Randomized trial of Promoting First Relationships: Effects on maltreated toddlers' separation distress and sleep regulation after reunification

https://doi.org/10.1016/j.childyouth.2013.09.021Get rights and content

Highlights

  • A randomized clinical trial of Promoting First Relationships (PFR) program

  • Sample of toddlers recently reunited with their birth parent in CWS

  • Significant effects on sleep mediated by a reduction in separation distress

  • Testing of a mediation model based on attachment theory is supported.

  • PFR reduces both separation distress and sleep problems for CWS toddlers.

Abstract

This study investigates the impact of an attachment focused intervention, Promoting First Relationships (PFR), on sleep problems among toddlers in child welfare recently reunified with their birth parent. Recently reunified parent–toddler dyads (n = 43) were drawn from a larger random control trial. Toddlers (11–36 months) and their parents were assessed in two-hour research home visits at enrollment (baseline), and a 6-month post-intervention follow-up. Measures included parental report of sleep problems and research visitor observation of separation distress (using the Toddler Attachment Sort-45). The PFR intervention predicted fewer sleep problems, adjusting for a baseline measure of sleep problems and other covariates. A path model showed evidence of an indirect effect of PFR on sleep problems through declines in separation distress. An attachment focused intervention like PFR that reduces infant separation distress can lead to reductions in sleep problems.

Introduction

In early childhood, sleep is an essential regulatory process that allows for periods of physical renewal, and is critical for consolidation of memory, regulation of the stress response system, and brain development (Dahl, 2007, Rivkees, 2001). Even though sleep is essential to growth and development, it is often elusive. In pediatrics, sleep problems constitute one of the most common complaints that parents share with their providers (Mindell & Owens, 2010) with frequent night awakenings and bedtime struggles occurring in approximately 20% to 30% of infants and toddlers (Mindell, Kuhn, Lewin, Meltzer, & Sadeh, 2006). Factors predicting the onset and maintenance of sleep problems include family stress (Mannering et al., 2011), maternal anxiety (Scher, 2008), maternal prenatal depression (Baird, Hill, Kendrick, & Inskip, 2009), poor limit setting (Sadeh, Flint-Ofir, Tirosh, & Tikotzky, 2007), and beliefs about the meaning of night-time crying (Tikotzky & Sadeh, 2009). A disruption in the parent–child relationship, which may be related to each of these factors, is also a likely contributor to sleep problems (Sadeh & Anders, 1993).

Recent research has demonstrated that the development of sleep patterns in infancy is influenced by the quality of the parent–child relationship denoted by the security of the attachment relationship (Morrell and Steele, 2003, Sadeh et al., 2010). Attachment insecurity has been shown to be a predictor of sleep problems (McNamara et al., 2003, Morrell and Steele, 2003); however, the mechanism for this relationship has not been empirically delineated. One mechanism is suggested by Bowlby (1982) who emphasized the experience of separations between toddlers and their caregivers. Separations from caregivers, beginning during the third quarter of the first year through the toddler years, are particularly anxiety provoking, especially when the parent–child relationship is not secure. In fact, in her seminal study, Ainsworth noted that anxiously attached infants (both avoidant and ambivalent) showed more separation distress in the home than securely attached infants (Ainsworth, Blehar, Waters, & Wall, 1978, p 126). An extension of attachment theory to understanding sleep problems suggests that separation from the caregiver at bed time and in the middle of the night provokes anxiety and contributes to displays of distress to draw the caregiver in to provide comfort (Scher & Asher, 2004). Morrell and Steele (2003) tested the argument put forward by Sadeh and Anders (1993) who stated that separation issues are implicated in the dyadic challenges that give rise to and maintenance of sleep problems. Morrell and Steele argued that certain behavioral correlates of types of insecure attachment would resemble night time problems that caregivers complain about: demand for parent intervention and lack of self-soothing. Morrell and Steele found support for their hypothesis, and demonstrated that children with ambivalent/resistant attachment strategies are the children with the greatest degree of sleep disruptions (night waking, sleeping with parent, and difficulty settling); moreover, this pattern of insecurity contributed to the persistence of sleep problems when children were two years old. Similar results were also found by McNamara et al. (2003).

