Interventions
for Infant and Toddler Sleep Disturbance: A Review
Brett
R. Kuhn, Ph.D.
and
Deb
Weidinger, M.S.
Munroe-Meyer
Institute
and
The
University of Nebraska Medical Center
Correspondence
should be addressed to:
Brett
R. Kuhn, Ph.D.
Assistant
Professor, Pediatrics
985450
Nebraska Medical Center
Omaha,
NE 68198-5450
Phone:
(402) 559-5761 (office)
email:
brkuhn@unmc.edu
Running
Head: Infant and Toddler Sleep Disturbance
Abstract
Sleep disturbance affects nearly 25% of infants and
toddlers, resulting in fatigue, stress, and family dissatisfaction. This review describes empirically-based
treatments for infant and toddler sleep disturbance involving difficulty
setting and night waking, including behavioral and pharmacological
approaches. Pharmacological
interventions include antihistamines, chloral hydrate, benzodiazepines, and
melatonin. Behavioral
interventions include extinction and its many variants, positive bedtime
routines, scheduled awakenings, and disassociating feeding from sleep-wake
transitions. Advantages and
disadvantages of each approach are discussed, and suggestions for future
research are offered.
Key Words: children, infant, night-waking,
pediatric, sleep disturbance, sleep problems, toddler, treatment
Studies consistently find
that around 25% of children display some form of sleep disturbance (Mindell,
1993). Although parents are often
told their infant or toddler will “outgrow” the sleep problem, the empirical
evidence suggests otherwise (Butler & Golding, 1986; Kataria, Swanson,
& Trevathan, 1987). When sleep
difficulties and crying endure, parents themselves can become fatigued,
reducing their tolerance for bedtime problems and impairing family satisfaction
(Kataria et al., 1987; Rickert & Johnson, 1988). While infant and toddler sleep disturbance (ITSD)
encompasses a variety of problems (e.g., parasomnias, apnea, disrupted sleep
schedule), the “hallmark” of ITSD involves difficulty settling at bedtime and
frequent night waking (Johnson, 1991; Lozoff, Wolf, & Davis, 1985), which
will be the focus of this article.
Our purpose is to review empirically-based treatment approaches for ITSD
involving settling and waking problems, to discuss advantages and disadvantages
of each, and to suggest future research.
Pharmacological Treatment
Physicians are frequently
faced with tired, frustrated parents who desire an immediate resolution for
their infant or toddler’s sleep problem (Dahl, 1992). Although generally discouraged by sleep experts (e.g.,
Sheldon, Spire, & Levy, 1992; Ware & Orr, 1992), pediatricians commonly
prescribe sedative medication for pediatric sleep disturbance (Mindell, Moline,
Zendell, Brown, & Fry, 1994).
Unfortunately, there are few controlled outcome studies to guide
physicians in this area, leaving them to rely largely on anecdotal reports and
clinical experience.
Antihistamines, chloral hydrate, and benzodiazepines are most often used
for ITSD. Melatonin, a
hormone, was recently introduced and has received a great deal of public
attention in the treatment of sleep problems.
Antihistamines. Children are often prescribed antihistamines for
temporary relief from allergy symptoms such as runny nose, itchy eyes, and
sneezing. Those containing
dyphenhydramine (e.g., Benadryl) are highly sedating, making them a popular
first line treatment for children with sleep disturbance. Empirical studies indicate that
antihistamines produce short-term improvements such as quicker sleep onset,
decreased infant crying, and lowered parental anxiety (Besana, Fiocchi,
De Bartolomeis, Magno, & Donati, 1984; France, Blampied, & Wilkinson,
1991; Ottaviano, Giannotti, & Cortesi, 1991; Richman, 1985; Russo, Gururaj,
& Allen, 1976; Simonoff & Stores, 1987). Unfortunately for parents, these improvements are temporary
and not clinically striking in the long-run, and few children respond by
sleeping through the night (France & Hudson, 1993; Richman, 1985; Russo et
al., 1976). Problems with
adaptation, withdrawal insomnia, paradoxical arousal, and next day “hangover”
have limited the utility of antihistamines in the treatment of ITSD (Edwards
& Christophersen, 1994; France & Hudson, 1993).
Chloral hydrate. First synthesized in 1832, chloral hydrate is one of the
oldest hypnotic agents in use today.
