Exploring the Mechanisms of a Family-Centered Behavioral Intervention for Behavioral Sleep Problems in Young Children
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Purpose: The purpose of this dissertation is to address the paucity of knowledge about predictive and causal (both direct and mediating) parent-driven pathways to parent sleep practices in the context of a family with a young child who has/is experiencing a behavioral sleep problem. Unpacking these complex pathways will help us to understand the origins and challenges of behavioral sleep problems in young children, so that we can intervene in more informed and effective ways on a trajectory towards better population level health. There are 3 papers in this dissertation, the first of which is a theoretical framework paper and the second and third are data-based papers which include a sample of dyads (parent and a 2- to 5-year-old child with a behavioral sleep problem) from the Sleep Health in Preschoolers (SHIP) study. Paper 1 describes the development and design of a theoretically derived, family-centered, and home-delivered health change intervention to address behavioral sleep problems in young children. Paper 2 explores the predictive relationships between parent emotional functioning and family relationships, and parent sleep practices, mediated by parent doubts and parent self-efficacy in a sample of parents from the control group of the SHIP study. Paper 3 examines the effect of the SHIP intervention on targeted parent cognitions (i.e., doubts, limit setting, sleep outcomes expectations and self-efficacy) and the effect of these parent cognitions on parent sleep practices and children's sleep over time. Background: Sleep is a foundational pillar of health and well-being. Sleep is a complex, active biobehavioral state that is critical to young children's growth, socio-emotional, cognitive and behavioral development. In young children, sleep health is influenced by multiple interactions among biology, parent characteristics, and sociocultural and environmental factors. Sleep problems are prevalent in young children, affecting an estimated 25-40%, and are associated with negative short- and long-term consequences in children's health and behavior as well as family level outcomes. Parents play a critical role in the development and maintenance of children's sleep and are an overarching influence across socioecological levels from proximal to distal factors. Behavioral interventions targeting parents to improve children's sleep have largely had positive outcomes, but how the interventions work is less understood and various gaps and questions remain in examining sleep in young children in a family context. A barrier in advancing this science is the lack of understanding of the causal mechanisms between parent level factors and parent sleep practices. Additionally, we need to better understand how parent or family-level context may predict parent-level mediating factors to parent sleep practices. Methods: All papers in this dissertation are based on the Sleep Health in Preschoolers (SHIP) study, a longitudinal, randomized controlled trial comparing a family-centered behavioral intervention to improve child sleep problems to an active control group. Paper 1 is a theoretical paper and does not include data-based/statistical analysis. Papers 2 and 3 are based on secondary data analysis of the SHIP study and have different samples (active control [Paper 2], and active control and intervention groups [Paper 3]), measures and other methodological variation. Paper 2 includes young child-caregiver dyads randomized to the active control group (N = 215). Measures include parent reports on; parent emotional functioning and family relationships, parent doubts and self-efficacy, and parent sleep practices. Paper 3 includes young child-caregiver dyads from both the intervention (N = 216) and active control groups (N = 216). Measures include parent reports on; parent doubts, limit setting, sleep outcomes expectations and self-efficacy, parent sleep practices, and child behavioral sleep. Results: Paper 1: Sleep Health in Preschoolers (SHIP) was a longitudinal randomized control trial grounded in Bandura’s Social Cognitive Theory and Bronfenbrenner’s Socioecological framework. SHIP integrated a personalized, stepwise approach that included self-management skills and recognized the inherent and dynamic interactions between individual child factors, parents and family level factors and diverse socio-ecologic factors. SHIP utilized a personalized approach by partnering with parents and providing knowledge, motivation, and skills for setting and achieving goals, adapting to setbacks, and problem-solving to improve their child's sleep. Paper 2: Significant positive correlations were found between parent emotional functioning and family relationships (r = 0.56, p < 0.001), parent emotional functioning and parent doubts (r = -0.19, p < 0.05), parent emotional functioning and parent self-efficacy (r = 0.15, p < 0.05), and parent emotional functioning and parent sleep practices (r = 0.25, p < 0.01). A significant inverse association was found between parent emotional functioning and parent doubts ( = -0.20, p < 0.05). Path analysis showed a significant pathway between family relationships at baseline and parent sleep practices at 6 months ( = 0.19, p < 0.05). Contrary to our hypotheses, parent doubts and parent self-efficacy did not mediate either of the pathways from parent psychosocial functioning to sleep practices at 6 months. Paper 3: A significant positive association was found between parent sleep practices at 6 months and children's sleep at 12 months in both the intervention (B = 0.51, p = 0.001) and the control group (B = 0.59, p < 0.001) in multiple group analysis. In the intervention group parent doubts (B = -0.10, p = 0.002), parent sleep outcomes expectations (B = 1.11, p < 0.001) and parent self-efficacy (B = 0.08, p = 0.02) at 3 months had significant effects mediated by parent sleep practices at 6 months to children's sleep at 12 months, the only of these that had a significant effect mediated by parent sleep practices in the control group was parent sleep outcomes expectations (B = 0.63, p = 0.009). Parent limit setting at 3 months did not have a significant mediated or direct effect on children's sleep at 12 months. Self-efficacy had both a significant mediated (B = 0.08, p = 0.02) and direct (B = 0.14, p = 0.02) effect on children's sleep in the intervention group at 12 months, and a significant direct effect (B = 0.21, p = 0.001) on children's sleep in the active control group. Cross-lagged analysis confirmed the strong positive relationship over time between parent sleep practices and young children's sleep, and also points to a meaningful impact on parent cognitions in the intervention group that positively impacted parent sleep practices and children's sleep. Conclusion: Findings from my dissertation suggest that targeting parent doubts, self-efficacy and sleep outcomes expectations as important intervention components to promote sleep in young children is a promising approach. Findings from my dissertation add new knowledge to the literature in that family relationships/family functioning may have a direct role in influencing parent sleep practices. Further, there may be additional strategies to target in family relationships for some families in order to promote the best outcomes at the child, parent and family levels. Targeting parent doubts, sleep outcomes expectations, and self-efficacy in caregivers of young children promoted positive changes in parent sleep practices and subsequently children's sleep. Self-efficacy may be of particular importance in predicting and facilitating improved parent sleep practices and children's sleep over time. Finally, the findings also support the value of an intervention that recognized the inherent and dynamic interactions between individual child factors, parents and family level factors and diverse socio-ecologic factors, and integrated a personalized, stepwise approach that included self-management skills and motivation of caregivers.
- Nursing - Seattle