Elsevier

Sleep Medicine

Volume 32, April 2017, Pages 40-47
Sleep Medicine

Original Article
Cognitive–behavioral versus non-directive therapy for preschoolers with severe nighttime fears and sleep-related problems

https://doi.org/10.1016/j.sleep.2016.12.011Get rights and content

Highlights

  • CBT for preschool nighttime fears and SRPs was compared with an active control.

  • Improvement in fears and objectively measured sleep was observed in both groups.

  • CBT was superior to control in reducing reported SRPs and co-sleeping with parents.

Abstract

Objective

To compare the efficacy of a developmentally appropriate cognitive–behavioral therapy protocol for preschoolers with severe nighttime fears and sleep-related problems, with an active control treatment.

Methods

Ninety children aged four to six years (63% boys) with severe nighttime fears and their parents were randomized to either cognitive–behavioral therapy including parent involved play (CBT-PIP) or to a structurally equivalent non-directive treatment (TEPT; triadic expressive play therapy). Treatment conditions were also equivalent in parent- and child-rated credibility and expectancy, and in therapist-rated compliance. Children and parents were assessed at baseline, during the first intervention week and four weeks after treatment. Measures included actigraphy, daily sleep logs, structured diagnostic interviews and parent questionnaires.

Results

Significant reductions were observed in nighttime fears and objectively and subjectively measured sleep disruptions in both intervention groups following treatment. Parent reports indicated more advantageous outcomes for CBT-PIP compared to TEPT, with greater reductions in sleep problems and co-sleeping as well as higher customer satisfaction in the former group.

Conclusions

While CBT-PIP showed no significant advantage compared to the active control in reducing fears or in improving objectively measured sleep, it was significantly more beneficial in reducing the adverse behavioral features of nighttime fears.

Introduction

Nighttime fears (NFs) are highly prevalent among children of varying ages, and are generally considered a normal phenomenon, experienced by about 70% of children [1], [2]. However, in approximately 10% of children these fears become severe and persistent, interfere with normal functioning and cause considerable distress for the child and the family [1]. Apart from the emotional disruptive features, sleep problems are an integral part of the clinical picture as nighttime-fearful children present difficulty in going to sleep and in falling asleep, recurrent night waking and difficulty in resuming sleep [3]. Co-sleeping is also common in such cases. In a study by Cortesi et al. [4], 95% of co-sleepers reported NFs, whereas only 15% of solitary sleepers experienced them. Bed sharing with parents may be an effective way to soothe fears in the short term, allowing children to avoid the feared situation of being alone at nighttime, and providing an opportunity for closeness and affection from parents. Yet, similar to other avoidance behaviors, it may be highly reinforcing and thus perpetuate the problem in the long term [5], [6].

Despite being defined as “diseases” by Hippocrates two and a half millennia ago [7], NFs do not constitute an independent diagnostic entity in contemporary diagnostic systems. Nevertheless, intense fears of this nature are often associated with anxiety disorders and other psychiatric diagnoses [1]. The emotional implications of NFs may include impairment of the self-image and feelings of social embarrassment or isolation, due to avoidance of dark areas, refusal to visit friends or to sleep away from home [8]. Related sleep problems further augment this issue, as research has shown that sleep disturbances and insufficient sleep have deleterious effects on children's cognitive development, mood regulation, behavior, health and overall quality of life [9], [10], [11]. Given these potential adverse effects, it is clear that severe NFs and sleep-related problems require adequate assessment and intervention.

Much progress has been made over the past decades in the development of cognitive–behavioral therapy (CBT) approaches for the treatment of childhood anxiety symptoms, including NFs. The techniques vary by the specific intervention, and include various combinations of psychoeducation, self-monitoring of symptoms, somatic exercises, cognitive restructuring, imaginal or in vivo exposure to the feared stimuli, reinforcement and relapse prevention [12], [13]. When considering the disruptive behavioral features of NFs, such as persistent bed refusal and co-sleeping, the use of such cognitive–behavioral components seems highly appropriate. Correspondingly, the efficacy of brief CBT interventions for severe NFs has been demonstrated in several studies [14], [15], [16], including maintenance of improvement at 2.5- to 3-year follow-up assessments [17], [18].