It is commonly used to sedate children undergoing medical or dental procedures. In our experience managing a pediatric
sleep clinic, chloral hydrate is second only to dyphenhydramine as the most
frequently prescribed medication for ITSD. Obtaining a thorough sleep history and physical evaluation
are important before prescribing chloral hydrate because of the potential for
adverse effects in children with sleep apnea, as well as the potential for
accidental overdose (Biban, Baraldi, Pettennazzo, Filippone, & Zacchello,
1993; Graham, Day, Lee, & Fulde, 1988). Ample data attest to the effectiveness and safety of single
dose sedation of children undergoing medical or dental procedures (Fox, O’Brien, Kangas, Murphree, &
Wright, 1990; Needleman, Joshi, & Griffith, 1995), however we could
identify no studies evaluating repetitive dosing in children with sleep
disturbance. This fact is alarming
given the American Academy of Pediatrics’ concerns with repetitive dosing of
chloral hydrate due to the risk of accumulation of potentially carcinogenic
metabolites (AAPD, 1993; Salmon, Kizer, Zeise, Jackson, & Smith,
1995). With the introduction
of newer and safer alternatives, the controversy over the use of chloral
hydrate with pediatric populations will likely continue (Buchanon, 1989; Smith
& Whyte, 1988; Steinberg, 1993).
Benzodiazepines. Benzodiazepines such as clonazepam (Klonopin) and estazolam
(ProSom) are among the most widely prescribed medications of any type
world-wide (Buysse, 1991). They are
most commonly used in the treatment of anxiety, insomnia, and withdrawal from
alcohol or other sedatives.
Although there have been no studies evaluating the utility of these
medications for ITSD, we have encountered toddlers entering our clinic who were
prescribed a low dose benzodiazepine for problems with sleep onset and night
waking. Benzodiazepines are more
typically reserved for children exhibiting parasomnias such as sleep terrors or
sleepwalking. A low dose of
diazepam before bedtime markedly reduces these disorders of arousal, possibly
through the suppression of slow wave sleep (Fisher, Kahn, Edwards, & Davis,
1973; Glick, Schulman, & Turecki, 1971). Benzodiazepines have a well known side-effect profile that
includes carryover (daytime) sedation, cognitive/performance decrements,
alteration of normal sleep architecture, possible dependence, and a high rate
of relapse upon discontinuation.
Due to these side effects and the unknown effects on a developing
nervous system, the use of benzodiazepines with young children is generally
discouraged (Rosen, Mahowald, & Ferber, 1995; Weissbluth, 1984).
Melatonin. This hormone is secreted nocturnally by the pineal gland
that plays an important role in the induction of sleep and regulating
sleep-wake rhythms (Cassone & Natesan, 1997). The synthesis and release of melatonin is stimulated by the
onset of darkness, reaching peak levels by the middle of the night-time sleep
phase, and falling to nearly undetectable levels during the day. The effects of illumination are
passed from the retina through the visual pathway to the supra chiasmatic
nucleus of the hypothalamus (Cavallo, 1993). Consequently, persons with visual impairment frequently
experience irregular sleep wake cycles.
Exogenous melatonin has been synthesized for oral use and is now
available as an over the counter supplement. Melatonin appears to have a dual effect, both as a sedating
agent and a regulator of sleep wake schedules (Zhdanova, Lynch, & Wurtman,
1997).
Only a handful of studies
have evaluated melatonin with pediatric sleep disturbance. Those studies have focused on
children with neuro-developmental disabilities and/or visual impairments. Jan and colleagues have studied the
largest cohort of children who initially presented with “severe” sleep disorders
(Jan & O' Donnell, 1996).
Melatonin (2.5 mg. to 5 mg.) not only improved children’s sleep, but
reports also indicated improved daytime behavior, attention span, and school
performance. The authors
anecdotally reported fewer infections, increased appetite, growth, and
development, and an improvement in coexisting seizures, esophageal reflux,
colitis, and “non-specific chronic diarrhea” (Jan, Espezel, & Appleton,
1994). This research group
reported no adverse effects in treating more than 140 children (Jan & O'
Donnell, 1996). It should be noted
that this study combined melatonin administration with behavioral
recommendations for parents to “awaken their child at the same time each
morning and reduce afternoon naps.”
The authors conclude that melatonin treatment is most effective when
combined with strict environmental sleep scheduling (Jan & Espezel,
1995).
