014. Education in children's sleep hygiene: which
approaches are effective? A systematic review. Jornal de pediatria, 90(5), pp.449-456.