Sleep Interventions for Young Children

This assignment delves into the topic of sleep interventions for young children. It examines various approaches, such as cognitive-behavioral therapy and behavioral interventions, supported by a review of relevant literature. The analysis highlights the effectiveness of different methods in addressing sleep problems in this age group and discusses practical strategies parents can employ to promote healthy sleep habits.

Running head: RESEARCH LITERACY FOR HEALTH PRACTICE
Research literacy for health practice
Name of the student:
Name of the University:
Author’s note

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Table of Contents
Introduction:....................................................................................................................................2
Search strategy:................................................................................................................................2
Literature search:.............................................................................................................................3
Critical appraisal:.............................................................................................................................8
Conclusion:....................................................................................................................................13
Reference.......................................................................................................................................15
Appendix........................................................................................................................................18

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Introduction:
Bedtime sleep problems and crying episodes is common in infants and young children.
The stress level of parents often increases due to their inability to manage sleep problems in their
children. Children are often found to remain awake either for certain durations at night or they
wake up frequently at nighttime. This symptom bedtime awakening and sleep problems come
under the category of Behavioral insomnia of childhood and research has showed 20-30%
prevalent rate of bedtime problems in infants and preschoolers. Parental presence is also a
predictor of sleep disturbance and child temperament determined future sleep difficulties
(Honaker and Meltzer 2014). Research also pointed out to the impact of breastfeeding practices
in the problem of night awakening (Mindell et al., 2012). The adverse outcome of such problem
in children includes poor daytime behavior, high BMI, decreased health related quality of life
and injuries in children. Parents of such children were found to have poor physical health and
mental peace (Honaker and Meltzer 2014). In the past year several behavioral interventions has
been suggested that can be employed by parents to reduce night awakening in children and
Rickert. and Johnson 1988 compared the efficacy of scheduled awakening and systematic
ignoring intervention on reducing night awakening and crying episodes of children. The purpose
of the report is to find other relevant articles related to the topic and appraise the research by
Rickert and Johnson 1988 to decided which interventions should be funded. It also gives
recommendation to ensure parent’s comply with the intervention easily without any resistance.
Search strategy:
The research study by Rickert and Johnson (1988) used randomized control study design
to compare the effect of scheduled awakening and systematic ignoring on reducing nocturnal

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awakening crying episode in children. The research finally concluded that scheduled awakening
is better than systematic ignoring to manage night awakening in children. However, to decided
whether the intervention of scheduled awakening should be funded or not, it is necessary to
review other research studies to analyze what has been covered in literature regarding the
effectiveness of scheduled awakening for addressing night awakening in young children. The
relevant research article relate to the topic is retrieved from the databases like CINAHL,
Cochrane library, MedLine, Google scholar and PsychINFO. The search process was filtered by
setting the date between 2008 to 2017. The inclusion criteria for taking the articles were all the
articles must be published in English language and they must cover the intervention related to
nocturnal awakening in small children. The main search terms were ‘nocturnal awakening’,
‘nocturnal awakening and crying episodes’, ‘interventions for nocturnal awakening’ and ‘impact
of scheduled awakening in addressing nocturnal awakening’. The studies, which did not
mentioned about any interventions related to the topic was not included.
Literature search:
The data collected from the literature search were tabulated by including the author name,
date, journal sources, key findings and notes. The outcome of the literature search and key
findings are as follows:
Author(s) Year Journal (Source) Findings Note
Galbiati et al. 2015 Behavioral
neurology
The study
reviewed
behavioral and
cognitive-
behavioral
Although
scheduled
awakening
intervention is a
low risk

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interventions for
management of
parasomnia. It
reviewed many
interventions and
the results for
scheduled
awakening
(Awaking the child
before the onset of
crying episode)
was that the
evidence regarding
the effectiveness
of this intervention
was very weak.
intervention,
however special
attention should be
given not to make
children sleep
deprived.
Sarah, Hayley, and
Hauck
2016 Children The research
evaluated the
reasons for
parent’s resistance
of sleep extinction
interventions
which emphasized
on ignoring child’s
cry for a certain
period. The
The study
indicated that sleep
extinction
interventions are
successful in
eliminating night
waking episodes,
however as many
parents disagree to
such interventions,

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findings of the
research showed
that parents
concern regarding
such interventions
has not been
investigated and
there is no
negative impact on
parents or children
in the long term.
other choices must
be provided to
them. In general,
behavioral sleep
interventions are
effective in
bringing
significant change
in children
Meltzer & Mindell 2014 Journal of
pediatric
psychology
All evidence
regarding
behavioral
interventions for
pediatric insomnia
was reviewed in
this study and the
study results
showed that
behavioral
treatment
improves certain
sleep related
parameters such as
sleep-onset
The study
provided support
for interventions
like scheduled
awakening,
bedtime fading and
scheduled
awakening
however there was
lack of evidence to
prove it as well
established
intervention

