Introduction to This Therapist Guide

Difficulty falling asleep and frequent nocturnal awakenings are common sleep problems in young children. These are highly influenced by parent choices about sleep schedules, bedtime routines, and psychosocial factors but are usually very treatable with effective behavioral interventions. Parents may respond with actions that actually end up perpetuating sleep problems based on their beliefs about the nature of the sleep disturbances. Parents may misattribute the sleep disturbance to other medical problems or misinterpret benign sleep disturbances such as confusional arousals. Even if these conditions are ruled out or identified, the learned negative sleep-onset associations can be challenging to alter. Fortunately, children’s sleep habits are amenable to change when caregivers apply empirically supported behavioral sleep medicine strategies. Sleep physicians and psychologists specializing in behavioral sleep medicine can work collaboratively to solve the mystery of complex toddler sleep problems, tailoring parent guidance and behavioral treatments to the individual child and family dynamics.

Sleep problems in young children are highly prevalent and place children at risk for numerous detrimental child and family outcomes. This pilot study aimed to assess the feasibility of an unguided, parent-focused, online sleep intervention, the Lights Out Online program, in terms of adherence rates, acceptability to parents, and effects on (a) child sleep, anxiety, and behaviour problems, and (b) parental self-efficacy, and parent sleep, depression, anxiety. The study was a pilot, open (uncontrolled) trial with a within-group repeated measures (baseline (T1), 12-weeks post-baseline (T2)) design. Participants were 24 parents (Mage = 36.2, SD = 4.1) of children aged 3-6 years (Mage = 4.1 years, SD = 1.1) with sleep problems. Participants completed an average of 3.58 out of 4 sessions by T2, and parents reported satisfaction with program content and presentation. A series of mixed-effects linear regression models demonstrated significant improvements in child sleep, child anxiety, child behaviour problems, parent sleep, parent anxiety and parental self-efficacy, from T1 to T2. However, significant improvements were not demonstrated for parent depression and parent stress. The results of this study should be taken with caution given the small sample size and lack of control group. However, the study provides preliminary support for the feasibility of Lights Out Online.

Research examining factors contributing to preschool sleep problems is limited. This study investigated the mediating role of parenting styles (authoritarian, authoritative, and permissive parenting) in the relationship between parental psychological distress and sleep problems in young children. Participants were parents of 232 young children aged three to five years. Parents completed the Children's Sleep Habits Questionnaire, the Parenting Style and Dimensions Questionnaire—Short Version, and the Depression Anxiety and Stress Scale. Only permissive parenting was found to significantly mediate the relationship between parental distress and preschool sleep problems (indirect effect = 0.16, p < 0.01), with a significant direct effect of parental psychological distress on child sleep problems (0.16, p < 0.01) also being present. Authoritarian and authoritative parenting were found to be unrelated to child sleep problems. These findings suggest that augmenting treatment programs for preschool sleep problems with strategies targeting parental distress and permissive parenting where required, may be beneficial in improving preschool sleep problems.

Sleep problems and bedtime resistance are common in young children. Treatment is critical because sleep problems typically persist, and insufficient sleep is related to worse outcomes. Current behavioral treatments do not work directly with the child to reduce anxiety and distress at bedtime. Cognitive–behavioral play therapy is a treatment approach designed to teach coping skills to young children by combining cognitive–behavioral therapy with pretend play, a developmentally appropriate intervention mode. The current case series examined the effectiveness of adding a brief cognitive–behavioral play intervention (CBPI) to parent behavior management for young children with sleep difficulties. Four children (4–6 years of age) received 3 20- to 30-min individual sessions during which the child played out stories with an advanced graduate student therapist (first author, K. F.) about a child coping with sleep problems. Each child’s parent also received a 30-min sleep information session. Three parents returned questionnaires posttreatment. As expected, all 3 parents reported improvements in their child’s sleep habits, sleep anxiety, and general fears. All 3 parents also reported a high level of satisfaction with the treatment. These preliminary results suggest that the CBPI may be effective for decreasing anxiety and child distress when added to behavioral treatment, thus increasing the breadth of treatment approaches available for young children with sleep problems. These results are promising, although a randomized study is needed to further refine the intervention and establish the efficacy of a CBPI for treatment of sleep problems in young children.