Palm, Blennow, and
Wetterberg (1991) used melatonin (.5mg. to 4 mg.) to treat four children and
four young adults with circadian sleep-wake disturbances in an uncontrolled,
open-label study. All patients
were mentally handicapped and functionally blind. Melatonin reportedly improved the sleep-wake pattern in all
patients. The effect was
maintained during long-term therapy for one to six years in 6 of the 8
patients. No adverse side effects
were noted. McArthur and Budden
(1998) obtained mixed results with melatonin treatment (2.5mg to 7.5 mg) for
nine female patients with Rett syndrome and sleep disturbance. Nearly all patients were concurrently
taking anti-convulsive medication.
While clinical response was highly variable across children, group data
indicated that melatonin resulted in quicker sleep onset during the first 3
weeks of the study. Improvements
in total sleep time and sleep efficiency were also noted for those children with
the poorest baseline sleep quality.
No adverse effects were noted.
Camfield, Gordon, Dooley, and Camfield (1996) is the only study to date
that has reported melatonin to be ineffective in treating children with mental
handicaps and sleep disturbance. However, this study employed a lower dosage (.5 mg to 1 mg.)
and earlier administration time (6:00 p.m.) that may have limited patient’s
response (Jan, Espezel, Freeman, & Fast, 1997).
Sheldon (1998) recently
reported that melatonin (5 mg.) produced considerable improvement in total
sleep time, sleep continuity, and time to sleep onset for 5 of 6 children with
multiple neurological deficits.
Unfortunately, this well-designed study had to be suspended because 4 of
the 6 children exhibited increased or new onset seizure activity shortly after
initiating melatonin treatment.
Seizure activity returned to baseline levels upon discontinuing the
hormone. This sleep expert
suggested that further investigations are needed before recommending melatonin
for the treatment of sleep disorders in children with neurological disabilities
(Sheldon, 1998).
In summary, the empirical
literature on melatonin treatment for pediatric sleep disturbance is still in
its infancy. Differences in study
design such as whether or not melatonin was combined with behavioral
programming, melatonin composition, dosage, time of administration, and outcome
measures have produced few reliable findings to guide the practicing
clinician. We could find no
systematic studies evaluating melatonin with non-disabled children and little
information on the safety of long-term melatonin administration in normally
developing children. Finally,
because melatonin is currently classified as an over the counter supplement, it
is not regulated by the U.S. Food and Drug Administration (FDA) and, therefore,
is not subject to testing for composition or potential impurities (Lord,
1998). FDA approval and further
research on the safety and long-term efficacy are needed before practicing
physicians will consider melatonin a viable option for ITSD (Cavallo, 1993).
Behavioral Approaches
Behavioral interventions have become increasingly recognized
as the treatment of choice for ITSD (Bootzin & Chambers, 1990; Dahl, 1992;
Ferber, 1985). Principles of
behavior that are successful in reducing daytime behavior problems have been
equally effective in managing sleep disturbances (Douglas, 1989). This finding should not be surprising,
given the role early conditioning and parental sleep practices (e.g., whether
infant is put into crib awake or already asleep) play in predicting children
who become “good sleepers” versus “poor sleepers” (Adair, Bauchner, Philipp,
Levenson, & Zuckerman, 1991; Anders, Halpern, & Hua, 1992; Johnson,
1991; Van Tassel, 1985).
Behavioral interventions that have received empirical support include
extinction and its variants, positive bedtime routines, scheduled awakenings,
and disassociating feeding from sleep-wake transitions. Readers are reminded that while this
review describes standardized treatment protocols, these interventions are no
replacement for a thorough functional assessment of interpersonal or
environmental factors that may cue, motivate, or reinforce a specific child’s
sleep disturbance (Didden, Curfs, Sikkema, & de Moor, 1998; Kuhn, Mayfield,
& Kuhn, 1999).
Unmodified extinction. This procedure has also been referred to as systematic
ignoring, or more commonly, “letting the child cry it out.” As applied to ITSD, unmodified
extinction involves establishing a regular bedtime and bedtime routine, then
placing the child in bed and not attending to him or her until morning. Parents are informed that the
only exception to ignoring is the possibility of illness or danger to the child
(Wolfson, 1998). Williams (1959)
was the first to apply extinction to eliminate night-time infant crying. Although additional case studies have
replicated the effectiveness of this procedure (e.g., Chadez & Nurius,
1987; Wright, Woodcock, & Scott, 1970), lack of experimental control and
small sample size limit their generalization. Multiple-baseline and group design studies have been
conducted to address these methodological weaknesses. Extinction combined with positive bedtime routines or
response cost (time-out and loss of night-time story) has been shown to
decrease disruptive behavior at bedtime and night waking (France & Hudson,
1990; Sanders, Bor, & Dadds, 1984).
