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Impact of Nocturnal Awakening in Children


Discuss about the Bedtime Sleep Problems for Health.

Bedtime sleep problems and crying episodes is common in infants and young children. The stress level of parents often increases due to their inability to manage sleep problems in their children. Children are often found to remain awake either for certain durations at night or they wake up frequently at nighttime. This symptom bedtime awakening and sleep problems come under the category of Behavioral insomnia of childhood and research has showed 20-30% prevalent rate of bedtime problems in infants and preschoolers. Parental presence is also a predictor of sleep disturbance and child temperament determined future sleep difficulties (Honaker and Meltzer 2014). Research also pointed out to the impact of breastfeeding practices in the problem of night awakening (Mindell et al., 2012). The adverse outcome of such problem in children includes poor daytime behavior, high BMI, decreased health related quality of life and injuries in children. Parents of such children were found to have poor physical health and mental peace (Honaker and Meltzer 2014). In the past year several behavioral interventions has been suggested that can be employed by parents to reduce night awakening in children and Rickert. and Johnson 1988 compared the efficacy of scheduled awakening and systematic ignoring intervention on reducing night awakening and crying episodes of children. The purpose of the report is to find other relevant articles related to the topic and appraise the research by Rickert and Johnson 1988 to decided which interventions should be funded. It also gives recommendation to ensure parent’s comply with the intervention easily without any resistance.

The research study by Rickert and Johnson (1988) used randomized control study design to compare the effect of scheduled awakening and systematic ignoring on reducing nocturnal awakening crying episode in children. The research finally concluded that scheduled awakening is better than systematic ignoring to manage night awakening in children. However, to decided whether the intervention of scheduled awakening should be funded or not, it is necessary to review other research studies to analyze what has been covered in literature regarding the effectiveness of scheduled awakening for addressing night awakening in young children. The relevant research article relate to the topic is retrieved from the databases like CINAHL, Cochrane library, MedLine, Google scholar and PsychINFO. The search process was filtered by setting the date between 2008 to 2017. The inclusion criteria for taking the articles were all the articles must be published in English language and they must cover the intervention related to nocturnal awakening in small children. The main search terms were ‘nocturnal awakening’, ‘nocturnal awakening and crying episodes’, ‘interventions for nocturnal awakening’ and ‘impact of scheduled awakening in addressing nocturnal awakening’. The studies, which did not mentioned about any interventions related to the topic was not included.

Rickert and Johnson (1988) Study - Scheduled Awakening vs. Systematic Ignoring Intervention

The data collected from the literature search were tabulated by including the author name, date, journal sources, key findings and notes. The outcome of the literature search and key findings are as follows:



Journal (Source)



Galbiati et al.


Behavioral neurology

The study reviewed behavioral and cognitive-behavioral interventions for management of parasomnia. It reviewed many interventions and the results for scheduled awakening (Awaking the child before the onset of crying episode) was that the evidence regarding the effectiveness of this intervention was very weak.

Although scheduled awakening intervention is a low risk intervention, however special attention should be given not to make children sleep deprived.

Sarah, Hayley, and Hauck



The research evaluated the reasons for parent’s resistance of sleep extinction interventions which emphasized on ignoring child’s cry for a certain period. The findings of the research showed that parents concern regarding such interventions has not been investigated and there is no negative impact on parents or children in the long term.

The study indicated that sleep extinction interventions are successful in eliminating night waking episodes, however as many parents disagree to such interventions, other choices must be provided to them. In general, behavioral sleep interventions are effective in bringing significant change in children

Meltzer & Mindell


Journal of pediatric psychology

All evidence regarding behavioral interventions for pediatric insomnia was reviewed in this study and the study results showed that behavioral treatment improves certain sleep related parameters such as sleep-onset latency, night awakening frequency and night awakening duration. However, moderated level of evidence is present regarding and more work is needed to validate the finding

The study provided support for interventions like scheduled awakening, bedtime fading and scheduled awakening however there was lack of evidence to prove it as well established intervention

Fehr, Russ. and Ievers-Landis 2016.


