Table III.

Selected Themes and Representative Quotes

Theme/sub-theme	Caregiver quote	Clinician quote
Sleep as critical for child wellbeing	“It [sleep] is affecting her behavior in a way, because it's like when she wake up in the morning, you know, that's bad. She has a bad—negative—she has a negative attitude. Because she's up, she's not asleep, she's not under her blanket. So, it's like really negative, and sometimes it takes her a while to get out of that space.”	“I think it's [sleep] very important. I think some of my families don't recognize it, at least when I first meet them, why it's so important. Like, they're coming because this kid is having explosive tantrums. They think he has some sort of maybe ASD [autism spectrum disorder] or another disorder, and then I find out he's only sleeping 6 hr a night, and then I'm like, ‘actually, let's start—you know, here.’”
Lack of education/knowledge about pediatric sleep	“I drink green tea so they [her children] might drink it here and there. But I didn’t know that had caffeine in it.”	“But I’ve never said, ‘Make sure your child gets 10–13’ [hr]—like I didn’t know that was the recommendation, you know, so um, that’s something I haven't been educating families about. But again, I don’t really know what education is out there for us in teaching our families that.”
Child versus family characteristics as major contributor to sleep problems	“She [the child] makes it real hard. She just don’t want to go—I don’t know. She just don’t want to go to sleep.” “He’s extremely headstrong. If he doesn’t want it, that’s it. He’s not taking it. If he wants something, it doesn’t matter what I say, how I threaten to take away toys, electronics, Christmas, anything, he doesn’t care. Like he just doesn’t care.”	“…There’s parents who really just have never even really thought through some of the basic limit setting and then there’s parents who sort of like know what the challenges are but have other barriers to implementing a, like, a successful strategy.” “It’s disorganization. And to be honest with you, sometimes over generations, so the grandparents are disorganized. The parents themselves are disorganized and don’t have routines.”
Familial and contextual barriers to intervention components  Work schedules  Multiple children, caregivers, or sleep locations	“…But I work night shift so it’s hard…. And then aside from that, you know, on the nights that I go to work, um, which is generally from Friday to Tuesday, he’s at his sister’s house with his step mother and she generally keeps a good schedule. …But he gives her issues too…And then, you know, so I’m trying to put him on a schedule. I noticed that that did help somewhat in the past, but, with my work schedule it’s hard.” “…But then dad was working overnight. So it was like, and you know, our neighborhood wasn’t really that good, so it was like I wanted them [the children] with me so like, you know, if something was to happen, I had them.”	“…Work schedules, childcare schedules, and general just sort of household chaos. And sometimes, I should have added lack of control over the home environment if they're living in a home with a bunch of other people and it's not their own space, and they can't kind of set the rules about, you know, lights out and bedtime and electronics and all that stuff.” “I think is possibly parents being overwhelmed. Having possibly multiple children in the same age group, or just multiple children in general…I think a big thing could also be possible work schedules…So, just various shifts, and also just a mom may just get off at 8, so the child is just not getting home until late, and then the child themselves may be having a 12–14 [hr] day….”
Caregiver stress and exhaustion	“By that point in the day., um, and it’s just, like I’ve just—I’m, I’m frustrated because I, I get frustrated because it’s like I’ve dealt with him all day. It’s literally me and him, or else I’m at work and then that’s it. So by the time bedtime rolls around, like I just need him to listen. Like if there’s one time in the day that I need him to listen, it’s at bedtime. Because he hasn’t listened all day. So yeah, I don’t know. I think frustration gets in the way a lot.”	“…So parents are tired and sometimes the lesser evil is to just give in to what the child wants. Because they know that then everyone will get back to sleep faster and they’re looking at kind of the short term versus a long term view of what will be good sleep habits.”
Reliance on electronics	“I can’t fall asleep without the TV on. So the TV’s on 'cause of the sound and the light. And then sometimes I’m on my phone a lot too just 'cause that’s when I can answer my emails and things like that. So I think that’s really difficult. [Interviewer: It’s hard for yourself.] It’s hard for myself and then once she [the child] sees it, it’s, you know, she wants it.” “Because when she [the child]wakes up and then wants it [the iPad], it, you know, it keeps her quiet. And I can get the, you know, sleep that I need before I gotta get up and work. So that’s really the main reason. I—in ideal situation, I would love for her not to have it, you know?”	“…this [bedtime] may be a time when the parent is trying to do a lot of things and it’s much easier to give their child the screen then it is to sit and do a puzzle or even read a story since most in this age range, the kids aren’t reading.” “…Sometimes, it's [an electronic item] used as kind of the babysitter, you know. Like ‘oh, go watch TV.’ You know. And if the TV is in their bedroom, then you know, it's just—you know, there, available for the whole night.”