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latency, night
awakening
frequency and
night awakening
duration.
However,
moderated level of
evidence is present
regarding and
more work is
needed to validate
the finding
Fehr, Russ. and
Ievers-Landis
2016.
2016 Clinical Practice in
Pediatric
Psychology
This research
evaluated the
effectiveness of
including
cognitive
behavioral play
intervention with
parent behavior
management to
address sleeping
difficulty in
children. The
intervention was
found to reduce
Randomized study
is needed to
establish the
efficacy of
cognitive-
behavioral play
intervention

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anxiety and stress
in children.
Tikotzky & Sadeh 2010 Sleep medicine The research
evaluated the role
of cognitive-
behavioral therapy
in behavioral
childhood
insomnia and
results gave
support regarding
the positive effect
of the intervention
on addressing
sleep problem
The study
mentioned about
ignoring the
child’s cry and
leaving them so
that they fall sleep
and randomized
controlled studies
proved it
beneficial for
treating night
waking problem.
In addition,
scheduled
awakening was
given less favour
because parents do
not comply with
the procedure.

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Critical appraisal:
The critical appraisal of the Rickert and Johnson (1988) work has been done by the application
of RCT CASP tool and the results are as follows:
A. SCREENING QUESTION
Focussed issue in trail:
For analyzing any randomized controlled trial (RCT), it is necessary that the paper has
clear statement regarding the population studied, intervention provided , comparator analysed
and the outcome considered. Rickert. and Johnson (1988) stated the purpose of study by giving
the clear statement regarding studying the effectiveness of scheduled awakening (intervention)
and systematic ignoring (comparator) on reducing nocturnal awakening crying episode
(outcome) in toddlers and infants (population studied). This statement clearly defined the
focused issue in trial.
Randomization of patients to treatment:
As RCT studies mainly compares the effect of an intervention on treatment group and
control group, it is critical to prevent biasness in study findings by means of randomization to
treatment and allocation concealment. This means that the person involved in randomizing
patients to different group should not be aware about the next treatment allocation. This is done
by keeping a randomization code. This may be either unique code or explicit codes (Dettori
2010). Rickert and Johnson (1988) selected 33 children between 6 months to 54 months and the
children were randomly assigned to the different condition. Different groups included control
groups, systematic ignoring group and scheduled awakening group. Hence, it is seen that explicit

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randomized coding approach has been used to minimize bias and confounding factors in the
study.
Consideration of all patients till conclusion:
A common limitation seen in RCT studies is that researchers fail to follow up with the
participants after the implementation of intervention. This affects the strength and validity of the
trial. Attrition effects occur because failure to follow up results in missing important data at one
point or another. This form of attrition effect is seen in RCT study comparing nocturnal
awakening and scheduled awakening (Dumville et al. 2006). This was seen because earlier 50
children were included in the study, but 17 children dropped out in between the study. However,
the researcher focused on reducing the attrition effects by instructing all parents not to parents
not to implement any treatment if their child was ill. This also reflects that follow up was kept
regarding illness in any child in between the research. The attrition effect was further minimized
by extending the treatment for those child who fell sick between the study. Therefore, total
treatment days in the study was 5 days and it was modified for those who child who fell ill
(Rickert and Johnson 1988).
Detailed Question
Blinding to treatment:
Blinding is another approach to minimize biasness and increase the vigour of study. This
is done by process to ensure that no one, neither the participants not the research analyst is aware
of the allocation of groups treatment. Based on the number of individuals from whom allocation
is concealed, it is classified into single blind and double blinding. The more number of persons
are blinded, the better is the assessment of study results (Karanicolas et al., 2010). While

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analyzing Rickert and Johnson (1988), it has been found that single blinding was done to
enhance the research analysis process. For example, all participants were randomized to three
treatment conditions and participants got to know about their assigned group only after the data
related to the daily schedule of awakening was collected from each participants. The
randomization to treatment group was also done by predetermining the group for each family
before the home visit. The process of blinding is also understood from another research articles
which aimed to determine the long benefits or harms of infant behavioral sleep programs on
child, child and parent; and maternal outcomes. In that study, single blinding was seen however
here the allocation was concealed from the researchers and not the parents unlike the above study
(Price et al., 2012).
Similarity of the group at the start of the trial
Similarity of the group at the start of the trial is determined by researcher’s consideration
to maintain the same baseline data for the participants. Having similar baseline variables for all
participants is also important this also has an impact of study results. Baseline variable is related
to age, education, social class or disease severity in participants. Adjustment in baseline variables
provides protection against chance bias (Higgins et al. 2011). The equality in baseline variable
was maintained by Rickert and Johnson (1988) by recruiting children between 5 to 54 months
only. However, similarity in family type was not seen as single parent families and two parents
both were taken for the trial. Different in terms of demographic variables was also seen because
subjects came from small towns and cities too. This may also give a prediction regarding the
impact of sociocultural variable on child crying and nocturnal awakening problem. In another
research study, the main focus was on including participants based on Diagnostic and Statistical