Clinical Practice in Pediatric Psychology

This research evaluated the effectiveness of including cognitive behavioral play intervention with parent behavior management to address sleeping difficulty in children. The intervention was found to reduce anxiety and stress in children.

Randomized study is needed to establish the efficacy of cognitive-behavioral play intervention

Tikotzky & Sadeh


Sleep medicine

The research evaluated the role of cognitive-behavioral therapy in behavioral childhood insomnia and results gave support regarding the positive effect of the intervention on addressing sleep problem

The study mentioned about ignoring the child’s cry and leaving them so that they fall sleep and randomized controlled studies proved it beneficial for treating night waking problem. In addition, scheduled awakening was given less favour because parents do not comply with the procedur.

The critical appraisal of the Rickert and Johnson (1988) work has been done by the application of RCT CASP tool and the results are as follows:

Focussed issue in trail:

For analyzing any randomized controlled trial (RCT), it is necessary that the paper has clear statement regarding the population studied, intervention provided , comparator analysed and the outcome considered. Rickert. and Johnson (1988) stated the purpose of study by giving the clear statement regarding studying the effectiveness of scheduled awakening (intervention) and systematic ignoring (comparator) on reducing nocturnal awakening crying episode (outcome) in toddlers and infants (population studied). This statement clearly defined the focused issue in trial.

Randomization of patients to treatment:

As RCT studies mainly compares the effect of an intervention on treatment group and control group, it is critical to prevent biasness in study findings by means of randomization to treatment and allocation concealment. This means that the person involved in randomizing patients to different group should not be aware about the next treatment allocation. This is done by keeping a randomization code. This may be either unique code or explicit codes (Dettori 2010). Rickert and Johnson (1988) selected 33 children between 6 months to 54 months and the children were randomly assigned to the different condition.  Different groups included control groups, systematic ignoring group and scheduled awakening group. Hence, it is seen that explicit randomized coding approach has been used to minimize bias and confounding factors in the study.

Consideration of all patients till conclusion:

A common limitation seen in RCT studies is that researchers fail to follow up with the participants after the implementation of intervention. This affects the strength and validity of the trial. Attrition effects occur because failure to follow up results in missing important data at one point or another. This form of attrition effect is seen in RCT study comparing nocturnal awakening and scheduled awakening (Dumville et al. 2006). This was seen because earlier 50 children were included in the study, but 17 children dropped out in between the study. However, the researcher focused on reducing the attrition effects by instructing all parents not to parents not to implement any treatment if their child was ill. This also reflects that follow up was kept regarding illness in any child in between the research. The attrition effect was further minimized by extending the treatment for those child who fell sick between the study. Therefore, total treatment days in the study was 5 days and it was modified for those who child who fell ill (Rickert and Johnson 1988).

Literature Review on Effectiveness of Scheduled Awakening

Blinding to treatment:

Blinding is another approach to minimize biasness and increase the vigour of study. This is done by process to ensure that no one, neither the participants not the research analyst is aware of the allocation of groups treatment. Based on the number of individuals from whom allocation is concealed, it is classified into single blind and double blinding. The more number of persons are  blinded, the better is the assessment of study results (Karanicolas et al., 2010). While analyzing Rickert and Johnson (1988), it has been found that single blinding was done to enhance the research analysis process. For example, all participants were randomized to three treatment conditions and participants got to know about their assigned group only after the data related to the daily schedule of awakening was collected from each participants.  The randomization to treatment group was also done by predetermining the group for each family before the home visit. The process of blinding is also understood from another research articles which aimed to determine the long benefits or harms of infant behavioral sleep programs on child, child and parent; and maternal outcomes. In that study, single  blinding was seen however here the allocation was concealed from the researchers and not the parents unlike the above study (Price et al.,  2012).

