The researchers suggested focusing on better sleep-related parenting practices to support positive behavioral development across cultures.
The importance of good sleep during childhood development has been extensively researched. Bad sleep quality and behaviors are detrimental to neurobehavioral functioning, emotional reactivity and regulation, and can pose a risk for future psychopathology.
“Parental sleeping techniques are correlated with children’s sleep quality, and the importance of cultural context in child development has been long recognized,” said corresponding author Christie Pham, of Washington State University.
“We wanted to examine whether cross-cultural differences in parental sleep-supporting strategies account for differences in toddler temperament.”
They hypothesized that passive ways of helping a child fall asleep (e.g., cuddling, singing, and reading), but not active methods (e.g., walking, car rides, and playing), would be positively related to a child’s temperament.
Child temperament is defined as the way children regulate their behavior and handle their emotions. Different child temperaments can have effects on a child’s mental and physical well-being and can pose a risk for future disorders. Researchers define temperament by three overarching factors:
- Surgency (SUR), which reflects positive affect such as smiling and laughter, approach tendencies, activity, and enthusiasm.
- Negative Emotionality (NE), which captures overall distress proneness, including in situations eliciting fear, anger, sadness, and discomfort.
- Effortful Control (EC), involving attention-based regulatory skills and enjoyment of calm activities.
Each of the factors independently contributes to predicting behavioral, achievement, and interpersonal outcomes, such as behavior problems, social competence, and academic performance.
The international group of researchers asked 841 caregivers across 14 cultures (Belgium, Brazil, Chile, China, Finland, Italy, Mexico, Netherlands, Romania, Russia, Spain, South Korea, Turkey, and the US) to complete an early childhood behavior questionnaire and a daily activities questionnaire.
They were asked to report on their toddlers’ (between 17 and 40 months of age, 52% male) temperament and their sleep-supporting parenting techniques, respectively.
“Utilizing linear multilevel regression models and group-mean centering procedures, we assessed the role of between- and within-cultural variance in sleep-supporting practices in relation to temperament,” explained Pham.
Active vs. passive sleep support
They found that differences in sleep-supporting methods between cultures and within the same culture were associated with different temperament characteristics. The difference was larger between cultures, meaning that sleeping methods independently contribute to differences in child temperament across cultures.
“Our study shows that a parent’s sleep-supporting techniques are substantially associated with their child’s temperament traits across cultures, potentially impacting their development,” said Pham. “For example, countries with greater reliance on passive strategies had toddlers with higher sociability scores (higher SUR).”
On the other hand, fussy or difficult temperament (higher NE) was significantly correlated with active sleep techniques.
Overall, passive sleep-supporting techniques were associated with lower NE and higher SUR at the culture level and higher EC at the individual level. Active sleep-supporting techniques were associated with higher NE at an individual level only.
Rank-ordering the extent to which a culture’s sample endorsed using passive techniques, the results show that the U.S., Finland, and Netherlands top the list and South Korea, Turkey, and China are at the bottom of this distribution.
“Our results demonstrate the importance of sleep promotion and suggest that parental sleep practices could be potential targets for interventions to mitigate risk posed by challenging temperament profiles across cultures,” concluded Pham.
Disturbed and inadequate sleep in infants in the first year of life can be problematic1 with approximately one-third of parents reporting an infant that requires parental assistance for initiating and/or reinitiating sleep.2
Such sleep disturbance can be problematic for the whole family and is related to a substantial increase in the risk of parental depression and anxiety,1 poorer parent/infant attachment3 early cessation of breastfeeding,4 significant sleepiness, fatigue and subsequently poorer psychosocial functioning,5 parental and marital discord6 and even an increased incidence of child abuse such as shaken baby syndrome.7
Effective sleep training to reduce the consequences of disturbed parental sleep typically increases the infant’s capacity to re-initiate sleep alone, thus reducing the time taken by parents for re-settling. The most common sleep training for parents is based on what are termed within the literature ‘extinction’ methods, that is, ‘extinguishing’ (eliminating) the undesirable, learned behaviours (crying for parental assistance), by removing the ‘reward’ component (parental attention).
