Efficacy and Acceptance of Scheduled Awakening Intervention in Children

The provided content discusses the issue of nocturnal awakening and crying episodes in children and their impact on both parents and children's health. The critical appraisal of a research study by Rickert and Johnson (1988) revealed that scheduled awakening is a beneficial strategy to reduce nocturnal awakening time in children. The literature search also showed that scheduled awakening is more favorable for reducing sleep problems in children. Therefore, the intervention should be funded and its mechanism improved for easier implementation in the community.

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:.............................................................................................................................5
Conclusion:....................................................................................................................................11
Reference.......................................................................................................................................13
Appendix........................................................................................................................................15

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Introduction:
Nocturnal awakening and frequent crying episode in young children gives major
challenges to parents while caring for their children. Bed time problem and night awakening
affect about 20 to 30% of infants and toddlers. This problem initiating in infancy often persist in
school age too. This is found to have deleterious effect on children such as poor cognitive
development, mood problems, aggressive behavior and attention deficit. All this consequently
has an impact on health and quality of life of children too. In case of parents, crying episodes and
nocturnal awakening in children increases their distress level due to fatigue and lack of sleep
(Honaker and Meltzer 2014) Hence, there is a need to find strategies or intervention to manage
bedtime tantrums of children. The research by Rickert and Johnson (1988) identified the
intervention of scheduled awakening as an effective strategy to reduce and gradually eliminate
the crying episodes and night awakening in young children. The study mainly evaluated the
effectiveness of scheduled awakening by comparing it with systematic ignoring procedure. The
scheduled awakening intervention is the process of waking and consoling a child 15 to 30 minute
before nocturnal awakening to assist in sleep consolidation. The maturation in sleep pattern was
analysed by means including a no treatment group without the intervention too. This report
critically analysed the research study by comparing it with recent literature on the same issue to
assess whether such intervention should be funded or not. Hence, the decision for funding the
intervention depends on its critical appraisal by means of relevant CASP tool
Search strategy:
To analyse the effectiveness of scheduled awakening in reducing nocturnal awakening in
young children, there is a need to review recent research literatures related to the topic to find out

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whether same strategies or other interventions has been proposed for addressing the research
problem. The main strategy for searching the research article is to include only those articles
which have been published between 2007 and 2017. The other inclusion criteria for articles
includes they must be peer reviewed journal articles written in English and they must cover the
strategies to manage nocturnal awakening in young children. The relevant research articles were
retrieved from the databases like CINAHL, PubMed, Cochrane library and the search engine
called Google Scholar. The key search term used in searching the articles included ‘nocturnal
awakening and crying episodes in young children, ‘intervention for nocturnal awakening in
infants’ and strategies to address nocturnal awakening issues in children’. The inclusion criteria
and specific search term can help to review current studies and evaluate current interventions
proposed for the same issue.
Literature search:
The key findings from the review of literature are as follows:
Author and date Intervention Key findings
Honaker and Meltzer (2014). It analysed the effect of behavioral
interventions on bedtime problem and night
awakening
Almost 94% studies
reported efficacious
outcome and clinical
improvement in
young children by
using behavioral
therapy. Support was
given to interventions
like scheduled

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awakening and
positive routine
Meltzer and Mindell, 2014 Behavioral interventions like graduated
extinction, parent education, bedtime fading,
scheduled awakening was evaluated for their
effect in sleep consolidation
Behavioral treatment
resulted in
improvement in
children’s sleep onset
latency and night
waking frequency,
however there is lack
of studies that
identified factors
needed for success of
treatment.
Vriend and Corkum, (2011) Clinical management of behavioral insomnia It explained about
different form of
interventions for
behavioral insomnia
such as
pharmacological
intervention,
behavioral treatment
and sleep treatments.
Behavioral treatment
was found to be the
first in line treatment
for the night

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awakening
Werner et al. (2015) The Zurich 3 concept for the management of
sleep disorder in children. This process
combines the sleep regulation model on
introducing regular rhythm with adjusting bed
time with behavioral strategies.
The intervention was
found to decrease
nocturnal wake
duration of children
and increase night
sleep duration.
Price et al. (2012) Evaluation of behavioral infant sleep
intervention to improve infant sleep
Sleep intervention
has no long term
impact and parents
can use their
technique only for
managing short to
medium term sleep
problems and
maternal depression
Critical appraisal:
As the research study by Rickert and Johnson (1988) is based on randomized controlled
method, the CASP tool for randomized controlled trial has been applied for critically appraising
the articles. The results of the appraisal are as follows:
Section A
Validity of the results of the study

