Journal of Consulting and Clinical Psychology Copyright 1992 by the American Psychological Association Inc.

1992, Vol. 60, No. 1,41-48 0022-006X/92/$3.00

Effects of Parent Training on Infant Sleeping Patterns, Parents' Stress,

and Perceived Parental Competence
Amy Wolfson Patricia Lacks
Fallen Clinic, Worcester, Massachusetts Washington University
Andrew Futterman
Holy Cross College

First-time parent couples from childbirth classes were randomly assigned to a four-session training
group (n = 29) or a control group (n = 31). Members of the training group were taught behavioral
strategies to promote healthy, self-sufficient sleep patterns in their infants, whereas the control
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group received the same amount of personal contact without the behavioral training. Six sleep
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variables were derived from a daily infant sleep diary completed by parents at two time points.
Results show that at age 6-9 weeks, infants in the training group displayed significantly better
sleeping patterns than did control infants. Training group parents awakened and responded less
often to infant signaling and reported greater parental competence. By contrast, control group
parents indicated increased stress over time.

One of the issues most salient to parents of newborns is the
amount of sleep their infant obtains and when the sleep occurs
(e.g., daytime vs. nighttime). The frequent question, "Is your
baby sleeping through the night yet?" is a reference to the un-
avoidable sleep deprivation and stress new parents experience
with their infant's night awakenings. An important goal of most
new parents is to alleviate this stress by getting their infant to
form early, healthy, and independent sleep habits.
Sleeping through the night or settling is a misleading concept.
Settling refers to an infant consistently sleeping without awaken-
ing between 12:00 a.m. and 5:00 a.m. However, most adults and
children periodically awaken throughout the night and fall
back to sleep without being aware of these awakenings (Anders,
1979; Paret, 1983). Parents of newborns cannot expect the baby
to have 8 uninterrupted hours of sleep. However, it is reasonable
to expect gradual improvement in the quality of sleep (e.g., learn-
ing to fall back to sleep on their own after awakening; Anders &
Keener, 1985; Coons & Guilleminault, 1982; Cuthbertson &
Schevill, 1985).
Research shows that the goal of establishing an early, stable
sleeping pattern is often not met; up to 30% of children have
sleep problems in their first 4 years. For example, Moore and
This research was conducted in partial fulfillment of the require-
ments for the doctoral degree by Amy Wolfson under supervision of
Patricia Lacks. Portions of a draft of this article were presented at the
Annual Meeting of the Association for the Advancement of Behavior
Therapy, November 1988, New York.
We would like to thank the following individuals for their thought-
ful critique of an early draft of this article: Amy Bertelson, Vicki Carl-
son, Michael Noetzel, and Michael Strube. We would also like to thank
Helena Kraemer for her assistance regarding data analysis and inter-
pretation of results.
Correspondence concerning this article should be addressed to Amy
Wolfson, Fallen Clinic, 361 Plantation Street, Worcester, Massachu-
setts 01605.
41
Ucko (1957) found that by 1 year of age, 10% of infants did not
regularly sleep for 5 uninterrupted hours per night. Zuckerman,
Stevenson, and Bailey (1987), in a large longitudinal sample,
found that 18% of 8-month-olds and 29% of 3-year-olds had a
sleep problem; 5% of the mothers of the younger babies had
their own sleep severely disrupted by their child. Factors asso-
ciated with child sleep problems were behavior management
difficulties and maternal depression. Pediatricians report that
26% of their practice have sleep complaints; child psychiatrists
report 61 % (Coates & Thoresen, 1981). Surveys of adult chronic
insomniacs (e.g., Bixler, Kales, Soldatos, Kales, & Healey, 1979)
show that about 6% report their sleep problems began before
the age of 10 years. These findings lead to the conclusion that
sleep difficulties prevalent in infants and children may persist
even into adulthood and may affect the mood and sleep of
parents.
A significant variable affecting infant sleep is maturation.
Research on the maturation of infant sleep (e.g., Anders,
Keener, & Kraemer, 1985; Coons & Guilleminaut, 1982) shows
that infants begin to differentiate day and night within 2
months; newborns sleep randomly for a total of 16-20 hr each
day, while 2-month-olds spend more of their sleeping hours
during the night; their longest sleeping period generally dou-
bles to about 8 hr between birth and 4 months.