While the majority of these treatment packages have been proven to yield positive effects in children aged six years and older, to the best of our knowledge their effectiveness has yet to be studied in younger children. The applicability of CBT methods in younger children has often been questioned, considering their cognitive immaturity [19], [20]. Nonetheless, it should be stressed that there could be significant advantages to intervening at an earlier stage of development. Intervening in the preschool age has the potential to adaptively influence the representations of self and others that become consolidated during this age period [21]. Furthermore, early intervention reduces the risk for later psychopathology and impairment in functioning [22].

Consequently, there have been efforts to develop suitable CBT adaptations tailored for the needs and abilities of preschoolers. Most of these adaptations gave more emphasis to behavioral components and included play therapy techniques and involved parents in the treatment protocol. Parental participation is of great importance since parents may unintentionally reinforce anxiety by being overprotective, modeling maladaptive responses, or facilitating avoidant behaviors [5], [23]. Due to their high influence and involvement in the child's daily routine, they could be regarded as active collaborators, responsible for the implementation of therapeutic procedures such as exposure exercises [22].

Considering these guidelines and recommendations, we developed and manualized a protocol adapted specifically for preschoolers with severe NFs, called Cognitive Behavioral Therapy including Parent Involved Play (CBT-PIP). The protocol includes active parental participation and play components, as well as standard cognitive and above all behavioral techniques suitable for young children, namely psychoeducation, problem solving, gradual exposure and reinforcement management. The primary objective of the present randomized controlled trial was to evaluate the efficacy of CBT-PIP in treating four-to-six year-old children with severe NFs, compared with a non-directive treatment as an active control.

Based on Virginia Axline's Non-directive Play Therapy [24] and more recent Child-Centered Play Therapy [25], [26], we developed and manualized the Triadic Expressive Play Therapy (TEPT) protocol. TEPT includes free play with parental involvement, while all other CBT components are excluded. The guiding principles of this approach include promoting acceptance, establishing a warm relationship with the child and parents, allowing them to express their feelings freely and refraining from directing their actions. An active comparison condition was chosen over a monitoring-only (wait-list) condition in an attempt to maximize control for common curative factors (eg, positive expectations, monitoring) [27]. Hence, CBT-PIP and TEPT conditions were structurally equivalent. To further control for nonspecific factors, participant expectancy and treatment credibility ratings were assessed. Multiple outcome measures, including both objective and subjective measures, were used to assess NFs and sleep patterns. It was hypothesized that both interventions would lead to a reduction in NFs and related sleep problems following treatment, but that greater improvement would be seen in the CBT-PIP group.

Section snippets

Participants

Participants were recruited through local media (eg, newspapers and the internet), as well as advertisements for the treatment study that were distributed to parents in kindergartens. Inclusion criteria were (1) age four to six years, (2) severe NFs, existing for a minimum duration of 2 months, with significant adverse impact on the child and family, requiring parental involvement for at least two nights per week, and (3) fluency and parent literacy in Hebrew. Exclusion criteria were (1)

Baseline demographic and clinical characteristics

Demographic characteristics of the participants (children and parents) in each of the intervention groups are shown in Table 1. No significant differences were found between CBT-PIP and TEPT groups for child's age (t(85) = −1.73, n.s.), gender (χ2 = 1.08, n.s.), or for any of the other demographic variables. In addition, significant differences were not found at baseline between intervention groups in the presence of psychiatric disorders, as indicated by the DAWBA, with the exception of

Discussion

To the best of our knowledge, the present study is the first randomized controlled trial to evaluate the effectiveness of a brief CBT package for preschoolers with NFs and related sleep problems, and to compare it with an active control treatment. The advantages of this study included use of objective as well as subjective measurements of sleep, and a structurally equivalent comparison intervention, which was found to be equivalent also in parent and child expectancy and credibility ratings,

Acknowledgments

Funding: This work was supported by the Israel Science Foundation [Grant # 1047/08 to Avi Sadeh]. The authors are thankful to Ornit Arbel for coordinating the study and to the participating families.

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