11RESEARCH LITERACY FOR HEALTH PRACTICE
Manual of Mental Disorders as it aimed to evaluate strategies for improving sleep problems in
children with ADHD. This helped to balance baseline data for the study (Hiscock et al., 2015).
Equal treatment of groups
Equal treatment of participants groups is determined by researcher’s consideration
regarding the factors that will influence the performance of one group from another. In the study
by Rickert and Johnson (1988), three groups of participants were present and equality in
treatment was done by maintaining separate data for those children for became ill. As illness in
any child would have impact of crying episodes and nocturnal awakening, this data was deleted
and length of treatment was extended for such group. This ensures that no biased data is
collected and it enhanced the validity of the research work.
RESULTS
Treatment effect
Treatment effect is related to the key outcomes measured and the comparison in mean
outcomes between treatment group and control group. Rickert and Johnson (1988) analyzed the
difference in all group by conducting one way analysis of variance for all groups on the basis of
baseline data such age and frequency of crying and awakening episodes. The benefits of this
approach was that it helped to conclude that mean number of night awakening and crying
episodes was the same for all groups before the interventions. Post the intervention, the main
outcome variable that was measured included number of spontaneous awakening and crying
episodes. Among all groups, children in systematic ignoring group was found to have lesser
number of awakening in the past 8 weeks. However, difference in awakening for systematic
ignoring group was found only in week 3. Finally, in term of treatment effect, it was find that

12RESEARCH LITERACY FOR HEALTH PRACTICE
main effects for group did not achieved statistical significance. An effect was found only for a
week, which was small. The research study by Hiscock et al. (2014) also analyzed the treatment
effect by evaluating different between groups at follow up and no differential effects were found
for infants who were first born or later born.
Preciseness of the treatment effect
The width of the confidence interval determines the preciseness of the treatment effects.
In the study comparing systematic ignoring and scheduled awakening, it was found that the
treatment effect was large. This is because wide variability were found in control group after
reviewing the scatterplot analysis. Another research article evaluating prevention program for
infant sleep and cry problems analysed the study results by calculations of confidence interval
(Hiscock et al. 2014).
APPLICATION OF RESULTS LOCALLY
Application of the result in the local population
The validity and reliability of any research is understood if the outcome of the results can
be easily applied in the local setting. From the analysis of study result, it was found that both
systematic ignoring and scheduled awakening yielded positive outcome for children. The study
showed that systematic ignoring gives better and faster outcomes compared to scheduled
awakening which is effective but a slow process. Although there is empirical evidence
supporting systematic ignoring for reducing night awakening in children, however this
intervention cannot be locally applied. This is because majority of parents resist the idea of
letting their child cry it out and leaving them alone. Hence, to apply this locally, parents needed
to be taught about the strategies to ignoring the child’s cry. Therefore, scheduled awakening is

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most likely to be applied in local setting when parents are unwilling to let their child cry out.
However, one work that is needed before implementing it is to identify better strategies for
effectively implementing it in community setting (Tikotzky & Sadeh 2010).
Consideration of clinically important outcomes
The main target of Rickert and Johnson (1988) to bring changes in child’s outcome of
crying and night awakening, however as such issues increases stress level and health of children,
it was necessary to consider such clinical outcomes too. However, the researcher considered only
the frequency of night awakening and not other clinical outcomes such as health of child and
parents after the intervention. This is the limitation of the study and future research work in this
area is required.
Value of research
Overall, the benefit of the research is high because the author efficiently presented the
pros and cons in each intervention. Secondly, considering the level of acceptance of each
intervention in local setting, the researcher also suggested the areas where more work is needed
so that parents as well as other groups can easily implement this intervention.
Conclusion:
The main purpose of this report was to analyze whether the intervention of scheduled
awakening or systematic ignoring should be funded or not. Based on critical appraisal of the
research articles by Rickert and Johnson (1988) and comparing it with similar peer reviewed
journals, it has been found that scheduled awakening is a beneficial intervention based on its
influence on addressing sleep problems and level of acceptability among parents. Hence, this

14RESEARCH LITERACY FOR HEALTH PRACTICE
interventions should definitely be funded and investment should be done to train clinicians
regarding effective way in which this intervention can be applied in children. The competency of
clinicians in implementing such intervention will further support parents to overcome the
problem of night awakening in their children.

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Reference
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spine-care journal, 1(03), pp.7-9.
Dumville, J.C., Torgerson, D.J. and Hewitt, C.E., 2006. Research methods: reporting attrition in
randomised controlled trials. BMJ: British Medical Journal, 332(7547), p.969.
Fehr, K.K., Russ, S.W. and Ievers-Landis, C.E., 2016. Treatment of sleep problems in young
children: A case series report of a cognitive–behavioral play intervention. Clinical Practice in
Pediatric Psychology, 4(3), p.306.
Galbiati, A., Rinaldi, F., Giora, E., Ferini-Strambi, L. and Marelli, S., 2015. Behavioural and
cognitive-behavioural treatments of parasomnias. Behavioural neurology, 2015.
Higgins, J.P., Altman, D.G., Gøtzsche, P.C., Jüni, P., Moher, D., Oxman, A.D., Savović, J.,
Schulz, K.F., Weeks, L. and Sterne, J.A., 2011. The Cochrane Collaboration’s tool for assessing
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