Similarity of the group at the start of the trial

Similarity of the group at the start of the trial is determined by researcher’s consideration to maintain the same baseline data for the participants. Having similar baseline variables for all participants is also important this also has an impact of study results. Baseline variable is related to age, education, social class or disease severity in participants. Adjustment in baseline variables provides protection against chance bias (Higgins et al. 2011). The equality in baseline variable was maintained by Rickert and Johnson (1988) by recruiting children between 5 to 54 months only. However, similarity in family type was not seen as single parent families and two parents both were taken for the trial. Different in terms of demographic variables was also seen because subjects came from small towns and cities too. This may also give a prediction regarding the impact of sociocultural variable on child crying and nocturnal awakening problem. In another research study, the main focus was on including participants based on Diagnostic and Statistical Manual of Mental Disorders as it aimed to evaluate strategies for improving sleep problems in children with ADHD. This helped to balance baseline data for the study (Hiscock et al., 2015).

Critical Appraisal of Rickert and Johnson (1988) Study

Equal treatment of groups

Equal treatment of participants groups is determined by researcher’s consideration regarding the factors that will influence the performance of one group from another. In the study by Rickert and Johnson (1988), three groups of participants were present and equality in treatment was done by maintaining separate data for those children for became ill. As illness in any child would have impact of crying episodes and nocturnal awakening, this data was deleted and length of treatment was extended for such group. This ensures that no biased data is collected and it enhanced the validity of the research work.

Treatment effect

Treatment effect is related to the key outcomes measured and the comparison in mean outcomes between treatment group and control group. Rickert and Johnson (1988) analyzed the difference in all group by conducting one way analysis of variance for all groups on the basis of baseline data such age and frequency of crying and awakening episodes. The benefits of this approach was that it helped to conclude that mean number of night awakening and crying episodes was the same for all groups before the interventions. Post the intervention, the main outcome variable that was measured included number of spontaneous awakening and crying episodes. Among all groups, children in systematic ignoring group was found to have lesser number of awakening in the past 8 weeks. However, difference in awakening for systematic ignoring group was found only in week 3. Finally, in term of treatment effect, it was find that main effects for group did not achieved statistical significance. An effect was found only for a week, which was small. The research study by Hiscock et al. (2014) also analyzed the treatment effect by evaluating different between groups at follow up and no differential effects were found for infants who were first born or later born.

Preciseness of the treatment effect

The width of the confidence interval determines the preciseness of the treatment effects. In the study comparing systematic ignoring and scheduled awakening, it was found that the treatment effect was large. This is because wide variability were found in control group after reviewing the scatterplot analysis. Another research article evaluating prevention program for infant sleep and cry problems analysed the study results by calculations of confidence interval (Hiscock et al. 2014).

Application of the result in the local population

The validity and reliability of any research is understood if the outcome of the results can be easily applied in the local setting. From the analysis of study result, it was found that both systematic ignoring and scheduled awakening yielded positive outcome for children. The study showed that systematic ignoring gives better and faster outcomes compared to scheduled awakening which is effective but a slow process. Although there is empirical evidence supporting systematic ignoring for reducing night awakening in children, however this intervention cannot be locally applied. This is because majority of parents resist the idea of letting their child cry it out and leaving them alone. Hence, to apply this locally, parents needed to be taught about the strategies to ignoring the child’s cry. Therefore, scheduled awakening is most likely to be applied in local setting when parents are unwilling to let their child cry out. However, one work that is needed before implementing it is to identify better strategies for effectively implementing it in community setting (Tikotzky & Sadeh 2010).


Consideration of clinically important outcomes

The main target of Rickert and Johnson (1988) to bring changes in child’s outcome of crying and night awakening, however as such issues increases stress level and health of children, it was necessary to consider such clinical outcomes too. However, the researcher considered only the frequency of night awakening and not other clinical outcomes such as health of child and parents after the intervention. This is the limitation of the study and future research work in this area is required.

Value of research

Overall, the benefit of the research is high because the author efficiently presented the pros and cons in each intervention. Secondly, considering the level of acceptance of each intervention in local setting, the researcher also suggested the areas where more work is needed so that parents as well as other groups can easily implement this intervention.