Rickert and Johnson (1988) compared unmodified extinction with scheduled
awakenings and found that, while both treatments were effective, unmodified
extinction produced more rapid improvement with the fewest number of
spontaneous night wakings.
The major advantage of
extinction is that it produces rapid results, with the worst of the crying usually
extinguished within three nights (France, 1996). The procedure is easy for parents to understand, and the
underlying operant theory is relatively well-established; termination of the
reinforcement contingency that maintains a response (e.g, crying) reduces the
occurrence of that response over time (Lerman & Iwata, 1996). Despite the rapid effectiveness of
extinction, there are undesirable side effects associated with its use,
including the occurrence of response bursting and spontaneous recovery (Lerman,
Iwata, & Wallace, 1999; Lerman, Kelley, Van Camp, & Roane, 1999). Parents who are unaware of these
effects may inadvertently resume to reinforcing (e.g., attending) the problem
behavior, creating an intermittent reinforcement schedule thereby increasing
the resistance to future extinction procedures (Lawton, France, & Blampied,
1991). Additionally, parents who
have attempted unmodified extinction often view it as socially unacceptable and
difficult to carry out (Johnson, 1991).
Due to the difficulties parents encounter with extinction, modifications
to the procedure have been designed.
Graduated extinction. Also called graduated systematic ignoring, this procedure
was popularized by Ferber (1985) in his popular self-help book. The protocol involves gradually
reducing parental attention to inappropriate bedtime behaviors and allowing the
child to fall asleep without parental assistance. Two variations of graduated extinction have received empirical
support. The first version
requires parents to wait for progressively longer periods of time before
responding to their child (Durand
& Mindell, 1990). A second
version calls for immediate response, but parents gradually decrease the time
they spend attending to the child
(Lawton et al., 1991). The
goal of both versions is to systematically reduce parental attention, allowing the child’s inappropriate
bedtime behaviors to gradually extinguish while promoting independent sleep
onset. A similar procedure called
the quick check method (Schaefer & Petronko, 1987) is virtually identical
to the first version of gradual extinction, except that the waiting time
between parental checks is not progressively lengthened but maintained at a
constant interval (e.g., every 10 minutes).
Empirical studies indicate
that quick check and graduated extinction are effective at reducing bedtime
struggles and eliminating night waking (Adams & Rickert, 1989; Lawton et
al., 1991; Pritchard & Appleton, 1988; Reid, Walter, & O’Leary, 1999;
Rolider & Van Houten, 1984).
Amelioration of children’s sleep disturbance is associated with
subsequent improvement in parents’ sleep, mood state, and marital satisfaction
(Durand & Mindell, 1990; Mindell, 1993; Pritchard & Appleton, 1988). The advantages of modified
extinction procedures include the convenience of employing them at the child’s
regular bedtime, and positive results are generally evident within the first
week of implementation. Parents
report that the ability to check on their child between intervals of crying
makes the procedure easier to tolerate than unmodified extinction, resulting in
higher rates of treatment compliance (Adams & Rickert, 1989; Reid et al.,
1999). Disadvantages include
the possibility that the child’s crying can be shaped into longer and longer
durations, and parents may increase the length and/or “reinforcement value” of
the checking procedure (France, 1996).
Extinction with parental
presence. This approach calls for the parent to
sleep in the same room with the child for one week while using unmodified
extinction (Sadeh, 1994). After
placing the child in bed, the parent remains in the room (in a different bed)
and ignores the child until he or she falls asleep. This protocol relies on the child’s awareness of parental
presence, which is expected to reassure the child and promote quick sleep
onset. Parental presence has been
shown effective, with results comparable to the quick check procedure, in
eliminating children’s bedtime disturbance (Jones & Verduyn, 1983; Sadeh,
1994). The advantage of parental
presence is that it appears to produce rapid results ameliorating bedtime
resistance with decreased infant crying and reduced parental anxiety. Disadvantages include some parents’
reluctance to change sleeping accommodations and the possibility of increased
parental distress while attempting to tolerate infant crying in close proximity
(France, 1996). Additionally, the
protocol does not teach the infant or toddler to fall asleep independent of
parental presence, and little description is provided as to how the parent
resumes sleeping in a separate room without reactivating the child’s
protests. Positive Bedtime
Routines. While
extinction-based procedures may reduce or eliminate inappropriate behavior,
they do little to teach or reinforce adaptive replacement behaviors. Positive bedtime routines can be
conceptualized in part as a differential reinforcement procedure, as it is
designed to teach children appropriate pre-bedtime behaviors and sleep onset
skills. Establishing a positive
bedtime routine involves temporarily moving the bedtime later in the evening to
more closely coincide with the child’s natural sleep onset time, thus creating
high probability for rapid sleep onset
(Milan, Mitchell, Berger, & Pierson, 1981). Next, parents institute a positive and
enjoyable pre-bedtime routine that teaches the child to engage in relaxing
activities. Each activity is
followed by parental praise and encouragement, signaling transition to the next
activity. Once the behavioral
chain is well established and the child is falling asleep quickly, the child’s
bedtime is systematically moved earlier in the evening until reaching a
pre-established bedtime goal (Adams & Rickert, 1989). Milan and associates (1981) claim
that positive routines are quick to establish, and rapidly eliminate tantrums
while replacing them with constructive sleep onset skills.
