Children’s night waking among toddlers: relationships with mothers’ and fathers’ parenting approaches and children’s behavioural difficulties Anat Zaidman-Zait & Wendy A. Hall Accepted for publication 2 January 2015

Correspondence to A. Zaidman-Zait: e-mail: [email protected] Anat Zaidman-Zait PhD Assistant Professor Department of School Counseling and Special Education, Constantiner School of Education, Tel-Aviv University, Israel, Department of Human Early Learning Partnership (HELP), University of British Columbia, Vancouver, British Columbia, Canada Wendy A. Hall PhD RN Professor and Associate Director Graduate Programs University of British Columbia School of Nursing, Vancouver, British Columbia, Canada

Z A I D M A N - Z A I T A . & H A L L W . A . ( 2 0 1 5 ) Children’s night waking among toddlers: relationships with mothers’ and fathers’ parenting approaches and children’s behavioral difficulties. Journal of Advanced Nursing 00(0), 000–000. doi: 10.1111/jan.12636

Abstract Aims. To explore associations between children’s sleep problems, and behavioural difficulties and parenting approaches. Background. Children commonly have problematic night waking; however, relationships between parenting cognitions and behaviours and children’s sleep problems are rarely examined. Design. Longitudinal children’s cohort study from 5–29 months post birth. Methods. Data were taken from the Quebec Longitudinal Study of Child Development (1998–2007) at three phases: 5, 17 and 29 months of age. Thousand four hundred and eighty-seven families were included in our study based on: participation from phase 1 (5-months old), both parents’ reports on parenting cognitions/behaviours and child behavioural difficulties at 29 months, and mothers’ reports of children’s sleep at 29 months. In 2013, we conducted repeated measures ANOVAs and MANOVAs including children’s gender. Results. Extended night-time waking patterns (wakes of ≥20 minutes) were associated with mothers’ and fathers’ lower sense of parenting impact and higher overprotectiveness and mothers’ lower self-efficacy and higher coerciveness for 29-month-old children. In the extended waking group, mothers consistently reported lower self-efficacy, higher overprotectiveness and lower parenting impact at 5, 17 and 29 months. For those children, fathers were only more overprotective at 5 and 29 months. Regarding 29-month-old children’s behaviour, children in the extended night waking group had highest scores on externalizing and internalizing behaviours. Girls had higher scores on shyness/inhibition and boys had higher scores on aggression/hyperactivity. Conclusion. Mothers’ and fathers’ parenting cognitions and behaviours are affected by 29-month-old children’s night waking patterns and night waking patterns are associated with children’s behavioural problems. Keywords: child behaviour, children, nursing, parenting cognitions, sleep problems

© 2015 John Wiley & Sons Ltd


A. Zaidman-Zait and W.A. Hall

Why is this research or review needed? ● Children’s behavioural sleep problems are common in many countries. ● Fathers’ parenting in the context of children’s behavioural sleep problems is rarely examined. ● Children’s behavioural difficulties have been linked to behavioural sleep problems but mostly reported for preschoolers and school-aged children.

What are the key findings? ● 29-month-old children’s extended night waking time is associated with mothers’ and fathers’ parenting impact,

waking with signalling has been used in international studies to indicate fragmented or unconsolidated sleep (Sadeh et al. 2009). The American Academy of Sleep Medicine Classification of Sleep Onset Association Type Insomnia (2005) has defined night wakes of 20 minutes or as indicative of a sleep problem. Parents have been more concerned about children’s sleep problems than difficulties with language and motor development, toileting and teething (Mindell & Owens 2003). Children’s chronic behavioural sleep problems can have a lasting effect on how parents perceive their own mental health, their relationships with their children and their children’s behaviour (Wake et al. 2006).

and overprotectiveness, and mothers’ self-efficacy and coerciveness. ● For 29-month-old children with extended night waking, fathers report being more overprotective at 5 and 29 months. ● At 29 months, parental reports of levels of children’s internalizing and externalizing behaviour are highest in children with extended night waking.

How should the findings be used to influence policy/ practice/research/education? ● Longitudinal research examining children’s behavioural sleep problems could indicate whether early extended night waking leads to lower maternal self-efficacy and increased coerciveness. ● Health care providers could assist parents to manage toddlers’ night waking duration to reduce effects on parenting cognitions. ● Health care providers could assist parents to examine their rationale for overprotectiveness and potentially reduce overprotective behaviours.

