Sleep training in the real world!

News from sleep science: Would you benefit from sleep training? What percentage of mothers try it? Does it work? For those who did not try it, what were the main reasons?

Today’s episode is based on the following research paper:

Sarah Morsbach Honaker , Jodi A. Mindell , James E. Slaven & A. J. Schwichtenberg (2020): Implementation of Infant Behavioral Sleep Intervention in a Diverse Sample of Mothers, Behavioral Sleep Medicine, DOI: 10.1080/15402002.2020.1817745

Hello everyone, it's Anna. Thank you so much for tuning in today. You are listening to The Baby Sleep Project Show: the place to learn about baby sleep and sleep coaching.

Hello everyone, I'm back, sorry for not publishing an episode last week, but I got my usual yearly sinusitis, which means that my voice was really nasal and horrible. So I couldn't record last week. So today I wanted to try something new, because I have just found a very interesting research article. So for those who don't know me, originally I'm researcher, I have a PhD in theoretical biology. So I am subscribed to all kinds of scientific newsletters. I follow several researchers and I get reminders and notifications in email when they publish new papers.

So I've been thinking about starting a kind of "news from sleep science" type episode, where I would tell you about interesting and useful new research that I come across, but I put it off because I felt it was a bit risky. People might find it too complicated or too dull, and I might come across as geeky or nerdy. But you know what? I am a nerd. I have a PhD afterall and I enjoy reading and talking about this stuff. So I hope that I can make it interesting for you too.

So today I will talk about a scientific paper or article that is about sleep coaching in the real world. So it is about how often moms decide to sleep coach their children. Do they finish it? Do they see improvements? And what are the factors that influence whether mothers start sleep coaching in the first place? So the title of this article is "Implementation of infant behavioral sleep intervention in a diverse sample of mothers". So infant behavioral sleep intervention is the scientific term for sleep training. So basically this paper will be about sleep training in a diverse sample of mothers. So the researchers made sure that their respondents, because this will be a questionnaire type of research, so their respondents come from diverse backgrounds and with diverse racial and ethnic profiles.

Okay. So the authors are Sarah Morsbach Honaker, Jodi A. Mindell, James E. Slaven and A.J. (Oh my God) Schwichtenberg, sorry for butchering your names. I don't know the other authors, but I know Jody Mindell. She's a professor of psychology at St. Joseph's University in Philadelphia. And she's also an author of several popular books, like, um, Sleeping through the night, Take charge of your child's sleep or A clinical guide to pediatric sleep. You might have read some of her books. This paper was published in behavioral sleep medicine in September of 2020. I will put the citation in the, in the show notes.

So the goal of this research was to discover more about sleep coaching in the real word and to assess racial, ethnic group differences.

So the researchers devised a questionnaire that asked mothers questions about their demographics, about how their child slept and about sleep coaching. They had 353 participants, all mothers of children between 6 and 18 months of age. And all of them were US residents. So what did they find? First of all, about sleep problems. They have found that 22% of mothers found their child's sleep problematic, but... - which is quite a low number - but, when they completed the infant sleep questionnaire part of the questionnaire, which is a scientific method of determining whether someone has a sleep problem, it seemed that 47% of the children had sleep problems. So it's more than twice.

And they also used a different measure for sleep problems, which they called sleep difficulty. This sleep difficulty variable indicated if the parent reported one or more of problematic infant sleep characteristics, and these were the following. So if you reply yes to any of these that means that, in their definition, your child has a sleep difficulty. So first, if sleep onset latency is more than 30 minutes, what does it mean? Sleep onset latency is the time between putting your child to bed and when your child actually falls asleep. So the time it takes for your child to fall asleep. Second, if wake after sleep onset, or WASO is more than 30 minutes, what does it mean? It means that if your child is awake more than 30 minutes per night during the night, so after bedtime, not counting, the time it takes for him or her to fall asleep. So this is in the middle of the night and third, if your child wakes more than three times per week, or more, than that indicates a sleep difficulty. So according to this sleep difficulty variable 50% of infants had a sleep difficulty. So this means that this is a little bit even more than according to the other measure, the infant sleep questionnaire.

Okay. How about sleep training? So 60% of mothers were familiar with sleep training. They actually asked about sleep intervention and they explained it in their questionnaire, what it is, so I will read that quote, so: "Sleep intervention refers to some different strategies for teaching a baby to self-soothe or fall asleep without help from an adult. When using a sleep intervention an adult puts a baby in his or her crib, or sleeping place while awake. The adult may leave the room and stay away until the baby falls asleep, check on the baby, or stay in the room until the baby's asleep. Usually the adult does not pick up the baby when he or she cries. Sleep intervention is sometimes called sleep training and includes strategies such as the Ferber method, the no-cry sleep solution or cry-it-out. Sleep intervention goes beyond encouraging positive sleep habits and is usually used when a parent has a concern about their child's sleep and wants to change something".