There are theoretical underpinnings in attachment theory and the beginning of empirical support in the literature for the hypothesis that infant–parent relationships marked by anxious attachment and displays of separation distress contribute to toddler sleep difficulties. In other words, for toddlers who protest routine separations in the home, separation distress may be an underlying factor in developing and maintaining poor sleep patterns.

Section snippets

The current study

This study tests whether an attachment focused, relationship-based intervention reduces sleep problems among children who have been in foster care and are newly reunited with their birth parents. We know that young children in the foster care system have experienced early maltreatment, most often neglect, chaotic early environments, and frequent caregiver changes. A significant experience for children within child welfare is their separation from and later reunification with their birth parent.

Participants

Recruitment and study procedures were approved by the state institutional review board. Two hundred and ten toddlers and their caregivers were recruited into the Fostering Families Project (FFP) (Spieker et al., 2012a), between April of 2007 and March of 2010. The primary recruitment area was a single county. Using state Department of Social and Health Services (DSHS) records, a DSHS social worker identified all infants in state dependency between the ages of 10 and 24 months who had experienced

Results

As shown at the bottom of Table 1, children in the PFR and the comparison condition were similar at baseline with respect to means on the baseline measure of sleep problems and separation distress scores. At 6-month follow-up, children in the PFR condition were approximately half a standard deviation lower in sleep problems, PFR M = 2.1, SD = 2.7; EES M = 3.6, SD = 3.4 (t = 1.54, p = .132), and close to a full standard deviation lower in their separation distress scores, PFR M =  0.07, SD = 0.13; EES M = 0.08, SD

Discussion

For birth parents recently reunified with their toddlers, random assignment to Promoting First Relationships (PFR), a brief, relationship-based home visiting intervention, resulted in less observed separation distress in the children and parents reporting fewer child sleep problems at 6-month post-intervention, compared to dyads in an alternative condition. These findings are consistent with dyadic models of infant sleep (Goodlin-Jones et al., 2000, Sadeh and Anders, 1993). Because sleep

Implications

Behavioral treatments, specifically unmodified extinction and graduated extinction, for bedtime struggles and night wakings are recommended by the Standards of Practice Committee of the American Academy of Sleep Medicine (Morgenthaler et al., 2006). Sleep problems, however, exist along a continuum and may reflect issues in the parent–child relationship, such as children being uncertain and anxious about the emotional and physical availability of the parent, which contributes to the display of

References (31)

  • A. Sadeh et al.

    Parenting and infant sleep

    Sleep Medicine Reviews

    (2010)
  • A. Scher et al.

    Is attachment security related to sleep–wake regulation? Mothers' reports and objective sleep recordings

    Infant Behavior and Development

    (2004)
  • T. Achenbach et al.

    Child behavior checklist for ages 1 1/2–5

    (2000)
  • M.S. Ainsworth et al.

    Patterns of attachment: A psychological study of the strange situation

    (1978)
  • T.F. Anders et al.

    Sleeping through the night: A developmental perspective

    Pediatrics

    (1992)
  • J. Baird et al.

    Infant sleep disturbance is associated with preconceptional psychological distress: Findings from the Southampton Women's Survey

    Sleep

    (2009)
  • J. Bowlby
    (1982)
  • M. Briggs-Gowan et al.

    Brief Infant-Toddler Social and Emotional Assessment (BITSEA) manual, version 2.0

    (2002)
  • R.E. Dahl

    Sleep and the developing brain

    Sleep

    (2007)
  • B.L. Goodlin-Jones et al.

    Sleep and sleep disturbances: Regulatory processes in infancy

  • J. Kelly et al.

    Promoting First Relationships: A program for service providers to help parents and other caregivers nurture young children's social and emotional development

    (2008)
  • J. Kirkland et al.

    An alternative approach for the analyses and interpretation of attachment sort items

    Early Child Development and Care

    (2004)
  • D.P. MacKinnon et al.

    Distribution of the product confidence intervals for the indirect effect: Program PRODCLIN

    Behavior Research Methods

    (2007)
  • A.M. Mannering et al.

    Longitudinal associations between marital instability and child sleep problems across infancy and toddlerhood in adoptive families

    Child Development

    (2011)
  • P. McNamara et al.

    Infant sleep disorders and attachment: Sleep problems in infants with insecure-resistant versus insecure-avoidant attachments to mother

    Sleep & Hypnosis

    (2003)
  • Cited by (0)

    This study was supported by a grant from the National Institute of Mental Health, MH077329.

    View full text