Introduction Behavioral sleep problems are common in many countries and affect between 25–40% of the paediatric population (Owens 2005). Predominant problems have been difficulties in falling asleep and staying asleep (Palmstierna et al. 2008). When left untreated, children’s sleep problems can become chronic (Mindell et al. 2006, Meltzer 2010). Studies are not consistent when defining children’s behavioural sleep problems; however, presence and length of night waking is a common marker for ongoing sleep problems in early childhood (e.g. Gaylor et al. 2001, Morrell & Steele 2003, Hiscock et al. 2007a,b, Beijers et al. 2011). Night 2

Background Sadeh and Anders (1993) proposed a systems model that incorporates infant self-regulation or the infant’s ability to transition smoothly from wakefulness to sleep and to sustain continuous sleep for an age-appropriate period. They viewed the sleep-wake system as an initial marker of behavioural organization and adaptation. Difficulties with children settling to sleep and night waking indicate disruptions in children’s consolidation and regulation of sleep. They propose that dynamic transactional relationships between children and parents mediate sleep-wake regulation and affect sleep continuity. Parents contribute varying cognitive and emotional representations to relationships; children bring developmental/maturational factors, constitutions and temperament. France and Blampied (1999) have suggested that night waking with signalling is linked to parental overstimulation which inhibits infants’ learning about self-regulating sleep. They describe overstimulation as vigilant monitoring, low thresholds for detecting infant signals and low latency of response to signalling, and settling responses characterized by high intensity and long duration. Intense and prolonged parental responses to infant night waking imply longer duration of night waking. When examining relationships between parenting and children’s sleep problems it is important to consider sleep problems that have the most significant effects on parents, and those indicative of children’s difficulties with self-regulation. Night waking with signalling has been linked to British children’s difficulties with self-regulation (Morrell & Steele 2003), and has had significant effects on Australian parents’ physical and mental health (Martin et al. 2007, Hiscock et al. 2008). Longitudinal data on parenting are important when examining children’s sleep problems beyond infancy, particularly night waking and its relationship with children’s behavioural difficulties. © 2015 John Wiley & Sons Ltd


Parents are necessary to meet their children’s needs because children are not capable of identifying their own needs (Mowder & Shamah 2009). Moreover, sensitive and supportive parenting facilitates the development of children’s self-regulatory skills (Keown 2012). Parenting interactions that encourage appropriate challenges and opportunities for mastery (self-regulation) promote children’s self-confidence and sense of self-worth (Sander 2000). Parenting styles, with high levels of parental affection and behavioural control, can provide an optimal environment for children’s development of self-regulation (Baumrind 1966, Belsky & Barends 2002). Several studies have suggested that parenting approaches affect children’s sleep problems. An Australian study of preschoolers reported that hardier parents had children who experienced fewer sleep problems, because parents were less doubtful about parenting competence and had fewer difficulties with limit setting for children (Johnson & McMahon 2008). Hall et al. (2007) found that lax parenting (giving in to children) in Australian children’s second year of life predicted higher sleep problem scores in their third year. Mothers’ higher scores on negative parenting (hostile, punitive and aversive interactions) were associated with more sleep problems for Canadian preschool children (Reid et al. 2009). Other study findings have suggested that infant night waking and settling difficulties decrease British mothers’ feelings of competence (Morrell 1999) and undermine Canadian parents’ confidence (Tse & Hall 2008). Simard et al. (2008) found that, rather than maternal self-efficacy predicting children’s total sleep time, Canadian mothers’ active involvement in physically comforting children at settling and difficulty setting limits mediated the relationship between previous and ongoing night waking. Although most studies rely on reports of maternal behaviour, fathers also influence children’s sleep problems. For example, Israeli fathers’ involvement in infant care has been associated with less infant night waking but shorter total sleep time due to later sleep onset (Tikotzky et al. 2011). Israeli fathers have been more likely to endorse a limit-setting approach to children’s sleep problems but both mothers and fathers have had more difficulty with limit setting when their children have clinically defined sleep problems (Sadeh et al. 2007). Because fathers’ contributions to parenting in the context of children’s sleep have received minimal attention it is important to explore their reports of parenting and contributions to children’s sleep. In sum, examining both mothers’ and fathers’ approaches to parenting and parenting cognitions can illuminate their potential contributions to children’ sleep behaviour. © 2015 John Wiley & Sons Ltd