Sleep problems in young children

Poor sleep in children predicts mental and physical disorders later in life. Identifying and changing modifiable factors associated with sleep problems in young children may improve their health trajectory. Our aim was to establish whether overprotective parenting was associated with problems sleeping in children. Parents of children aged 2-6years completed questionnaires about their own anxiety, parenting style, and about their children's sleep. We obtained 307 reports on 197 children from 240 parents. Using mixed-effects linear regression, we found that maternal (beta = 0.26, 95% CI 0.11 to 0.41, p = 0.001) and paternal (beta = 0.35, 95% CI 0.17 to 0.53, p < 0.001) overprotection were associated with impaired sleep in children. This relationship remained unchanged when controlling for parental anxiety. Decreasing parents' overprotection may improve children's sleep, and reduce the risk of physical and mental disorders later in their life.

Introduction The aim of this study was to assess parent perceptions of sleep problems in young children and parent-identified areas of change in a global sample. Methods Caregivers (95.6% mothers) of 1555 infants/toddlers (birth-37 mos; M=12.2 mos; 49.5% male) completed an online survey, representing Indonesia (n=187), Japan (n=718), New Zealand (n=231), Singapore (n=199), and Thailand (n=221). The survey included an abbreviated version of the Brief Infant Sleep Questionnaire, and a list of potential sleep-related areas of change. Results 36.9% reported a perceived sleep-problem, whereas 92.9% indicated an area of desired change related to their child’s sleep. In terms of areas of change, 82.5% endorsed bedtime/how child falls asleep, 70.0% nighttime sleep, and 57.8% related to the morning. As expected, 99.7% of parents who endorsed a problem indicated a desired change compared to 88.9% who did not perceive a problem, p &amp;lt; .001. Those who noted a problem were more likely to endorse a change at bedtime (92.5%) and during the night (90.1%), compared to the morning (68.8%). There were country-based differences, with caregivers in New Zealand (47.0%) and Singapore (44.2%) more likely to report a child sleep problem compared to Thailand (35.3%), Japan (34.1%) and Indonesia (29.4%), p &amp;lt; .001. No differences were noted in parent-report of desired change across Japan, New Zealand, Singapore, and Thailand (94-96%) but were significantly higher than Indonesia (83.4%). Conclusion Although one-third of parents of young children in a global sample indicate a perceived sleep problem, almost all parents wish to change something about their child’s sleep, primarily relate to bedtime and during the night. Sleep education and assessment delivered by health care providers should focus not only on what families consider to be “problematic,” but also what families would like to modify, or improve, about their child’s sleep within a developmentally appropriate framework. Support Johnson &amp; Johnson Consumer Inc., Skillman, NJ, USA.

BackgroundSleep disturbance is common in children with neurodevelopmental disorders, with high rates identified in children with Smith-Magenis syndrome (SMS), Angelman syndrome (AS), autism spectrum disorder (ASD) and tuberous sclerosis complex (TSC). Phenotypic sleep profiles for these groups may implicate different pathways to sleep disturbance. At present, cross-group comparisons that might elucidate putative phenotypic sleep characteristics are limited by measurement differences between studies. In this study, a standardised questionnaire was administered across groups affording comparison of the prevalence and profile of sleep disturbance between groups and contrast to chronologically age-matched typically developing (TD) peers.MethodsThe modified version of Simonds and Parraga’s sleep questionnaire, adapted for use in children with intellectual disabilities, was employed to assess sleep disturbance profiles in children aged 2–15 years with SMS (n = 26), AS (n = 70), ASD (n = 30), TSC (n = 20) and a TD contrast group (n = 47). Associations between sleep disturbance and age, obesity, health conditions and overactivity/impulsivity were explored for each neurodevelopmental disorder group.ResultsChildren with SMS displayed severe night waking (81%) and early morning waking (73%). In contrast, children with ASD experienced difficulties with sleep onset (30%) and sleep maintenance (43%). Fewer children with ASD (43%) and AS (46%) experienced severe night waking compared to children with SMS (both p < .01). Higher sleep-disordered breathing scores were identified for children with SMS (p < .001) and AS (p < .001) compared to the TD group. Sleep disturbance in children with AS and TSC was associated with poorer health. Children experiencing symptoms indicative of gastro-oesophageal reflux had significantly higher sleep-disordered breathing scores in the AS, SMS and ASD groups (all p < .01). A number of associations between overactivity, impulsivity, gastro-oesophageal reflux, age and sleep disturbance were found for certain groups.ConclusionsThese data reveal syndrome-specific profiles of sleep disturbance. The divergent associations between sleep parameters and person characteristics, specifically symptoms of gastro-oesophageal reflux, overactivity and impulsivity and age, implicate aetiology-specific mechanisms underpinning sleep disturbance. The differences in prevalence, severity and mechanisms implicated in sleep disturbance between groups support a syndrome-sensitive approach to assessment and treatment of sleep disturbance in children with neurodevelopmental disorders.