Other factors that affect infant sleeping patterns include (a)
child characteristics such as age and temperament (Keener,
Zeanah, & Anders, 1988; Weissbluth, 1981); (b) events of preg-
nancy, labor, delivery, and birth (e.g., low birth weight, problem-
atic deliveries, anoxia, and prolonged labor; Anders et al., 1985;
Coren & Searleman, 1985); (c) developmental and medical is-
sues (e.g., colic, teething; Ferber, 1985; Schmitt, 1981); and (d)
environmental factors (e.g., parenting practices, birth of a sib-
ling, parental stress, and parent-child interaction; Illingworth,
1966; Paret, 1983; Van Tassel, 1985).
Given these influences on infant sleep, infant sleep patterns
 42 A. WOLFSON, P. LACKS, AND A. FUTTERMAN
are quite variable. Most of the influences, such as maturation,
colic, and delivery problems, are not amenable to control. Par-
enting practices regarding infant sleep, however, may lend
themselves to alterations that would facilitate healthy sleep-
wake patterns in infants. For example, child sleep disturbance
can frequently be traced to maternal anxiety, inconsistent han-
dling, and overresponsiveness to child night waking (Coates &
Thoresen, 1981; Crowell, Keener, Ginsburg, & Anders, 1987).
All such behaviors could be targets for behavior change. Recent
studies indicate that parents can alter their child's already exist-
ing poor sleep difficulties (Largo & Hunziker, 1984; Rickert &
Johnson, 1988; Schaefer, 1987). However, none of these studies
were preventive.
Recently, several authors have taught parents to help their
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newborn infant develop healthy sleep-wake patterns (Cuthbert-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
son & Schevill, 1985; Ferber, 1985). Research is needed to exam-
ine the presumed impact that parents can have on their infant's
sleep. Moreover, improved infant sleep might also lead to paren-
tal benefits such as reduced stress levels and increased sense of
parental competence during the difficult postbirth period. For
example, Erickson (1976) found that parents who know in ad-
vance what to expect from a child feel more competent about
how to respond to their child's sleeping behaviors.
Beginning evidence indicates that intervention during the
transition to parenthood period may prevent the negative, stress-
ful effects that first-time parents often experience (Waldron &
Routh, 1981). Markman and Kadushin (1987) found that La-
maze training may be an effective primary prevention against
the anxiety and stress associated with the birth of the first
child. Others have demonstrated that social support and help
with caretaking tend to buffer parents against the stress that
they experience as new parents (Crnic, Greenberg, Ragozin,
Robinson, & Basham, 1983; Crockenberg, 1981. Training that
guides parents in establishing early good sleep patterns in their
infants may lower stress levels and increase competence.
This study compared first-time parents who received specific
parent training with a group of parents and their infants who
did not receive such training, the control group. Three hypothe-
ses were tested: (a) infants of training group parents would dem-
onstrate better sleeping patterns at postbirth (6-9 weeks) and at
follow-up (16-20 weeks); (b) trained parents would awaken and
respond less frequently than the control group parents; and (c)
trained parents would demonstrate less stress and greater self-
efficacy.
Method
Subjects
The participants in this study were 60 couples recruited from La-
maze childbirth classes at a local hospital. Criteria for inclusion were
the following: (a) parents were expecting their first child; (b) mothers
were near the end of their 7th month of pregnancy; (c) both parents
were from 21 to 40 years of age; and (d) the couple was married, and
both partners gave written informed consent to participate.
Of the approximately 260 people in 25 Lamaze classes, 25% met the
selection criteria and elected to participate. Common reasons for non-
participation in the study were conflicting demands on time and too
much record keeping. Couples in the study were married an average of
3.4 years, had a mean age of 28.7 years, and had a mean education of
15.7 years. The couples were primarily middle- to upper-middle-class
(40% of the couples had joint incomes above $50,000) with the major-
ity of the husbands and wives employed in managerial or professional
jobs.
Infants had to meet the following criteria: (a) gestational age of at
least 38 weeks; (b) birth weight of 5 Ib or more; (c) Apgar score (rating
from 0-10 of infant behavior at delivery) at 5 min of at least 6; (d) no
gross congenital abnormalities or serious health problems; and (e) a
single birth. No study infants were eliminated for any of these reasons.
In the overall sample, there were 51.7% female babies and 48.3% male
babies. Seventeen percent of the mothers had caesarian sections. The
average gestational age of the infants was 39.6 weeks. They had a mean
birthweight of 8.1 Ib. and a mean apgar score of 9.0, and the mothers'
average length of labor was 14.8 hr.
Procedure
Interventions and measures were given during three time periods.
The first contact was during the last trimester of pregnancy and was
designated the prenatal period. Parents were seen again at postbirth
when their infant was settling ready (defined as a healthy infant of at
least 6 weeks of age who was gaining weight continuously and weighed
at least 9 Ib; Cuthbertson & Schevill, 1985). The third period was a
follow-up when infants were 16-20 weeks of age. Participants were
randomized into parent training and control conditions.