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1. Presence of focused issue in the study:
Rickert and Johnson (1988) gave clear indication of the focused issue in the study by
clearly stating the main purpose of research. The main aim was to evaluate the effectiveness of
scheduled awakening and systematic ignoring procedures (intervention) for decreasing
awakening and crying episodes in infants and young children (population). Hence, the main
intervention was scheduled awakening and systematic ignoring and the comparator was no
treatment condition
2. Process of allocation:
In RCT studies, random allocation process is needed to randomly assign participants to treatment
and control group. When this process is done correctly, it is effective in reducing bias in the
system. Therefore, the two critical aspects of the random allocation process is developing
random sequence and concealing the treatment before patients have been assigned to specific
groups (Dettori 2010). The participants for the randomized controlled trial included 33 children
with average age of 20 months and they were recruited via local newspaper advertisements. All
the children were randomly assigned to treatment group and control group before home visit
(Rickert and Johnson 1988). Hence, it is confirmed that allocation sequence were concealed from
researcher and patients as parents got to know about their assigned group only after data was
collected regarding each child’s daily schedule (duration of time awake for the day, feeding time,
duration when child spontaneously woke up and cried and unusual situations disrupting routine)
for 9 nine weeks.
3. Treatment of patients who entered the trial:

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To assess whether all participants who entered the trial were properly accounted for its
conclusion or not, it is necessary that complete follow up of patient is done and researcher
analyze the outcome in participants assigned to specific group. In this context, anomalies have
been found in the treatment of group in the study. For instance, at first children were randomly
assigned to control, scheduled awakening or systematic ignoring group. However, as many
children dropped out in between, only 33 participants remained for the study out of 56. To ensure
that all participants were analyzed in their assigned group, parents were asked to report seven
days prior to treatment. This helped in maintaining baseline data for the study. The maintenance
of baseline data reflects the validity and transparency of the study as it helps in effectively
interpreting the study results (Deke and Puma 2013).
4. Blinding to treatment
Blinding in randomized controlled trial is done by having procedures that prevents
participants and assessors from knowing which intervention was given to them. However, it is
impossible to achieve blinding in studies, because for evaluating the outcome of the studies,
active engagement of participants is required. In the research study by Rickert and Johnson
(1988), all children and their parents were randomly assigned to treatment. This means allocation
to treatment was concealed from them, however it cannot be said that they were blinded to
treatment too. They were randomly assigned to control and the two intervention group and
participants got to know about their assigned group only after data related to the history of
spontaneous awakening in each child were collected. Hence, open labeling in this study was seen
which did not fulfilled the blinding criteria and this may lead to biasness too. In a similar RCT
study done to evaluate the effectiveness of behavioral sleep intervention, infants were selected on
the basis of parents reported sleep problem, however the difference in approach from the above

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study was that allocation was concealed and only researchers but not parents were blinded to
group allocation (Price et al. 2012).
5. Similarity of the groups at the start of the trial
While evaluating the quality of a RCT study, the similarity of the group at the start of the
trial is denoted by baseline factors such as age, sex, social class, education and health status.
Keeping these baseline parameters similar is critical for maintain the validity of the study
because baselines factors also influence study outcome and effect of interventions (Higgins et al.
2011). Rickert and Johnson (1988) maintained the similarity of group at the start by taking
children in the age group of 6 to 54 months. However, biasness in baseline factors was that same
social factor was not maintained. For instance, there were single parent families as well as two-
parent families. Difference in level of education of parents was also seen which might have great
impact on the study outcome. Such baseline recruitment is not maintained in many other studies
too.
6. Equal treatment of the group:
Equal treatment of the group in randomized controlled trial is maintained if researcher can
identify any other factors apart from the intervention that might have an impact on performance
on each participant. Rickert and Johnson (1988) equally treated the group by means of exclusion
criteria for recruiting the participants. For instance, since two interventions- scheduled
awakening and systematic ignoring was compared in this study, researchers took care to
eliminate all those factors that could have an impact on interventions. Hence, the main
consideration for the researcher was to exclude those parents who did not had concern regarding
spontaneous awakening. Secondly, children who resisted in going to bed were excluded because