Extinction methods are based on Skinner’s original behaviourist theory of operant conditioning8 in learned behaviour and can be positioned along a continuum of interaction.9 However, most of these methods require the parent to ignore the child’s cries for care to some degree, usually for brief periods but in some cases, for longer stretches of time.
The least responsive is Unmodified Extinction, (‘Cry-It-Out’), in which parents are instructed to place their infant in their own sleep space alone, leaving the room with no parental attendance until morning. Unmodified extinction is interestingly the least popular with parents10 and may be less recommended by clinicians now that there are more interactive alternatives.11 Graduated Extinction (‘Controlled Crying’) is more responsive.
Parents place their infant in their own sleep space alone and attend periodically with minimal interaction, leaving their room for increasingly longer intervals until the infant ‘learns’ to depend less on parental attendance and falls asleep alone.12 More interactive again, is ‘Camping Out’, sometimes called Parental Presence, Fading of Parental Presence or Parental Fading, based on the fact that parents stay with their child until asleep,12 gradually distancing themselves from the infant at sleep onset, until they are out of the room.
In reviewing current practice, Meltzer10 categorises Camping Out as a form of Graduated Extinction because it is suggested that parents are instructed to simultaneously ignore their baby’s cries at the time of being present, as reiterated by Honaker et al.,13 who refer to this as ‘Parental Presence without Support’. Standard methodology to describe levels of ignoring (and even nomenclature) for ‘Camping Out’ is lacking. Many suggest complete ignoring,10 some suggest minimal talking with no touching12, 14 while the Raising Children’s Network15 and Blunden16 are rare in advocating the use of both where necessary.
While other well published interventions such as bedtime fading and bedtime routines are also effective,10 those interventions that do include elements of ignoring currently dominate the research. Specifically, 81%9 of all sleep intervention literature and 61%9, 17 of parent help books are dedicated to interventions involving ignoring.
The findings suggest they are effective12 in both the short12 and long term18, 19 with significant reductions in crying during overnight wakings reported in 80% of those who undertake them.20 This supports the public health intervention messages for sleep health for families in Western society,21 confirming the importance of parents not putting themselves and their families at risk (if they are not well rested).22
Quick and widely published sleep interventions such as these interventions involving ignoring, constitute plausible and often effective solutions particularly in non-collectivist societies where infant caregiving is not often shared. As well as being well researched, interventions involving ignoring have easy to follow protocols and are quickly explained by primary health-care professionals.
However, a significant proportion of parents report difficulty with ignoring children’s bedtime crying because in order to be successful, parents must ignore their child’s cries, either completely or periodically.12, 20, 23, 24 In fact, parental concerns about ignoring their child’s cries were first raised by France and colleagues during studies of Graduated Extinction almost 30 years ago.25, 26
Subsequently discrepancies have resulted between parental dissatisfaction with ignoring interventions despite the considerable empirical evidence to support their efficacy. Similarly, a paucity of empirical data to refute the core arguments against this approach (largely regarding concerns about impacts on the infant’s mental health or parent/child attachment from parental non-responsiveness), has still not quieted debate and has not assisted parents to overcome the immediate distress some feel if their infant cries alone.
Previous researchers have reported varying degrees of non-compliance to treatment protocols with attrition rates reportedly due to this immediate difficulty of hearing an infant cry and subsequent reticence to use of these ignoring techniques.25, 27, 28 Tse and Hall28 investigated parental uptake of ignoring methods in a qualitative study finding that parental reticence to ignore resulted in attrition from their study.
In two recent Australian pilot surveys, 53.5%29 and 52.9%30 of parents reported never even attempting to use ignoring techniques citing concerns about the stress to mother and child when utilised. This percentage increased to 60%29 and 72%30 when those parents who started and stopped were included.
