Meeting families where they sleep: a collaborative approach to improving sleep health for urban children

In this issue of the Journal of Clinical Sleep Medicine, Williamson and colleagues¹ bring to light the question of fidelity vs flexibility in implementing an evidence-based intervention for pediatric sleep difficulties. Observing that most investigations of pediatric behavioral sleep interventions have had predominantly White, highly educated, and higher-socioeconomic-status (SES) participants,^2,3 study investigators met with community stakeholders to explore ways to adapt evidence-based behavioral sleep interventions to meet the needs of primarily Black, low-SES, urban young children and their families. First and foremost, adaptations were guided by the goal of fostering empowering and collaborative care that is culturally sensitive and family centered. The intervention was delivered in pediatric primary care with the goal of increasing access and providing delivery in a setting where families are already comfortable and engaged. Specific treatment modifications included flexibility in timing of sleep individualized to family work schedules, collaboration among multiple family members to implement sleep routines, working with shared sleep spaces due to limited resources and/or family preference, and increased visual support and technology use in intervention delivery. Results of the intervention with 15 parent-child dyads suggested that, despite notable changes to the traditional behavioral sleep treatment approach, children demonstrated significant improvements in several aspects of their sleep (ie, reduced sleep-onset latency, reduced duration of nocturnal awakenings, and increased nocturnal sleep time). Importantly, the treatment was feasible to deliver, well accepted by all families who participated, and perceived by families as creating permanent changes in their child’s sleep.

Results of this study help address the critical issue of pediatric sleep health disparities⁴ and have important implications for clinical care. Williamson and colleagues¹ demonstrated that traditional approaches that were developed through research with White, middle-class young children with behavioral sleep challenges may not fit all families. Families tend to view their child’s sleep behaviors through their own cultural lens, comparing their child’s sleep patterns with cultural expectations for sleep. Child sleep behaviors that are considered problematic may instead be different from cultural norms. Specific sleep factors that may be influenced by both biology and cultural expectations include, but are not limited to, timing, duration, where and with whom we sleep, and bedtime routines.⁵ Universally, children benefit from an adequate amount and quality of sleep, while the specific sleep behaviors may vary significantly across cultures. Williamson and colleagues¹ highlight the need to consider and exercise flexibility with respect to the timing of sleep, sleep location, and use of electronic devices prior to bedtime. At the initial visit, an opportunity to build rapport may focus on family preferences with respect to sleep behaviors and assessment of factors, such as family work, school, and child care schedules, which may impact sleep timing and setting. Notably, despite making modifications to some of the pivotal features of traditional behavioral sleep interventions, the treatment was successful in improving overall sleep health. Of particular significance, rather than prescribing a modified directive treatment plan for use with all families, the success of the intervention was due in part to working collaboratively with families and aligning with each individual family’s needs and values.

Benefits of this collaborative approach are exemplified in the study results regarding the use of electronics. The data are clear that electronics usage before bedtime is associated with delayed bedtime, reduced total overnight sleep duration, and poor sleep quality.^6,7 As such, it was surprising to read that Williamson and colleagues¹ decided, with stakeholder input, not to implement the elimination of electronics from the bedtime routine. However, study results were unexpected in this regard. Although study clinicians did not advocate for removal of electronics from the bedtime routine, there was a significant change from pre- to postintervention in the percentage of children with electronics in their bedrooms. This finding supports the notion that pediatric sleep practices are influenced by parent sleep knowledge⁸ and suggests that a less directive approach of providing psychoeducation about screen use without pressure to remove it completely may be an effective way to improve sleep hygiene while maintaining families’ autonomy.

Moreover, this study explores how pediatric primary care settings can play an important role in the treatment of sleep issues for young children, which is an important mechanism for increasing access to care for all families and improving sleep equity. Past research has highlighted that pediatric sleep disorders and concerns are underreported, underdiagnosed, and undertreated within pediatric primary care^9,10 This highlights an important missed opportunity given that the vast majority of young children attend well-child visits with a primary care doctor.¹¹ Williamson and colleagues¹ offer a brief, practical, simple intervention that can be disseminated to reach a wide array of families who would likely otherwise not receive sleep intervention and support.

Although this study offers promise for disseminating culturally sensitive sleep interventions in primary care, it will be important to replicate and extend this work in larger samples. It is unfortunate that, given how this study sought to contribute to this gap in the literature, the authors were unable to include non–English-speaking families. Future research is needed to explore this intervention in samples with other cultural groups as well as in children with neurodevelopmental disorders. Moreover, going forward, it will be interesting to assess specific child and family factors that impact treatment outcomes.

In summary, this study begins to address a gap in the literature on culturally sensitive approaches to improving sleep for Black, Latinx, and low-SES families. In practice, the use of traditional behavioral sleep treatment approaches in pediatric primary care often falls short for families and ends in premature termination of treatment. A typical treatment approach can feel overly directive and impossible for parents when the sleep recommendations are drastically different from the family’s current situation and may not align with their family’s values. Sleep Well! offers a hopeful alternative approach that meets families where they are, considers their individual needs/preferences, and focuses only on the key aspects of sleep health.

DISCLOSURE STATEMENT

Both authors have seen and approved the manuscript. The authors report no conflicts of interest.