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scheduled awakening is not meant to address this problem and this could have an impact on
study outcome. In addition, the researcher also analysed the baseline data for age and number of
night awakening episodes to determine difference in groups according to baseline factors.
Section B
7. Vastness of treatment effect
In RCT studies, treatment effect is understood from the method of comparison between
outcome in intervention and control group. While comparing the decrease in the number of
spontaneous awakening and crying episodes in each group, it was found that children in
systematic ignoring group has faster rate of positive outcome in 8 weeks period. Another
significant result from the study was that scheduled awakening was also considered to be
effective in reducing night awakening, however the change or improvement in symptoms was
slow in this case. The researcher also specified the period at which major difference in outcome
in three groups were seen and this was observed mainly in week 3, 4, 5, 6 and 7 ( Rickert and
Johnson 1988). Hence, it can be said that be evaluating treatment groups in the order of
intervention, the first place was taken by systematic ignoring condition followed by scheduled
awakening and then the no treatment group. This result is also consistent with a study reviewing
sleep management interventions as the study showed that systematically ignoring the demands of
children for specific periods was effective in improving sleep patterns in children (Halal. and
Nunes 2014).
8. Estimate of the treatment effect
The precision of the treatment effect in RCT studies is determined on the basis of confidence
interval and effect size. This means that narrow confidence interval will denote clear precision in

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results, whereas wider interval is an indication of greater uncertainty in results. While evaluating
Rickert and Johnson (1988) study on the basis of precision of its results, it can be said that the
confidence interval is wide because great variability in control group and developmental trends
were seen. This indicates that more research is needed to identify why children in no treatment
group showed improvement in outcome. Despite this limitation, the study was successful in
proving that systematic ignoring and scheduled awakening have positive effect in reducing sleep
related behavioral issues in infants. Another study by Črnčec, Matthey and Nemeth, (2010) is
most appropriate to justify this study outcome because the study was about the behavioral
approaches of systematic ignoring and scheduled awakening only. The study proved the efficacy
of the intervention.
Section C
9. Application of the study result
The success of any research is understood when the research provided effective and validated
evidence regarding applying the intervention is local population. The generalisability and
transferability of a research is high if same intervention can be easily applied in local population.
In the RCT study reviewing the effectiveness of systematic ignoring and nocturnal scheduling, it
can be said that although systematic ignoring gave better outcome, however there is less chance
of applying it in local setting. This is because 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). Hence, this fact suggest that scheduled awakening
might be a better intervention to apply in local setting due its acceptance level among parents

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compared to systematic ignoring. The limitation in acceptance of systematic ignoring also
suggest that more research work is required to find effective alternative to ignoring that can give
positive results too. There is also a need to conduct more research on understanding the
mechanism to reinforce positive sleep behavior in children if systematic scheduling technique
needs to be applied in the local population
10. Consideration of clinically important outcomes
In the context of night awakening problem in children, the most clinically significant
outcome was reducing the period of nocturnal awakening and frequency of awakening in
children. Rickert and Johnson (1988) proved the efficacy of systematic ignoring and systematic
awakening by means of clinical outcomes too. For instance, dramatic improvement in frequency
of awakening in children was seen in the systematic ignorance group and the crying episodes
were reduced in other intervention group. Hence, clinically also the study is outcome, however
focusing on clinical outcome of parents like stress level post intervention would also have
enhanced the validity and quality of the study
11. Value of the benefits from research
The RCT trial needed both cost and time investment, however this investment was worth the
effort because the efficacy of both the interventions for children could be easily judged. The
study gave honest response regarding the efficacy of scheduled awakening intervention
compared to systematic ignoring on grounds of its viability and acceptance level by parents.
However, the only limitation is that its effects are slower and identifying the correct mechanism
for this intervention will improve the outcome associated with it.
Conclusion:

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This report highlighted the issue of nocturnal awakening and crying episodes in children
and it impact on both parent and child’s heath. The critical appraisal of the research by Rickert
and Johnson (1988) along with comparison from recent research literature revealed that
scheduled awakening is a beneficial strategy to reduce nocturnal awakening time in children. The
literature search regarding similar topic also revealed that scheduled awakening is more
favorable for reducing sleep problem in children. Hence, after realizing the efficacy of scheduled
awakening intervention, it can be said that this intervention should be funded. It is also
recommended to improve the mechanism associated with this intervention so that it can be easily
implemented in community. More research regarding appropriate mechanism behind scheduled
awakening would help to get clinical significant outcome in children and parents.

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Reference
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review of two behavioural approaches. Journal of Reproductive and Infant Psychology, 28(1),
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spine-care journal, 1(03), pp.7-9.
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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-
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