So from this definition, it is clear that what they asked about was not sleep coaching in general, which would be, as they say, encouraging positive sleep habits that is sleep coaching, but they specifically ask about sleep training. So teaching a child to self-soothe and stay asleep at night. Okay, so 60% was familiar with sleep training and 36% of mothers tried sleep training. So that means that more than one third of mothers tried sleep training. Of these, 20% stopped early before completion.

Stopping early was defined as stopping because it wasn't helping, or it was too difficult, and it's a pity they didn't ask more about it, because I would be really interested why mothers stopped sleep training. So, I think that it's a huge difference whether it was not helping, or it was too difficult and these problems could be addressed differently.

Okay. But of those who finished sleep training, 55% found it definitely helpful in improving their child's sleep, 21% felt that it helped temporarily, and 6% felt that it helped somewhat. So the rest felt that it was not helpful. So if we add this up, this will be 82%. Right? So the majority 82% of moms felt that it was at least a little bit useful or helpful.

Okay. They also asked mums about the possible reasons why someone would not try sleep coaching. And there were nine potential barriers, or they, they called them structural barriers, why some, someone would hesitate or wouldn't try sleep training. And they found that for six out of these nine potential barriers got an agreement around 40 or 50%, meaning that half the mothers thought that these things make it more difficult to try sleep training. And these were: first, that a crying baby in the middle of the night would wake up neighbors or others at home; second, that they don't have enough energy; third, that it would disturb their sleep, I mean the mother's sleep; fourth that other people at home would pick up the baby or would tell the mothers to pick up the baby; fifth, a baby crying in the evening might disturb neighbors or others at home; and sixth that they have other children at night to care for.

So half of the mothers agreed that these are barriers to try sleep training. And two of these, like the one where they don't have enough energy and the other one that it would disturb their sleep is a very valid reason because usually when you try sleep training first sleep gets worse, because the baby will not be able to fall asleep with the usual methods, the baby has to learn something new, so that means that first you and the baby will get less sleep. And most of the other reasons are concerning other people. These are about the fear that sleep training would mean a lot of crying, and it would disturb other people, neighbors, others at home or other kids.

Okay. But when the researchers tried to predict from these factors or these barriers who didn't try sleep training, they found that these barriers were not predictive, meaning that the answers to these questions were not enough to predict whether a mom would try sleep training.

But they have found other factors! And these were lack of familiarity with sleep training, negative cognitions and beliefs about sleep training and the perception that a child's sleep is not problematic. So more specifically, 55% of moms who did not try sleep training were unfamiliar with it. And it makes a lot of sense. Of course, if you don't know about it, you can't try it. 40% believed that sleep training causes attachment and emotional problems. However, the scientific literature doesn't support this misbelief. But those, who believed that it is important for an infant to self-soothe, those were more likely to... to try sleep training, and this is also for obvious reasons. And the last reason is that many of the mothers whose child had a sleep difficulty, or problematic sleep, according to the scientific definition, they don't perceive their child's sleep as problematic. So of course, if you don't perceive it as problematic, then you don't want to fix it, right? So of those who had not tried sleep training, only 19% reported that their child's sleep was problematic by their own subjective definition. But 44% had sleep problems when the researchers analyzed their children's sleep patterns.

Okay. So to sum up this research I think there were several very interesting facts and numbers in this research. So about half of the children have sleep problems, but only 22% of moms perceived their child's sleep as problematic. So less than half! I think this contradiction could come from the fact that many moms wear sleep deprivation as a badge of honor. So they don't want to complain about their child's sleep. They don't want to see it as problematic, because they take pride in their night parenting, basically. And I think it's beautiful. I think it's, it's an, it's a, it's a wonderful thing, but also it means that if you are unsure, if you feel that you are not coping well enough, it could be because you have a problem. It could be that you don't perceive it as a problem, but it doesn't mean that it cannot be improved.

Okay. Another interesting fact is that one third of moms try sleep training, and most of them find it helpful. So for me, this means that more moms could try sleep training and also that most find it helpful. But unfortunately we don't know that those who stop it early, why, why they stop it. So that for me, that would be an interesting research question. And the main reasons for not trying sleep training is unfamiliarity and misconceptions about sleep training and not finding their child's sleep problematic. So for me, the takeaway is that if we want to have more families [to try sleep training], we should educate mothers about the benefits of sleep training, and also do some myth busting about its negative effects, because these are the two important modifiable factors that influence whether moms try sleep training.

And for you dear listener, the takeaway is that you might perceive that your child doesn't have a sleep problem, and if you are coping well, then it is great. Just do whatever you did before! But if you don't, then it's worth checking whether your child has a sleep problem. Because if you see that your child doesn't have a sleep problem, even in this case, you both, you and your child and the whole family might benefit from sleep training and sleep coaching in general.

So if you want to check whether there's room for improvement, consider the three rule of threes that these researchers used for assessing sleep problems. So these are the following: If your child takes more than 30 minutes to fall asleep, then it might be worthwhile to try sleep training. If your child spends more than 30 minutes awake in the middle of the night. And if your child wakes up more than three nights a week in the middle of the night. So these are the three things that signify a sleep difficulty. And if your child has a sleep difficulty, then there is room for improvement and you both might benefit from sleep training.