Night waking and parenting approaches

Children’s sleep problems are associated with negative behavioural outcomes. Night waking has been linked to hyperactivity and emotional and behavioural difficulties, after controlling for maternal depressive symptoms (Hall et al. 2007, Hiscock et al. 2007b, Reid et al. 2009). Reid et al. (2009) found that Canadian children’s sleep problems accounted for variance in their anxiety (general and separation) and hyperactive, inattentive, and physically aggressive behaviours. Likewise, three-year-old Australian children who woke frequently demonstrated more aggressive behaviour at 4 years of age (Hall et al. 2007). Children’s gender was not a significant factor in either study. Australian children with sleep problems had higher rates of attention-deficit/hyperactivity disorder, after adjusting for age, child gender and household income (Hiscock et al. 2007b). Social inhibition or shyness in children, which has been considered an early indicator of maladaptive behaviour, (Rubin et al. 2009) has been overlooked in studies of children’s sleep problems. Shy boys have increased risk for maladjustment and depression compared with girls, but differences are inconsistent (Eggum et al. 2012). American toddlers’ with anxiety disorders have been significantly more likely to demonstrate shyness (Warren et al. 2006). For American school-aged children, parents’ ratings of shyness predicted children’s internalizing symptoms 2 years later (Eggum et al. 2012).

The study Aims This study explores the associations between children’s sleep problems, parenting approaches and children’s behavioural difficulties. Our research questions were: Do night-time waking pattern differences (presence and length of night waking) correspond with differences in mothers’ and fathers’ parenting cognitions/behaviours among 29-month-old toddlers? Are mothers’ and fathers’ parenting cognitions/behaviours already apparent before their toddlers’ differences in night-waking patterns at 29 months of age? Do night-time waking pattern differences relate to mothers’ and fathers’ shared perceptions of children’s behaviours among 29-month-old toddlers?

Design The study data came from the larger Quebec Longitudinal Study (survey/interview) of Child Development (1998– 2007) conducted by the Quebec Institute of Statistics (Petit et al. 2002). Children were recruited from the Quebec 3

A. Zaidman-Zait and W.A. Hall

Master Birth Registry of the Ministry of Health and Social Services and assessed on an annual basis from 5 months. This study, conducted in 2013, is based on family assessments when children were 5, 17 and 29 months of age (cycles 1, 2 and 3). The sample is representative of children born in the Province of Quebec in 1997–1998 (for more details on the QLSCD methodology, see Jette 2002, Jette & Des Groseilliers 2000).

Participants In phase one, 2223 families were enrolled. A total of 2120 families took part in initial data collection (age 5 months), and 1997 remained at 29 months of age, the first endpoint for the study. At 29 months (cycle three), 1796 families provided sleep data. Of those families, 1487 (740 boys and 747 girls) were included in our study based on having: mothers and fathers who participated in the study from phase 1 (5 months old), both parents’ reports on parenting cognitions/behaviours and child behavioural difficulties at 29 months, and mothers’ reports of children’s sleep at 29 months. In our sample, most children (898%) had a Canadian non-immigrant mother and father (895%). The majority of mothers (933%) and fathers (938%) were Caucasian. Most fathers (864%) and mothers (860%) spoke French as a primary language. The mothers’ education levels were university (353%), college (423%), high school diploma (101%) and incomplete high school (123%). Among fathers, 731% had some kind of postsecondary education, specifically college (458%) and university (273%). Regarding household income, 82% families had incomes of less than $19,999 (CD), 256% families had incomes between $20,000–39,999, 284% families had annual household incomes of between $40,000–59,999 and 377% of families had incomes of $60,000 or higher. At 29 months, most children lived in a 2-parent family (876%), 104% lived in a blended family, 17% lived in a single-parent family and 03% families did not indicate status.

Data collection Sleep problems Questions about the child’s sleep were part of the SelfAdministered Questionnaire for the Mother (SAQM), which takes about 20 minutes to complete and was completed by biological mothers in most cases (995% at 29 months). We used one item about the night waking at age 29 months: the presence and length of night wakes. 4

