To cry or not to cry? Understanding parents’ views on and uptake of infant sleep and settling interventions

Problematic child sleep is a common issue facing parents around the world, particularly during infancy, and can have deleterious effects on many aspects of health and wellbeing for the child, parents and broader family unit. Substantial literature exists on child sleep interventions, within academic, professional and general public settings. The most common intervention recommended for problematic child sleep behaviours employs behaviour theory’s concept of extinction, which involves ignoring a crying child to various degrees. Due to media and popular literature, such methods are widely known and also likely used outside of clinical settings. However, for decades, multiple sources have described parental resistance to implementing such methods and little is known about their uptake in the community. When extinction is the primary intervention recommended, this resistance potentially leaves parents without support or treatment for sleep problems, which can have significant health and wellbeing ramifications on the child, parent and broader family unit. Despite regular mention of parents’ reticence to utilise extinction sleep interventions, evidence of and explanation for this reticence is limited. Minimal space has been given to the voices of those most affected by and involved in managing child sleep problems - the parents. A transactional systems model of child sleep (Sadeh & Anders, 1993; Sadeh et al., 2010) illustrates the importance that parents and the family’s broader context play in understanding and altering child sleep. Therefore, this thesis sought to contextualise this model within an Australian context and explored (1) Australian parents’ use of three common, extinction-based sleep interventions (unmodified extinction, graduated extinction, and extinction with parent presence) and (2) views on managing sleep with their young child. Specifically, those with a child aged 6-18-months were targeted as extinction-based sleep interventions are usually recommended from 6-months of age and sleep problems are common in this age range. The paucity of previous evidence on parent perspectives on managing child sleep and use of extinction within the community meant this thesis used an exploratory, mixed methods approach to meet objectives. An online survey collected 1,344 complete responses from Australian parents (98% mothers) of a 6-18-month-old assessing factors relating to child sleep, including night-waking cognitions, parenting efficacy, psychological distress, sleep information access, extinction use and demographics. From this quantitative data, descriptive and path analyses were used to ascertain mothers’ use of extinction interventions, reasons for use or non-use, and factors which predicted use. To capture parents’ broader perspectives on child sleep, a qualitative descriptive design was also employed. Forty mothers from metropolitan (n = 3) and regional areas (n = 5) of three Australian states contributed their reflections within semi-structured, individual and group interviews. Quantitative results showed 53% of mothers had not used any of the extinction interventions, and graduated extinction was more popular than unmodified extinction or extinction with parent presence. Mothers typically used extinction for more functional reasons, while those who did not indicated more emotional and philosophical reasons. Generally, mothers valued socially sourced sleep information over professionals, the Internet over books, and information in postnatal classes over antenatal. The initial path model showed mothers’ cognitions about their child’s night-waking and perceptions of the extinction interventions were strong predictors of their use of extinction (R2 values = .24-.54). Various child, demographic and family factors were then incorporated into the model and were significant predictors of mothers’ night-waking cognitions, however, their contributions were generally small (R2 values = .09-.12). Thematic analysis of the interview data resulted in three themes, and sub-themes and dimensions within these, representing mothers’ thoughts on how they manage sleep with their young children. Theme one was “Do we have a sleep problem?” and comprised of four sub-themes, “Expectations and beliefs about what is normal”, “Is there something else effecting my child’s behaviour?”, “Comparing my child to other children”, and “How does the child’s behaviour affect my family?”. Theme two was “We have a problem, what can we do?” with three sub-themes, “Seek and find information”, “Making a choice” and “Seek support”. Theme three was “Living with my choices”, with three sub-themes, “Being judged”, “Dealing with judgement” and “Owning, embracing and accepting”. The themes highlighted how varied mothers’ perceptions of and responses to sleep challenges could be, and the emotional journey they experienced while managing sleep within their family context. The thesis findings are discussed in combination with quantitative and qualitative results to complement and contextualise each other; a valuable feature when examining the interconnected and complex nature of parents’ management of child sleep. Three key deductions are discussed based on these combined results; (1) extinction promotion is disproportionate to its use, (2) night-time parenting choices are highly personalised, and (3) child sleep information and support for mothers requires improvement. Recommendations are made for future research and clinical practice. Principally, there is a need for alternative, evidence-based, sleep intervention options to be available to parents wanting support. Extinction, the dominant sleep intervention, is not acceptable to a substantial proportion of Australian parents for a variety of reasons. A range of intervention options are required to address this variety. Further sleep intervention research is needed to provide options, and to assess how best to engage parents with professionals who can provide appropriate information and support. The findings within this thesis may not be representative of the views of fathers and different cultural groups who were underrepresented. This thesis contributes new information to the field by not only indicating the uptake of extinction sleep interventions in the Australian community, but also identifying reasons for using and not using these interventions. It also provides new, comprehensive information on how mothers make sleep-related decisions related to their young children. This information is important to advance future sleep intervention research and practice guidelines in accordance with the needs and preferences of parents, and subsequently reduce gaps in treatment acceptance.