Although comparative data from other westernised industrialised nations are scarce, these studies suggest that some Australian parents, if only offered an ignoring technique, may choose not to utilise it, even if this means they have no other strategies to improve sleep. This situation may maintain their difficulties and put them at risk.
Interestingly, despite the longstanding evidence of reticence with ignoring techniques (and attrition as a result), options for reducing parental assistance without necessarily ignoring, are lacking. This is despite the fact that consistently and steadily over many years, the need for methods based on alternative theoretical paradigms has been cited in rebuttal of these behaviourist8 ignoring techniques. These alternative paradigms are based on attachment and responsiveness to the infant and are grounded in the work of Bowlby31 and Ainsworth et al.32
Therefore, significant scientific literature for these original8, 31 but opposing theoretical frameworks, simultaneously support both (i) the necessity of ignoring a child’s cries in order to achieve infant sleep consolidation33 and (ii) also the importance of a parent’s response to infant distress for the optimal development and maintenance of maternal/infant attachment.34 The first theoretical approach results in significant advocacy for ignoring, while the second results in significant advocacy for responsiveness. As a consequence, there appears an unfortunately polarised debate35 of the literature in this field.
Prominent in westernised society,36 the first theoretical approach suggests having infants self-settle is essential to infants’ progress towards self-regulation and independence.35, 37 Parental cognitions are moulded by western societal expectations of early independent sleep and culturally specific norms for infant sleep, which in turn influence parental desires to attend or not to attend their sleep disturbed infant.38
Some studies report that Parental Presence at sleep time is ‘maladaptive and… intrusive’39 and an accepted part of neo-liberal Western childrearing practices which may place proportionally greater importance on individualist parenting approaches.36, 40 Indeed the majority of work in this field has been undertaken in these urban Western samples.35
By contrast, the second theoretical perspective considers increased maternal bedtime availability, and has its roots in attachment theory31 and is equally dependent on parental cognitions and perceptions although originating from an opposing view. This view emphasises the importance of responsive and emotional availability for social–emotional development (e.g. attachment security)31 and these ‘attachment based parenting practices’41 have been generalised to sleep.
A significant body of research cites the need for parental responding for infant self-regulation resulting in infant adaptation to independence,42 suggesting the opposite to that expressed by theorists promoting reduced parental attendance. For example, although research has suggested having infants self-settle is essential to infants’ progress towards self-regulation,37 research has also found important links between synchronous responding and self-regulation.41, 42
Further, attachment theorists suggest that not responding at bedtime/overnight can have negative impacts on the infant mental health and parent/child attachment.43, 44 Evidence to support or refute these claims is sparse,36 and although two studies18, 19 have reported no detrimental effects of ignoring over time, they cannot ascertain no impact of ignoring interventions as they could not strictly control other infant and parent variables over time, so doubt remains.
Until more data is presented, the status quo has led some36 to propose that this situation is comparable to trying to balance the expectations of western culture with primal parental instincts. So, the outcome of promoting ignoring techniques to parents who are advocates of an attachment based theoretical framework, can make things worse rather than better. For these parents the treatment is considered worse than the problem, most particularly at the moment of the intense crying.
Despite different approaches, both theories agree that responding to infants overnight does maintain infant dependency. Parents who cannot ignore or choose not to ignore but continue to attend, maintain this dependency with parent-led sleep associations, even to the detriment of their own sleep and well-being. As noted, how to reduce this dependency in sleep interventions is intensely debated.22, 40, 45, 46 Indeed, Blunden et al.40 suggest that immediate-responding and ignoring-based approaches share many common features in terms of preparation for bedtime especially and what might broadly be called stimulus control or reduced parental assistance.
However, Ramos and Youngclarke, remind us that extinction is ‘systematic parental non-responsiveness in order to teach the children how to sleep independently’.17 The debate remains polarised as mutually exclusive. However, the need for a greater choice of effective options to improve sleep, which takes into account differing levels of parental interaction and responsiveness, would suggest there is a strong rationale for integrating these differing perspectives and conceptualising sleep interventions along a continuum of interaction or responsiveness.