The aim of this study was to explore mothers' and public health nurses' (PHN) experiences with sleep problems in children aged 6 months to 3 years in Norway. Sleep problems in children are common, affecting their health and development, and their mothers' well-being. It is also the primary reason parents seek help in well-child clinics (WCC). However, there is limited knowledge regarding the experiences of these mothers and the public health nurses who consult them. Qualitative design. Four semi-structured focus group interviews were conducted: two with mothers (n= 14) who had children with sleep problems and two with public health nurses (n= 14) from well-child clinics. The Framework Method was used for analysing the interviews of mothers. Data from public health nurses were charted onto the analytical framework of maternal data to understand how or whether public health nurses addressed the issues raised by mothers. The study is reported according to the COREQ checklist. The analysis resulted in two main themes: 'therapeutic alliance' (categories 'alliance ruptures' and 'demanding negotiation process') and 'reorganisation of identity' (categories 'unfulfilled expectations' and 'internal tension conflicts'). Young children's sleep problems present challenges to new mothers due to failed expectations, negatively affecting their feelings as mothers and towards their children, and consequently the reorganising of maternal identity. Most mothers experienced unsatisfactory therapeutic alliances while seeking help from public health nurses because advice was considered overly general, contradictory and unsafe for their children. Public health nurses were mostly aware of the parental consequences of children's sleep problems, but many appeared unable to help because of limited time and knowledge. Public health nurses need to establish a therapeutic alliance and provide evidence-based knowledge and guidance on sleep problems while also considering women's reorganisation of identity when becoming mothers. Open Science Framework: osf-registrations-6ag38-v1 (https://archive.org/details/osf-registrations-6ag38-v1).

ABSTRACTBackground and objectives: Optimal sleeping habits are important for health development of infants. The role of culture in sleep habits cannot be underestimated. We aimed to characterize sleep patterns, sleep practices, and sleep problems; and assess the sleep settings and parental perceptions of sleep problems in children from birth to 36 months in countries in the Southeast Asian (SEA) region. Participants: Parents and caregivers of infants and toddlers (birth to 36 months old) from countries in Southeast Asia participated in this study. Methods: Data was collected using the Brief Infant Sleep Questionnaire for a total of 5,987 children from 6 countries in the SEA region (967 Indonesia/ID, 997 Malaysia/MY, 1,034 Philippines/PH, 1,001 Singapore/SG, 988 Thailand/TH, and 1,000 Vietnam/VN). Results: The sleep variables varied among SEA children studied. Bedtimes and nighttime sleep varied across the region by as much as 1 hr 34 min and 1 hr 15 min respectively. Conclusions: Despite being geographically very close together and having some common sociocultural characteristics, sleep variables in the young child within the SEA region do differ in significant ways.

