Internet-Based Therapy And Understanding Toddler Sleep Problems

Getting a good night’s sleep is important, when a child wakes throughout the night it is hard for them to get enough sleep. If you are struggling to help your toddler get to sleep and stay asleep, you are not alone. Sleep problems can be common in young children, with up to 30% of infants and toddlers having trouble falling asleep and staying asleep. For common sleep problems that are the result of physical issues, like sleep apnea, medical attention may be needed. However, behavioral interventions have generally shown to be effective in improving both toddlers’ and parents’ sleep habits, and internet-based therapy interventions can be effective as well. If you’re interested in getting help for insomnia or other common sleep issues, including night terrors, sleep talking, or separation anxiety, online therapy can be an excellent way to connect with a licensed mental health professional who can provide the guidance you deserve.

Sleep trouble: A common behavioral issue in toddlers

Sleep trouble is generally the most common behavior problem for which parents seek the advice of primary care or family medicine providers, and dysregulated sleep may impact many children and can lead to increased challenges with mood control, focus, and trouble keeping awake during daily activities. While this can be true for all ages, young children, in particular, tend to have a hard time coping with the symptoms of a sleep problem like sleep deprivation, as their quickly developing bodies usually require a greater amount of sleep. These impacts may become apparent in behavioral changes.

What has the research shown?

The American Academy of Sleep Medicine has indicated that sleep trouble can have a high potential for successful treatment through behavioral interventions. While these behavioral interventions have been conducted over face-to-face sessions in previous years, the integration of technology into our society has led researchers to wonder whether internet-based interventions have the potential to have beneficial effects on sleep disturbances for toddlers and may help build a solid sleep foundation.

Studies looking at the efficacy of internet-based therapy to improve sleep issues have been positive, showing that symptoms of insomnia have been effectively decreased, reducing the number of sleepless nights for patients, and the effects generally remained steady at the six-month follow-up. While this can indicate the beneficial effects on adults, studies have also been conducted specifically on toddlers. In one study, where 264 families were recruited with children between the ages of six months to three years, even just two weeks of behavioral interventions were shown to have beneficial effects on the children's sleep quality.

Despite initial studies showing positive effects on sleep quality, these studies generally only have follow-ups of six months or less. Because of this, it can be difficult to assess the long-term outcomes of or problems with these interventions. To look at longer-term measures, researchers conducted this study to find the effects of the internet-based sleep intervention for toddlers after one year.

Study set-up

The purpose of this study was to examine the effects of intervention methods on sleep problems  specifically in children, and note the difference in these effects when bedtime routines were manipulated and/or changed based on intervention. Though child sleep concerns were the larger topic, this study focused specifically on toddler sleep.

Two hundred sixty-four mothers and young children (ages six months to 36 months) were recruited to set up this study. These families were then randomly assigned to one of three groups. These groups included the internet-based intervention group, the internet-based intervention plus routine group, and the control group, which did not finish the intervention.

For those included in the internet-based intervention group, the mothers were instructed to finish the internet-based intervention at home and follow the individualized recommendations with their children when they go to bed. The internet-based intervention plus routine group did the same things as the intervention group, plus a three-step bedtime routine. This routine included a warm bath, lotion/massage, and quiet activities. Materials for these activities were provided. The control group kept their children's normal bedtime routine. This intervention lasted for three weeks.

A Customized Sleep Profile (CSP) was created for each child through an algorithm developed by Mindell and Sadeh, and it used the parent’s or caregiver's responses to various questions to assess needs in three core areas. The algorithm then gave individualized recommendations and information across three areas:

• Comparison of the child's sleep to other children of a similar age

• A rating of the child's sleep quality

• Customized advice on how caregivers could help improve their child's sleep at night

These recommendations were often based on the child's age and could include age-specific recommendations, such as those related to nursing or other feeding activities, room setup, and nap time routines.

Participant follow-up

Of the 264 families who participated, 171 were present at the one-year check in. The first way families were contacted was through an automated phone call, followed by an email link to a safe website. Participants then finished an online survey and received a five-dollar stipend for participation.

