Sleep Program Improves Sleep, Behavior in Children With Externalizing Issues

The Sleep Train Program, a brief behavioral sleep intervention, has been shown to significantly enhance sleep quality and behavioral outcomes in children with externalizing problems and comorbid sleep difficulties. However, the intervention does not yield substantial benefits for children with externalizing problems alone. These are the findings of a study published in Behavioral Sleep Medicine.

Researchers conducted a randomized controlled trial (ClinicalTrials.gov Identifier: NCT02783560) to assess the efficacy of The Sleep Train Program in improving sleep and externalizing behaviors in children aged 3 to 8 years. The researchers enrolled 25 children seeking treatment for externalizing problems at an outpatient behavioral health clinic, with participants randomly assigned to receive either the sleep intervention or an active control intervention focused on mealtime behaviors. Following this, all participants underwent standard Parent Management Training (PMT) before receiving the crossover intervention.

The primary outcome was parent-reported externalizing behaviors measured by the Eyberg Child Behavior Inventory (ECBI). Secondary outcomes included actigraphic and parent-reported sleep parameters, parent-child bedtime interactions, and sleep hygiene practices.

Among the 25 participants, 76% had a parent-identified sleep problem, and 84% of caregivers had a college degree or higher. The majority of children were boys (88%), and common externalizing diagnoses included oppositional defiant disorder (28%) and attention-deficit/hyperactivity disorder with comorbid oppositional defiant disorder (44%).

There were no significant differences in behavior or sleep outcomes between the sleep and mealtime interventions (ECBI change, –26.08 ± 23.52 vs –18.23 ± 25.48; P =.43). However, when assessing changes from pre- to post-sleep intervention, parent-reported externalizing behaviors significantly improved (mean ECBI reduction, 20 points; P <.001), along with enhanced parent-child bedtime interactions (P <.01) and sleep hygiene scores (P <.05). Objective sleep parameters, such as actigraphically-measured sleep duration and nighttime awakenings, did not change significantly.

Compared with the mealtime control group, among children with comorbid sleep difficulties (n=19), those randomly assigned to the behavioral sleep intervention exhibited greater reductions in externalizing behaviors (ECBI change, –35.25 ± 18.70 vs –12.82 ± 15.80; P =.02). Additionally, this group experienced fewer nighttime awakenings (P =.02) and increased parental reinforcement of sleep behaviors (P =.004).

Study limitations included a small sample size, reliance on parent-reported measures, and limited generalizability due to the predominantly White (76%), middle-to-upper-class sample.

“While PMT alone could conceivably improve sleep indirectly by facilitating positive parenting and improving parent-child reactions, study findings suggest that incorporating behavioral sleep intervention results in better outcomes,” the researchers wrote. They concluded, “However, for children presenting with behavior difficulties in the absence of problematic sleep, a behavioral sleep intervention may not be indicated.”

This research was supported by the Indiana Clinical and Translational Sciences Institute, the National Institutes of Health, the National Center for Advancing Translational Sciences, Clinical and Translational Sciences Award.