The training condition was promoted as a preventive program to
facilitate healthy infant sleeping patterns. Participants in the training
condition met in small groups for two consecutive weekly prenatal
sessions and two postbirth booster sessions. During all their sessions,
training group parents were provided with didactic information on
infant sleep and specific methods to assist their infants in establishing
early good sleep habits. During the prenatal period, the training group
completed the two parent adjustment measures of stress and parental
efficacy; the stress scale was repeated in the postbirth period. Parent
self-report questionnaires were not given at all times of measurement
to avoid burdening the participants. At the first postbirth booster ses-
sion, the parents were given infant sleep diaries to take home and
complete daily for 3 weeks. The second booster session was held 2
weeks later.
The control condition was described as research on the development
of infant sleeping patterns. All discussions with control parents cen-
tered solely around observing and reporting infant sleep. Control group
parents met three times with the experimenter. The first meeting was
conducted in small groups during the prenatal period. During this
prenatal meeting, the experimenter explained the three meeting times
(e.g., prenatal, postbirth, follow-up) and explained that at the postbirth
meeting the parents would be instructed on how to fill out the sleep
diaries. They completed the same prenatal measures of stress and effi-
cacy as the parent training group. When each control infant was set-
tling ready, the parents were seen in their own home to complete the
stress measure and receive instructions on completing the sleep diar-
ies. The third meeting was held in groups at follow-up when the infants
were each 16-20 weeks old. All parents and their infants from training
and control groups were again administered measures of stress, effi-
cacy, infant sleep, and parent awakening and responding. At the end of
the study, after all measures were completed, the control group was
offered similar training materials to help with their infants' sleeping
behavior.
Measures
Infant sleep diary.' The infants' sleep-wake patterns were assessed
with a 24-hr sleep diary. The diary consisted of a chart of 15-min blocks
' The infant sleep diary is available from Amy Wolfson on request.
 PARENT TRAINING OF INFANT SLEEPING PATTERNS
of time on which the parent shaded in the blocks when the baby was
sleeping, left blank waking times, and used a designated symbol to
indicate feeding the infant. The diary was adapted from a similar chart
used by Ferber (1985). This type of 24-hr parent report has been used
in many studies (e.g., Anders, 1978; Elias, Nicolson, Bora, & Johnston,
1986). Previous research has demonstrated the reliability of such par-
ent recordings by comparing time-lapse video recordings of children's
sleep patterns with diaries recorded on the same day (Anders, 1978;
Paret, 1983; Keener et al., 1988). Anders (1978) showed that parent
diaries and videotapes were in agreement over 90% of the time. Elias et
al. (1986) found a correlation of .70 (p < .001) between interview and
diary data of infant sleep patterns.
Diaries were completed by one parent (designated by the couple)
from each family for 3 consecutive weeks at the postbirth time and for 1
week at follow-up. Diaries or sleep charts were completed for 3 weeks at
postbirth for several reasons. During this period infants' sleep patterns
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are changing fairly quickly (Anders et al., 1985) and, therefore, 3 weeks
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of data would more adequately demonstrate the infants' sleeping pat-
terns than would a single measure. Also, requesting that the parents
complete the diaries for 3 weeks reduced the possible impact of any
missing data. Before filling out the diaries, parents designated their
own regular nighttime period (8 hr from x p.m. to x a.m.).
The following summary measures were calculated from the diaries:
(a) mean total sleep, (b) mean number of sleeping episodes, (c) mean
longest sleeping episode, (d) number of nights infant slept continuously
for more than 300 min, (e) number of waking episodes, and (f) mean
number of feedings. These infant sleep diaries were coded for analysis
by research assistants. To demonstrate their intercoder reliability, all
five coders transcribed the same 18 infant sleep variables. The diaries
also included questions on two parent behaviors related to infant sleep:
the number of times each night parents were awakened and the num-
ber of times parents responded and went to the baby during each night.
Parent adjustment measures. To measure life stressors and positive
experiences, we used the Hassles and Uplifts Scales (Kanner, Coyne,
Schaefer, & Lazarus, 1981). A summary score for frequency of hassles
and of uplifts experienced in the last month was generated for each
parent. This stress measure was given three times: before the baby's
birth, postbirth (6-9 weeks), and at follow-up (16-20 weeks).