After one year, the intervention group was given a 13-question questionnaire to measure each child's sleep quality. The intervention plus routine group was given a 14-question questionnaire. The control group was given a 10-question questionnaire. The questionnaires included eight core questions developed from the expanded Brief Infant Sleep Questionnaire. These questions covered topics such as:

• Sleep onset latency

• Perception of bedtime difficulty

• Number of night wakings

• Duration of night waking

• The longest stretch of sleep

• Total sleep during the daytime and night

• Perception of sleep problems

In addition to these questions, maternal sleep quality was also assessed through a question from the Pittsburgh Sleep Quality Index and maternal confidence in managing the sleep of their child. Maternal perception of internet-based sleep interventions and whether they continued to follow the intervention recommendations were also asked for relevant groups.

Descriptive analyses, such as means and frequencies, were used to analyze the demographic and sleep variables for those interested in the statistical analysis. One-way analyses of variance were used separately for each control and intervention group variable.

Results of the study

Overall, the results of this study supported the notion that internet-based therapy can significantly improve toddler sleep, not only directly after the intervention but also one year later. In general, all improvements made directly after the study were still true over one year. This included fewer concrete measures, such as the perception of the parents on whether their child's sleep had improved, and how significantly the child's sleep had been affected.

While the improvements in the internet-based intervention groups tend to support the use of the intervention, one thing to note is that the control group also saw small improvement levels. While the effects were slight, this may be due to normal developmental changes. Previous studies have shown that many sleep disturbances in young children resolve over time. However, up to one-third of infants with trouble sleeping through the night between the ages of five months to 17 months have been found to still have these problems at 29 months. This indicates that sleep problems may not always resolve with age, and internet-based interventions can be a great tool to help children lessen sleep trouble.

One positive finding from this study may be a large difference in sleep quality for toddlers and the effects of sleep problems in children before and after the intervention. Sleep wakings tended to decrease by over 50%, and there was a significant increase in how often the children slept for over two hours. The mothers' sleep quality also tended to improve.

When performing any intervention with children, it can be important that the parents are on board and confident that the intervention is what is best for their child. In this study, over two-thirds of the parents found the sleep recommendations helpful, and almost 70% were still using the recommendations after one year. One important factor with this number is that many of the sleep recommendations were specific to the child's age, so after one year, many recommendations may not have been as relevant. Additionally, if the child no longer experienced the sleeping concern, the recommendations would typically not need to be followed.

Overall, the bedtime routine was found helpful by parents, with almost 90% following the bedtime routine at least half of the time one year later, and over 50% following the recommendations most of the time.

Were there any limitations?

As with any study, it can be important to be aware of any limitations to be an objective judge of how the results should be used. One limitation of the study is that there were no objective measures of the sleep quality of the child or parent, such as using actigraphy. The reports were based on subjective measures and perceptions.

Another potential limitation of this study is that some participants did not finish the follow-up survey. However, no correlation was found between those who did and did not finish the survey.

The last reported limitation is that parents were not asked at the follow-up if they sought medical sleep treatment over the year following the study. It is possible that some did, and that could have affected the sleep improvement. It is unclear whether the participants’ children had diagnosed sleep disorders or if these sleep disorders in children affected the study.

Please note that the professionals involved in this study go well beyond clinical therapists.

As telemedicine grows in popularity, internet-based behavioral interventions generally continue to show positive effects on helping adults and children live their happiest and healthiest lives. If you’re experiencing insomnia or other challenges with your sleep, or wish to get parenting advice regarding your child’s sleeping habits, online therapy may be a fantastic choice. 

Online therapy can be a helpful option for busy parents who may have a hard time leaving the house. By signing up for an online therapy platform, you may connect with a licensed mental health professional from the comfort of your home, without having to set up childcare or drive to a therapist’s office.

As this study explains, online CBT for sleep problems can be effective in increasing sleep efficiency, refreshment, soundness of sleep, and quality of life, while also decreasing sleep onset latency, number of awakenings, and depression and anxiety symptoms. A therapist may also be able to recommend strategies for improving a child’s sleep such as allowing them to self-sooth, play quietly before bed, avoid screen time, and engage in soothing activities. If you’re having problems with your sleep, please don’t hesitate to reach out for help.