Behavioral Treatment of Pediatric Sleep Disturbance: Ethical Considerations for Pediatric Psychology Practice

Abstract

Delayed sleep onset and problematic night wakings are common during the infant and toddler years. Such sleep disturbances typically develop as the result of learned associations with specific cues needed for sleep initiation and/or maintenance that are not consistently available at bedtime or immediately available to the child after night wakings (e.g., rocking, feeding, being held). Effective empirically supported behavioral treatments for these common sleep problems exist. Despite the research evidence supporting the effectiveness of these behavioral treatments, widespread dissemination of unsubstantiated concerns about the appropriateness and theorized negative impact of behavioral sleep treatments persists. Some researchers have even raised concerns about the ethics of health providers providing behavioral sleep treatments, particularly extinction-based treatments. As a result, providers of pediatric behavioral sleep services routinely encounter parents who raise concerns about the use of extinction-based behavioral treatments. Unwarranted parental concerns may prevent some families from seeking services that could lead to positive health outcomes. This article discusses important ethical considerations for pediatric psychologists who provide behavioral sleep medicine services. Recommendations for evidence-based clinical practice are made considering American Psychological Association Ethical Principles of Psychologists and Code of Conduct, American Academy of Pediatrics guidelines for safe sleep practices, and current research on behavioral sleep treatment outcomes.

A systematic review of prevention and treatment of infant behavioural sleep problems

“…Many parents have difficulties with this, which contributes to abrasion, lack of conformity with the method and avoiding treatment. Why these methods are difficult to implement has rarely been addressed in the literature, nor are the potentially negative consequences on parent‐child interactions when parents are taught to avoid responding to children's signals . However, a study by Price et al did not find any negative effect of extinction on child health, child‐parent relationship, maternal mental health and parenting styles five years after the intervention .…”

An overview of reviews for preventing and treating sleep problems in infants

“…Furthermore, instead of focusing on dichotomous and contradictory ideological or theoretical perspectives such as infant behaviour management versus intuitive parenting, or night‐time feeding versus sleep, proponents of the intuitive parenting approach should acknowledge behavioural interventions. These are safe alternatives that work well for many families 31 . This does not mean, however, that behavioural sleep interventions should not undergo any further improvements or scrutiny.…”

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“…When crying is ignored, parents become stressed, believing that they are neglectful or insensitive. However, there is no evidence supporting these fears (Byars & Simon, 2016), although there is also limited evidence to conclusively rule out any lasting adverse effects of extinction (Etherton et al, 2016).…”