To tap parents' sense of self-confidence in their new role, the Paren-
tal Efficacy measure (Bandura, Adams, Hardy, & Howells, 1980; Sirig-
nano & Lachman, 1985) was revised to include items that reflected
both general parenting activities for infants and other specific tasks
related to getting the infant to sleep. Parents rated 10 parenting activi-
ties (on a 100-point scale) according to how sure they were that they
could handle each task. The 10 parenting tasks were the following:
easily soothe baby, successfully feed, put back to sleep, wait to pick up,
get to sleep through the night, get baby back to sleep without feeding,
refrain from playing at night, comfortably hold, interpret cries and
behaviors, and control sleep-wake schedule. Mothers and fathers rated
their sense of efficacy at prenatal and at follow-up.
Parent Training Protocol
Prenatal parent training was conducted in two weekly group ses-
sions. The training was modeled after Cuthbertson and Schevill's
(1985) recommendations to parents regarding the sleep of infants. The
training was patterned after their methods because we wanted to test
the usefulness of information that was easily accessible to parents and
that was written for them. This book has material directed to new-
borns, takes a preventive outlook, and has a clearcut, routinized plan
to follow. A training manual was developed to standardize proce-
dures.2 The parent training leader was an advanced female graduate
student in clinical psychology, who had completed an internship in
clinical child psychology. In general, sessions consisted of didactic
43
material and handouts, questions and answer periods, and group dis-
cussion and problem solving.
In the first prenatal sessions, the trainer explained the rationale and
procedures, encouraged a sense of parental self-competence, and pre-
sented didactic information on infant sleep. The trainer discussed the
following areas: sleep-waking patterns, sleeping through the night, the
association between feeding and sleeping, the basic physiology of in-
fant sleep, confident parenting, and the need to establish a sleep rou-
tine early on. A philosophy of independent infant sleep was promoted,
the idea being that infants do not require parental assistance to fall
asleep or return to sleep after awakening in the night (e.g., parents can
try not to hold or to nurse their infant to sleep). Parents were taught to
gradually shape the infant's sleep to nighttime hours, to establish a
nighttime "focal" feeding (between 10 p.m. and 12 a.m.), to learn to
discriminate infant wakefulness, and to aid their baby to differentiate
between night and day. Specific examples of the latter would be for
parents not to allow lengthy daytime sleep, to darken the bedroom at
night but not in the day, and to concentrate playtime during the day
hours.
The second prenatal session focused on guiding parents on how to
help their infant sleep through the night. They were taught a step-by-
step method to use for approximately 4 nights when their infant met
the settling-ready criteria. The method emphasized gradually moving
the focal feeding toward a later time, lengthening the time before re-
moving the awake and fussing baby from the crib, stretching the time
between later night feedings, and getting the baby to settle until early
morning without another feeding. Discussion and role play ing ensured
that the parents understood the routine. Parents completed daily prac-
tice records of six items related to treatment adherence. These records
were the focus of group discussion and problem solving.
Two postbirth booster sessions (1-lj hr each) were held 2 weeks
apart when the infants were settling ready. Parent couples participated
in the booster sessions when their own baby met the settling-ready
criteria. In these two sessions, the techniques that were learned at the
prenatal sessions were reviewed and reinforced. Parents were also
given the opportunity to discuss individual concerns and ways of im-
proving adherence.
Design and Analysis
This study used a randomized parallel group design (Fleiss, 1986).
Randomization of subjects to training and control groups was accom-
plished by the following process: (a) Each of 25 Lamaze classes was
randomly assigned to either training or control condition; (b) husbands
and wives were then recruited together as couples from these assigned
classes; (c) to minimize group process effects and group homogeneity
related to Lamaze classes (i.e., because of couples choosing to come
with friends to a particular Lamaze class), couples from the same La-
maze class were assigned to different training group sessions and filled
out forms individually.
Four sets of analyses were conducted. First, data on infant sleep was
analyzed in a 2 (training vs. control) X 4 (3 consecutive times at 1-week
intervals when infants were 6-9 weeks and 1 time at follow-up when
they were 16-20 weeks) repeated measures multivariate analysis of vari-
ance (MANOYA; Morrison, 1976). Second, parent behaviors related to
infant sleep (e.g., parent awakening and parent responding) were also
analyzed in a 2 (training vs. control) X 4 (3 weeks at postbirth and 1
week at follow-up) repeated measures MANOVA. Third, parent self-re-
ports of daily hassles were analyzed as a 2 (training vs. control) X 3
prenatal, postbirth, follow-up) repeated measures MANOVA. Fourth,
2
Training manual is available from Amy Wolfson on request.