Positive bedtime routines
were first used to eliminate bedtime tantrum behaviors of three children with
handicaps (Milan et al., 1981). In
all three cases, parents reported that positive routines were effective in
inducing voluntary bedtime compliance.
Piazza and colleagues have used a variation of positive routines
(“bedtime fading”), both with and without a response cost component, to
eliminate severe sleep disturbances and increase appropriate sleep in children
(Piazza & Fisher, 1991a, 1991b).
Evidence suggests that faded bedtime with response cost is superior to
simply enforcing a consistent bedtime schedule (Piazza, Fisher, & Sherer,
1997).
Comparatively, positive
routines appear to produce more rapid results than graduated extinction (Adams
& Rickert, 1989). The
procedure closely resembles a combination of two behavioral interventions
(sleep restriction and stimulus control instructions) that have received the
most empirical support for the treatment of adult insomnia (Morin, Culbert,
& Schwartz, 1994). Advantages
to positive routines include the prevention of long bouts of crying, fewer
bedtime struggles, and reduced parental anxiety. These advantages over extinction-based approaches have
prompted some to describe positive bedtime routines as an “errorless” procedure
(Durand, 1998). Potential
disadvantages include the time commitment and possible interruptions to
treatment (e.g., illness, family travel) during the bedtime fading
process. Also, some parents are
resistant to temporarily changing their child’s bedtime to a later time or
remaining awake with their child.
Scheduled awakenings. This protocol involves systematically scheduling
parent-prompted awakenings prior to those times when the child would be
expected to wake spontaneously.
After establishing a baseline of spontaneous night-time wakings, a
planned schedule of parent-prompted awakenings is initiated 15 to 30 minutes
prior to each of the child’s spontaneous wakings. Upon each scheduled awakening, the child is provided with
the usual parenting responses (e.g., rocking, patting) as if the child had
awakened spontaneously. The time
of each scheduled awakening is gradually delayed until the child sleeps for
longer periods between awakenings, eventually sleeping through the night
(Johnson, Bradley-Johnson, & Stack, 1981). Scheduled awakenings appear to systematically increase the length
of children’s sleep periods while eliminating spontaneous waking and excessive
crying (Johnson et al., 1981; Johnson & Lerner, 1985; McGarr & Hovell,
1980).
Rickert and Johnson (1988)
compared scheduled awakening with unmodified extinction and found that, while
both techniques were effective in reducing night wakings, extinction produced
the most rapid results. Treatment
effects were maintained for both conditions at three and six week follow-up
checks. Because scheduled
awakenings can prevent long bouts of crying, this procedure may be particularly
useful for parents who have reservations about extinction-based procedures
(Durand, 1998). The approach is
also useful for children who, through inadvertent shaping, have become
resistant to extinction-based procedures or engage in gagging, vomiting, or
self-injurious behaviors. While
some parents simply do not like the idea of setting their alarm to awaken a
sleeping child, the primary disadvantage with this procedure is the length of
treatment time required before a child sleeps through the night (Mindell,
1997). The data suggest that most
parents can expect to carry out scheduled awakenings for seven weeks or more
before yielding satisfactory results.
Another limitation of scheduled awakenings is that the protocol does not
address bedtime struggles or teach children to fall asleep independently. In fact, the most comprehensive study
of scheduled awakenings specifically excluded children who presented with
bedtime resistance, as the authors felt that the protocol was not appropriate
for treating this problem (Rickert & Johnson, 1988). Unfortunately, this may limit the
utility of scheduled awakenings because there is a strong association between
sleep onset skills and night-time awakenings for most infants and toddlers
(Anders et al., 1992; Mindell & Durand, 1993).