We propose a conceptual model offering an approach that can ‘unlearn’ parent-led sleep associations without ignoring, thus achieving similar aims to ignoring techniques, while still attending (albeit gradually withdrawing) and responding to the infant. As both methods are successful individually, there is a plausible expectation that they will also be successful when married together in a more flexible approach. So, by marrying the two theories and subsequent methods, this approach would potentially be more palatable for those parents who do not want to ignore, achieving similar short and long-term outcomes for sleep and well-being and catering for all current parental choices and de-polarise the clinical conversations. We propose ‘Plan B’.
There is some suggestion in the scientific literature that responsive parenting methods may be associated with increased sleep consolidation. This literature is sparse and has not been afforded the same level of study nor scrutiny compared to modified extinction methods described above but despite this, a growing body of evidence reports that responsive methods produce sleep consolidation without relying on parents adopting a rigid non-responsive mode of interaction with their infant(s).30, 41, 46-51
Definitions of what constitutes a ‘responsive’ sleep intervention have no doubt evolved from the literature on ‘responsive’ parenting, but definitive descriptions of responsive sleep methods are not universal. The most consistent defining feature of ‘responsive’ sleep interventions based on the sparse literature, involve clearly responding to a child at bedtime rather than not (i.e. ignoring). But how this is done varies according to the available literature. Currently there appear to be two broad categories of response1 those that aim to improve infant sleep settling by maintaining parental assistance (Responsive with Assistance)2 and those that aim to do this by decreasing parental assistance (Responsive with Decreasing Assistance (RwDA).
In the first group (Responsive with Assistance), parental assistance (e.g. picking up to soothe) is responsive and often effective in calming an infant and may subsequently increase sleep and reducing stress,46 but still necessitates ongoing parental-led sleep associations, parental assistance and fragments parental sleep. Two studies have reported data using these proactive responsive methods.46, 47
They report increases in total sleep time and reductions in wake after sleep onset, responsiveness, ease of breastfeeding and decreases in infant crying, but little reduction in parental assistance nor improvement in self soothing/regulation. Another study13 utilised Parental Presence with support, by staying in the room continuously and providing support (e.g. patting, picking up). These types of responsive methods do not fully integrate the two theoretical streams because they do not appear to aim for a reduction in parental assistance nor parental sleep fragmentation.
In the second group (RwDA), both theoretical perspectives are integrated. This is particularly targeted at infants after 6 months as prior to 6 months evidence suggests that decreasing assistance does not decrease crying.51-53 As discussed above, in most standard definitions of Camping Out in the academic literature, even if parents can respond minimally, periodic ignoring is usually included.10, 54-56 In RwDA, the parent is not instructed to ignore but to gradually reduce interaction so this is a compromise and integration between the theoretical models of extinction and attachment and more to the point, makes an attempt to systematically define the differences and or similarities of these two similar approaches. This strategy is structurally similar to Parental Presence with support, as described above by Honaker et al.,13 and on Raising Children’s Network15 because parents can always respond to the child but specifically, they progressively lessen settling support – the intensity and frequency of the response is gradually reduced over time until the infant can settle alone with nothing but a verbal response.
Although the withdrawal of optimal assistance in a dependent infant will result in some crying, the crying is reportedly less stressful for the parent.57 Responsive based interventions have reportedly increased sleep consolidation with less stress in both infant and parent.48-50, 57 An example of this method is presented in Table 1. These potential stages suggest attending to the infant verbally (always) and physically (at first), while systematically reducing the physical interaction (e.g. settling in arms, to patting in cot to staying in room to leaving the room). As the infant learns to associate the parent verbal response with a physical response, they learn to wait for the (reduced) physical response, until all that is necessary is a verbal response given as required. Matthey & Črnčec call this progressive waiting.43, 50 Parents can move through the stages at their own pace, or skip a stage, depending on the infant’s response. In this manner the infant is never ignored, yet physical assistance is reduced.