Need for intervention content flexibility	“I just felt like it was like one or nothing. Like, I didn't feel like anybody gave any other options, ‘cuz the—it was pretty much everybody was just like ‘Oh, just do the cry it out. Cry it out. That's what works.’ Nobody was like ‘these are the—these are the option—the different situations you can try. You can try the cry it out. You can try this.’ Nobody had anything else. And it felt like very much like this is the only solution, and that we were doing something wrong.”	“I think the big thing is just figuring out where that family is, keeping a consistent—I think the focus should be more so on the number of hours of sleep, not necessarily the time.”
Importance of empowering and collaborative care	“I feel like if—I feel like it [a sleep intervention program] will help because they will be living in my reality. Opposed to just thinking up advice but not really dealing with the situation. You know what I mean? Like it’s like some people have opinions but not actually in my situation. So come be in my situation with me… Because I felt like you still—as much as I tell you—you still don’t know.” “The only thing that I would say is just 'cause I’m working two jobs, sometimes it can be a little hard. So now I’m dependent on my sister who comes over and helps. And just getting her on board with trying to you know reinforce the same things that I would do if it—if I were home. And just making every kid—everybody involved.”	“… I think the advice is different depending on what the environmental construct is around sleeping, so I start there and then veer off depending on what is offered to me…So… rather than giving a prescriptive sleep or bedtime routine, I ask parents for their own suggestions about what may work for their family. Because it doesn’t work the same way for everybody.” “So just sort of empowering them [families] to recognize that like this [sleep] is a big, like it’s a real problem for their child and like, they’re allowed to do things that might seem somewhat extreme in the short term if it’s in the long-term best interest of their whole family. But then a lot of the time that gets into a conversation about all the other stakeholders in the household.”
Caregiver-to-caregiver communication as an implementation strategy	“It would be helpful like if you didn’t know like what that parent like what that parent and that family do at night, maybe they can help you and your child. You might can add that to your routine or take some of their advice. Like different stuff like that. Know what other parents are going through. If it’s the same problem, it also helps.”	“I think we, healthcare providers, could be a bit intimidating or disconnected from—you know, a parent where they are, you know. Maybe having a kind of peer support, you know, group. Whether the sessions are, you know, kind of with other peers, you know. So, I think there's value to having kind of one-on-one, you know, sessions. But hearing about other people—other parents', you know, strategies and what they're going through, I think is always helpful.”
Technology as an implementation strategy	“I would think text messages, phone calls…Phone and email—keep checking emails, you know, at times. I know I check my email all the time so I, you know, see if, you know, who’s important that’s emailing me.”	“…And create videos to demonstrate things. Like, that might be kind of neat, actually, for between-session reinforcement…Like some sort of video demonstration, both in-office and that someone could view between sessions, that you could text—you could even text people and say ‘remember, look at this video’…”
Willingness/lack of willingness to receive services outside of primary care	“I’m a parent that—any referral, I take. Because it’s only gonna—it’s helpful and if my doctor is referring it, she knows that it’s gonna be helpful. But my doc—me and my doctor, we have a 15-year relationship. So I know her well. So I wouldn’t have a problem with it at all.”	“…But I do think that coming here [to primary care], especially for a lot of our family where it's easier to get here versus having to go to the [main hospital] sleep clinic, [it] would be easier for parents.”
Barriers to treatment access and engagement	"The number of visits I think shouldn’t be that many, well right now, for me. 'Cause of my schedule at work. I work so many—like two jobs right now. So phone calls; no, I don’t have a problem with phone calls. Or you can call any day if you need to. Or, you know."	“…I assume that coming to visits would be the same obstacles that we all have in terms of coming to visits, which is people work, children are in school and they have to remember that the appointment exists. In terms of calls, a lot of people don’t have working phones. A lot of people text more than call, it seems to me…”