Sleep disturbances in autism spectrum disorder: Animal models, neural mechanisms, and therapeutics

BackgroundSleep disturbances are common in children affected by Autism Spectrum Disorder (ASD). The aim of our study was to describe sleep characteristics and disturbances in children with ASD, to evaluate possible related factors, and to assess parental stress.MethodsHundred children with a diagnosis of ASD (mean age: 66.7 months, SD: 27.4, range: 24.7–152.1 months, n = 79 males) were included in the study. We collected data on sociodemographic, clinical, genetic and instrumental variables as well as comorbid conditions. Parents filled out the Questionnaire on sleep behavior in the first years of life, the BEARS questionnaire, and the Parenting Stress Index Short Form. From the analysis on sleep characteristics, we excluded 25 children treated with melatonin.ResultsFifty-seven (57%) out of 100 children met the criteria for insomnia. Sleep disorders were associated with developmental or cognitive delay, emotional and behavioral problems (such as anxiety problems and aggressive behaviors) and absence of strategies for inducing sleep after nocturnal awakenings. From parents' reports, sleep disorders had diurnal repercussions on their offspring; however, we found no statistical correlation between disturbances and family stress. Also, no significant correlation was found between sleep disturbances and epilepsy. Finally, a statistical correlation was found between the regular intake of melatonin and the resolution of insomnia.ConclusionsMultifactorial variables may be associated to insomnia that could have an impact on the children' behavior. Clinicians need to be aware of the value of screening for sleep disturbance in children with ASD to integrate sleep interventions in the treatment plan.

To explore the parent reported sleep disturbances in children and adolescents with Autism Spectrum Disorder (ASD) and to compare it with the typically developing children (TYD). Another objective was to understand the relationship between sleep disturbances and behavioural problems in children with ASD. The participants of the study were parents of 30 children and adolescents diagnosed with ASD who had attended IP/OP services in NIMHANS, Bangalore and parents of 30 typically developing children studying at various schools in and around Bangalore. The participants were frequency matched based on the age of their children and their socio-economic background. Level of ASD was measured using Childhood Autism Rating Scale (CARS). Child Sleep Habits Questionnaire was administered. A range of other scales were also administered for understanding the behavioural problems in children with ASD.Children with ASD had more sleep disturbances than TYD. Sleep problems led to behavioural issues such as hyperactivity. The sleep disturbances are positively correlated to the severity of autism and social responsiveness deficits in children and adolescents with ASD. Even though it is a preliminary effort, the study suggests the need for intervention tending to the disturbances in sleep among children and adolescents with ASD. Implications and scope for future research also discussed.

Sensory processing abnormalities are core features of Autism Spectrum Disorder (ASD) and may contribute to sleep problems. This study tested whether sensory processing mediates the between problematic screen exposure (PSE) and sleep disturbances in children with ASD. This cross-sectional study included 108 children (6-12 years old) diagnosed with ASD according to the DSM-5. Autism severity was measured using the Childhood Autism Rating Scale (CARS). The caregivers completed the Dunn Sensory Profile, Children's Sleep Habits Questionnaire (CSHQ), Seven-in-Seven Screen Exposure Questionnaire, Autism Behavior Checklist (ABC) and Aberrant Behavior Checklist (AbBC). Group comparisons, and mediation models were also used. Children with PSE scored significantly higher on the AbBC and ABC scales and experienced more severe sleep disturbances than those without PSE. No differences emerged as regards autism severity in the non-problematic PSE and PSE groups. Significant sensory deficits were observed in the visual, vestibular, and tactile domains (p < 0.001). Mediation analysis accounted for the total indirect effects through visual (β = -0.067, p = 0.022) and multisensory (β = -0.055, p = 0.016), although the direct effect of the screen exposure on sleep disturbance was not significant. PSE is associated with sleep disturbances in children with ASD, with this association appearing to be statistically mediated by sensory processing dysregulation. These results highlight sensory regulatory mechanisms as a key pathway linking PSE to sleep difficulties and imply that both screen exposure patterns and sensory modulation may be appropriate targets for clinical consideration.

This book provides a therapist guide for the Sleep Parent Training (SLePT) Program, which was developed for young children with autism spectrum disorder and co-occurring sleep disturbances and tested in clinical trials. The five session intervention covers an overview of the causes of sleep disturbances in autistic children as well as strategies to address the common behavioral sleep problems experienced by autistic children. This therapist guide includes therapist scripts, activity sheets, and treatment fidelity checklists. It also includes case examples, data collection forms, and a sleep behavior plan. The intervention is intended to be delivered individually, but may be delivered in-person or virtually. While manualized, the intervention is designed to allow for personalized tailoring based on the child’s age and skills and parent preferences.