Table 1. Description of potential stages during a Responsive with Decreasing Assistance intervention
|Child wakes and signals to parent
|Parent always responds verbally before attending, immediately (at first).
|Parent begins to settle infant in their usual way but stops before the infant falls asleep (e.g. infant who is usually rocked to sleep, is rocked almost to sleep and placed into sleep space drowsy but awake and assisted to fall asleep there)
|Progressively the end point of the sleep assistance reduces from rocking to sleep, to patting to sleep, to ‘sshing’ to sleep, then delaying physical attendance (always verbally responding).
|Parent continues to verbally respond while moving in and out of the room and increasing the time before retuning.
|Eventually the verbal comfort will suffice, while the infant learns to wait, falling asleep while waiting.
In order to achieve Plan B, we therefore recommend the following:
- Alternatives to non-responsive sleep interventions need to be more available. There needs to be a concerted research effort to increase empirical evidence of the efficacy of responsive methods in reducing problematic infant sleep disturbance and thus improving parental outcomes. The paucity of high-quality studies in the responsive domain that adhere to the methodological scrutiny that has been applied to extinction techniques,12 is concerning and must be addressed. Research questions should include: the efficacy of responsive methods in ameliorating sleep and satisfying parents who are unwilling to ignore; testing the notion of a continuum of responsiveness to understand ‘which interventions, for whom and when’ and assessing if and how many parents would be better served with this gradual and possibly more lengthy approach.
- More empirical evidence will broaden the scope of sleep interventions, leading to less polarised language and broader integrated methods. Most modern behavioural interventions are based on some degree of continued caregiver response to the infant throughout the sleep initiation or resumption process. The main issues then should become how quickly parents are requested to respond to their infant and what constitutes the ‘most appropriate response’, or even whether the infant should be ignored at all.
- Infant sleep researchers and clinicians must then develop a clear conceptual framework for delivering targeted interventions to families that are consistent with their parenting values as minimising parental attrition from programmes parents find incongruent with their values, impacts positive treatment outcomes. Sleep interventions can then be chosen along a spectrum of interaction from completely ignoring (Extinction) to completely responding (Room sharing) (see Table 2).
- Primary and tertiary health-care professionals, especially specialist sleep clinicians, must have increased exposure to and training in the range of behavioural sleep interventions across all theoretical perspectives so that these targeted interventions are more broadly available. Clinicians need to be well versed in the other factors that can impact on the choices a parent makes about which treatment methods to undertake. One major factor is that responsive methods may take longer to achieve sleep consolidation16 and this consideration may well influence a parent’s decision if there are parental mental health issues or factors of reduced social and practical support.
Table 2. Five level conceptual model of behavioural sleep interventions along a continuum of interaction based on the level of ignoring
|Name of technique
|Level of ignoring/attentiveness
|Camping out with Graduated extinction
|Parental presence in bedroom ignoring cries either completely or periodically in and outside the room.
|Responsive with Decreasing Assistance
|Parental presence in bedroom responding with gradual withdrawal of level of interaction until no interaction
|Parental Presence with support (Responsive with Assistance)
|Parental staying in the room continuously and providing help (e.g. patting, picking up) until the infant is asleep.
|Room sharing close to mother
Varied options, perspectives and goals for addressing sleep problems exist but must be further studied. The argument is often put by advocates of immediate-responding approaches that this method is consistent with the infant’s attachment needs, and is more likely to promote secure attachment.
However, this claim has not been subject to empirical evaluation.43 As suggested by Sadeh et al.,22 it is ‘irresponsible and paternalistic’ (p. 336) to focus on one type of sleep intervention, particularly if that method is not achieving the desired treatment outcomes for the many families. Plan B may offer solutions where Plan A has not.
Original Research: Open access.
“Relations between bedtime parenting behaviors and temperament across 14 cultures” by Christie Pham et al. Frontiers in Psychology