Question

• The frustrated parents of a toddler in my affluent, suburban-located primary care pediatrics clinic ask how they can get their child to sleep better.  Would graduated ignoring (the Ferber method) increase the amount of time their child sleeps at night?

Clinical Bottom Lines

1. Bedtime refusal and night wakings are very common among toddlers, occurring in 20-42% of children.
2. In parents who agreed to allow their children to cry, graduated ignoring (allowing the child gradually longer periods of crying in which to console herself) increased the number of times per week that the children consoled themselves in less than ten minutes and the number of nights in which the child slept through the night, compared to the group which received no intervention.¹
3. A significant minority (at least 24%) of parents were unable to allow their children to cry even for brief periods of time, and these families were not included in the analysis.

Summary of Key Evidence

1. Forty-four patients with difficulty sleeping, defined as taking at least 30 minutes to settle or waking during the night requiring parental contact to fall back to sleep, were randomized in a single-blinded, controlled trial to attempt either total ignoring of all crying, graduated ignoring of crying, or a “waitlist” condition in which the parents continued methods they had previously attempted without success.
2. Waitlist and treatment groups had similar characteristics at the onset.
3. Primary outcome measures after one, two, three, and six weeks included number of “good bedtimes,” or nights that took less than ten minutes for the child to settle; and “good nighttimes,” or nights in which the child slept by himself without waking for the whole night.
4. Secondary outcomes were maternal stress, parent-child dysfunctional interactions, child behavior, maternal depression, and parent distress.
5. Analysis was not on an intention to treat basis.
6. Because of lack of intention to treat analysis, the subpopulation studied actually contained only parents who were willing to allow their children to cry themselves to sleep.
7. In this subpopulation, there was a valid, moderate-to-large effect, on both the number of good bedtimes per week and the number of good nights per week.
8. There were no adverse effects on any secondary outcomes in the subpopulation studied.

Additional Comments

• Alternative therapies must be evaluated for parents who know they will be unwilling to allow their children to cry themselves to sleep, because this study gives no information on the efficacy or side-effects of this treatment in this subpopulation.

Citation

1. Reid MJ. Walter AL. O'Leary SG. Treatment of young children's bedtime refusal and nighttime wakings: a comparison of "standard" and graduated ignoring procedures. Journal of Abnormal Child Psychology. 1999; 27(1):5-16.

CAT Author: Andrew Seiler, MD

CAT Appraisers: John G. Frohna, MD

Date appraised: November 8, 1999