The main purpose of this report was to analyze whether the intervention of scheduled awakening or systematic ignoring should be funded or not. Based on critical appraisal of the research articles by Rickert and Johnson (1988) and comparing it with similar peer reviewed journals, it has been found that scheduled awakening is a beneficial intervention based on its influence on addressing sleep problems and level of acceptability among parents. Hence, this interventions should definitely be funded and investment should be done to train clinicians regarding effective way in which this intervention can be applied in children. The competency of clinicians in implementing such intervention will further support parents to overcome the problem of night awakening in their children.


Dettori, J., 2010. The random allocation process: two things you need to know. Evidence-based spine-care journal, 1(03), pp.7-9.

 Dumville, J.C., Torgerson, D.J. and Hewitt, C.E., 2006. Research methods: reporting attrition in randomised controlled trials. BMJ: British Medical Journal, 332(7547), p.969.

Fehr, K.K., Russ, S.W. and Ievers-Landis, C.E., 2016. Treatment of sleep problems in young children: A case series report of a cognitive–behavioral play intervention. Clinical Practice in Pediatric Psychology, 4(3), p.306.

Galbiati, A., Rinaldi, F., Giora, E., Ferini-Strambi, L. and Marelli, S., 2015. Behavioural and cognitive-behavioural treatments of parasomnias. Behavioural neurology, 2015.

Higgins, J.P., Altman, D.G., Gøtzsche, P.C., Jüni, P., Moher, D., Oxman, A.D., Savovi?, J., Schulz, K.F., Weeks, L. and Sterne, J.A., 2011. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. Bmj, 343, p.d5928.

Hiscock, H., Cook, F., Bayer, J., Le, H.N., Mensah, F., Cann, W., Symon, B. and St James-Roberts, I., 2014. Preventing early infant sleep and crying problems and postnatal depression: a randomized trial. Pediatrics, 133(2), pp.e346-e354.

Hiscock, H., Sciberras, E., Mensah, F., Gerner, B., Efron, D., Khano, S. and Oberklaid, F., 2015. Impact of a behavioural sleep intervention on symptoms and sleep in children with attention deficit hyperactivity disorder, and parental mental health: randomised controlled trial. bmj, 350, p.h68.

Honaker, S.M. and Meltzer, L.J., 2014. Bedtime problems and night wakings in young children: an update of the evidence. Paediatric respiratory reviews, 15(4), pp.333-339.

Karanicolas, P.J., Farrokhyar, F. and Bhandari, M., 2010. Blinding: Who, what, when, why, how?. Canadian journal of surgery, 53(5), p.345.

Meltzer, L.J. and Mindell, J.A., 2014. Systematic review and meta-analysis of behavioral interventions for pediatric insomnia. Journal of Pediatric Psychology, 39(8), pp.932-948.

Mindell, J.A., Du Mond, C., Tanenbaum, J.B. and Gunn, E., 2012. Long-term relationship between breastfeeding and sleep. Children's Health Care, 41(3), pp.190-203.

Price, A.M., Wake, M., Ukoumunne, O.C. and Hiscock, H., 2012. Five-year follow-up of harms and benefits of behavioral infant sleep intervention: randomized trial. Pediatrics, 130(4), pp.643-651.

Rickert, V.I. and Johnson, C.M., 1988. Reducing nocturnal awakening and crying episodes in infants and young children: a comparison between scheduled awakenings and systematic ignoring. Pediatrics, 81(2), pp.203-212.

Sarah, B., Hayley, E. and Hauck, Y., 2016. Resistance to Cry Intensive Sleep Intervention in Young Children: Are We Ignoring Children’s Cries or Parental Concerns?. Children, 3(2), pp.1-5.

Tikotzky, L., and Sadeh, A. 2010. The role of cognitive–behavioral therapy in behavioral childhood insomnia. Sleep Medicine, 11(7), 686-691.

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