Disassociating feeding from
sleep-wake transitions. This category encompasses
several strategies designed to teach infants to feed during the day and sleep
through the night. Infant feeding
and sleep-wake patterns are closely linked and comprise a strong association
(Spasaro & Schaefer, 1995).
Infants who are fed until they fall asleep, and fed again upon each
awakening, quickly become dependent on this routine. Most experts agree that by the time an infant is 4 to 6
months old, there is rarely a nutritional basis to middle of the night
feedings, and waking to feed is usually the result of learned behavior or conditioned
hunger cues (Douglas & Richman, 1985; Schmitt, 1985). Infants who fall back to sleep quickly
upon nursing may be reliant on sucking behavior as a cue for sleep onset. Dissociating the feeding process from
sleep onset can be accomplished by placing these infants in bed drowsy but
still awake (Adair, Zuckerman, Bauchner, Philipp, & Levenson, 1992;
Schmitt, 1985). Infants who fall
asleep while feeding can be briefly awakened prior to placing them in the crib,
allowing the final stages of sleep onset to occur in the absence of feeding
associations. Those infants who
consume large quantities of milk upon each awakening may have developed
conditioned hunger cues that trigger frequent night-time awakenings (Ferber,
1995). This pattern is more common
in infants who are nursed frequently throughout the day or who are given a
bottle whenever they show minor signals of distress (Elias, Nicolson, Bora,
& Johnston, 1983; Schmitt, 1981).
Intervention for these infants involves lengthening feeding intervals
during the day while phasing out night-time feedings by gradually reducing the
volume or concentration of fluid intake (Ferber & Boyle, 1983; Mindell,
1990; Wolfson, Lacks, & Futterman, 1992).
Recent evidence suggests
that dissociating feeding from the sleep-wake schedule can be accomplished even
with very young infants. Pinilla
and Birch (1993) taught mothers of breast-fed infants to gradually lengthen the
period between night-time awakenings and feedings by carrying out alternative
care giving activities like reswaddling, diapering, or walking. By the time they were eight weeks old,
100% of the treatment infants were sleeping through the night, compared to 23%
of the control infants.
Twenty-four hour milk intake did not differ between groups, as infants
who slept through the night compensated for missed feedings by consuming a
larger morning meal.
The primary advantage of
interventions that disassociate feeding from sleep-wake transitions is their
potential for helping infants establish a stable sleep pattern early in
life. These efforts may avert the
need to use more demanding interventions to reverse maladaptive sleep patterns
in older children who are more resistant to change. Some parents, however, may have difficulty listening to
their infant’s crying at such a young age, and objections have been raised as
to the safety and ethics of altering the sleep patterns of newborn infants
(Walker, 1993).
Conclusions
Infant and toddler sleep
disturbance is commonly encountered and can be highly disruptive to family
functioning. Fortunately, the
empirical literature suggests that practitioners and families are afforded a
choice among a variety of effective treatment options. When offered in conjunction with
education and support, behavioral approaches provide effective, individualized
treatment strategies that enable parents to teach their infants to sleep
through the night (Spasaro & Schaefer, 1995).
The utility of
pharmacological treatment for ITSD has been limited due to lack of long-term
efficacy, side effects, withdrawal, and lack of parental acceptance (Kuhn,
Lund, & Pfeifer, 1999).
Consequently, most pediatric sleep experts recommend that medications be
used only in combination with behavioral interventions and only in severe and
chronic cases of ITSD (Durand, Mindell, Mapstone, & Gernert Dott, 1998;
Kales, Soldatos, & Kales, 1987).
Further research is needed
comparing the effectiveness, length of treatment, ease of implementation, and
acceptability of the available treatment options for ITSD. These comparison data would further
facilitate a consumer-driven model in helping families decide among the various
approaches (France, 1994, 1996).
Researchers are also encouraged to begin identifying characteristics
that might predict families who are at risk for treatment failure or premature
dropout. Treatment outcome might
be enhanced for these families by teaching the parents effective coping skills
to better handle anxiety and tolerate infant/toddler crying, or to employ
daytime strategies to pre-teach specific child behaviors (e.g., self-quieting
skills) that facilitate sleep onset (Edwards, 1993; Tyson, 1996).
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