Parenting cognitions and conduct (approaches) Both mothers and fathers completed the Parental Cognitions and Conduct towards the Infant Scale (PACOTIS) when children were 5, 17 and 29 months of age. The selfadministered questionnaire measures parental cognitions and behaviours for parents of young children (Boivin et al. 2005). The measure comprises four subscales: parental selfefficacy (ability to carry out tasks associated with the parental role); parental impact (evaluations of effect of their behaviour on their children); coercive behaviour (hostile and restrictive responses to children’s difficult behaviours) and overprotectiveness (excessive concern for the safety and protection of their children). The parents indicated on an eleven-point scale (0–10) how accurately statements described their actions, thoughts, or feelings, during their interactions with their children. Internal consistencies for all four scales across informants were high (all as > 075). For more detailed information about the psychometrics of the PACOTIS questionnaire (see Boivin et al. 2005). Child behaviour Child behaviour/symptoms were taken from the Interviewer-Completed Computerized Questionnaire (ICCQ), which is a 1-hour 45-minute, face-to-face structured interview with mothers. Fathers completed reports of child behaviour/symptoms. Mothers and fathers were asked to rate their children on a frequency scale indicating whether children never (0), sometimes (1) or often (2) exhibited any of the symptoms (in the last 12 months). We extracted child disruptive behaviours similar to those reported by Baillargeon et al. (2012). The behaviours included, opposition (i.e. does not feel guilty after misbehaving), physical aggression (i.e. physically attacked others) and hyperactivity (i.e. cannot sit still). In addition, we extracted depressive and anxiety symptoms as described by C^ ote et al. (2009). Their scale list of six symptoms (e.g. appears fearful or anxious) was selected from the Preschool Behavior Questionnaire (Behar & Stringfield 1974); the symptoms are similar to items on the anxious/depressed and emotionally reactive subscale of the Child Behavior Checklist (Achenbach 1991). Mothers and fathers also reported on their children’s separation anxiety (e.g. reacts badly away from parents) and inhibited (shy) behaviour (e.g. takes a long time getting used to being with children he/she doesn’t know). We selected those behaviours because they both are indicators of self-regulation and are associated with sleep problems in other studies (Reid et al. 2009, Hall et al. 2012). All socio-demographic indicators (e.g. socio-economic status, type of family) were obtained from the ICCQ. © 2015 John Wiley & Sons Ltd


Validity and reliability Fathers’ and mothers’ combined scores were computed using the principal components analysis-based approach outlined by Kraemer et al. (2003). This approach can measure a core characteristic (i.e. behavioural symptoms) while overcoming systematic error associated with reporters’ different perspectives. The first component of each principal components analysis (designated the core child behaviour scale score) represented the variance in reported child behaviour shared between the two parental reports (see Kraemer et al. 2003, for details). The factor loadings for each informant were between 078–087. The internal consistency values (alphas) were a = 060 for the depression and anxiety symptoms, a = 054 for opposition, a = 074 for hyperactivity, a = 079 for physical aggression, a = 061 for separation anxiety and a = 076 for shyness/ inhibition.

Ethical considerations All families received detailed information by mail about the study. Ethics approval from the Institut de la Statistique du Quebec’s review board was obtained and informed parental consent was obtained at each assessment.

Data analysis We created three sleep groups, no night wakes (no problem), total night wakes of less than 20 minutes and total night wakes of 20 minutes or more. Wakes of 20 minutes or more are based on the American Academy of Sleep Medicine Classification of Sleep Onset Association Type Insomnia (2005). We performed a series of two-way ANOVAs to determine whether parenting approaches for mothers and fathers varied by wake groups when children were 29months old. Because children’s gender may influence parenting approaches it was included in the model. After determining that parental behaviours/cognitions varied by wake group at 29 months, we used parents’ data from 5–17 months of age to examine whether parenting approaches predated parents’ identification of problematic night waking. In this analysis, we examined any differences in parenting approaches when children were younger; however, we only included scales of parenting cognitions/behaviours that were significantly different among children’s wake groups at 29 months. Using repeated measures GLM analyses, with wakes as a between-subject variable, time as a within-subject variable, and a time by wakes interaction, we compared each of the parenting scales. Finally, to test © 2015 John Wiley & Sons Ltd

Night waking and parenting approaches

differences in children’s behaviours between children with different night waking patterns a series of two-way MANOVAs were performed. The second main effect included in the model was children’s gender. In addition, we examined the interaction between children’s gender and wakes.

Results We examined parenting cognitions and behaviour by wake patterns (Table 1 for parents’ mean scores at 5, 17 and 29 months). Findings indicated significant main effects for wake groups on mothers’ self-efficacy (F (2, 1476) = 1308, P < 0001), sense of parenting impact (F (2, 1475) = 557, P < 001), overprotectiveness (F (2, 1475) = 945, P < 000 1), and coercive behaviours (F (2, 1477) = 555, P < 001). No significant gender main effects and interaction effects of gender and wake groups influenced mothers’ behaviours and cognitions. For mothers with children in the no wake group, parenting impact and self-efficacy scores, were significantly higher than those of mothers of children in the other groups (wakes of

Children's night waking among toddlers: relationships with mothers' and fathers' parenting approaches and children's behavioural difficulties.

To explore associations between children's sleep problems, and behavioural difficulties and parenting approaches...
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