 44 A. WOLFSON, P. LACKS, AND A. FUTTERMAN

parental self-efficacy was analyzed by using a 2 (training vs. control) x Table 1

2 (prenatal and follow-up) MANOVA. Demographic Characteristics of Parents and Their Infants
Gender of parent effects (mothers vs. fathers) were assessed in the
analyses of the parent adjustment measures (e.g., stress and efficacy); Group
where no gender differences were found, self-report data of mothers
and fathers were averaged into a single score. Analyses were conducted Training Control
using ordinary least squares estimation and listwise deletion proce- Characteristic (i. = 29)
dures (SYSTAT; Wilkinson, 1987). When multiple dependent mea- Parent characteristics
sures were involved, significant multivariate F tests (using Wilks's
lambda approximation; Rao, 1973) were performed first, and when Mothers' age (years)
significant, univariate F tests were examined (with Bonferroni adjust- M 28.3 27.6
ment to maintain overall .05 alpha; Bray & Maxwell, 1985). SD 4.2 4.2
Fathers' age (years)
M 29.2 29.7
SD 3.9 5.0
Results Mothers' education (years)
M 15.7
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15.0
Characteristics of Training and Control Groups
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SD 2.2 1.7
Sixty couples participated in the study (29 in training group, Fathers' education (years)
M 16.0 16.1
31 in control group). No couples dropped out until follow-up. SD 2.4 2.3
At that time, 3 training group couples and 4 control group Duration of marriage (years)
couples did not return for follow-up. The number of subjects M 3.6 3.2
completing measures varied slightly across time and across in- SD 2.2 2.1
struments. This accounts for small differences in degrees of
freedom in the analyses. Table 1 shows that there were no dif- Infant characteristics and birth information
ferences between the two parent groups on any of the demo-
Labor (hours)
graphic characteristics (Fs < 2.56). M 15.2 14.3
As we can see in Table 1, infants born to parents in the train- SD 7.7 7.1
ing and control groups were healthy and did not differ on any of Gestational age (weeks)
the background characteristics (Fs < 3.24). During postbirth M 39.6 39.8
weeks (3 weeks of sleep data collection) and at follow-up (1 week SD 1.4 1.7
Birthweight (Ib)
of data collection), infants in the training and control condi- M 8.2 7.9
tions were approximately the same age. Also, there was no sig- SD 0.89 0.94
nificant difference in the age at which the infants in the two Apgar score
groups met the settling-ready criteria (mean equaled 6.7 weeks M 9.0 8.9
SD 0.28 0.60
for the training group and 6.9 weeks for the control group). Age at which infant met
settling-ready criteria
Postbirth Week 1 data
Infant Sleep M 6.7 6.9
SD 0.69 1.0
Table 2 shows the means and standard deviations for the six Postbirth Week 2 data
infant sleep variables for the training and control groups at the M 7.6 8.0
four times of measurement (3 weeks postbirth and 1 week at SD 1.1 1.0
follow-up). At postbirth, Cronbach's alpha for the six dependent Postbirth Week 3 data
M 8.7 9.0
infant sleep variables was .50, and the median correlation for SD 0.64 1.0
the six variables was .68 with a range from .34 to .88. Follow-up
Training and control infants demonstrated different levels of M 19.4 18.0
sleep across the four times of measurement, F(6,41)= 2.43, p < SD 1.5 1.8
.05. Multivariate differences between groups were attributable
primarily to differences in the number of sleep episodes, F(l,
46) = 7.17, p < .01; number of times infant slept at least 300 min
at one time, F(l, 46) = 9.29, p < .01; mean longest sleeping min, F(l, 46) = 7.2l,p< .05, and mean longest sleep episode,
episode, F(l, 46) = 8.56, p < .01. As can be seen in Table 2, the F(l, 46) = 7.55, p < .05. Univariate tests were nonsignificant at
infants in the training group evidenced fewer and longer indi- follow-up after Bonferroni adjustment. In general, Table 2
vidual sleep episodes, were able to sleep for a stretch of 300 min shows that better sleep was demonstrated by the training group
or longer on more nights during the week, and displayed fewer than by the control sample. For example, the training group
waking episodes and fewer feedings. infants slept for longer blocks of time (mean longer episodes)
Significant differences in sleep between the two groups were than the control group infants, they had fewer individual sleep
found during the 3 postbirth weeks, F(6, 41) = 2.41, p < .05, episodes, they slept for more than 300 min at one time on more
and at follow-up, F(6,41) = 2.71, p < .05. Summing across the 3 nights during the week, and they evidenced fewer feedings dur-
postbirth weeks, multivariate group differences were attribut- ing the night.
able primarily to the number of times infants slept at least 300 Both groups showed significant change over time, F(l 8,29) =
 PARENT TRAINING OF INFANT SLEEPING PATTERNS 45

Table 2
Infant Sleep, Parent Behaviors, and Parents' Stress and Efficacy
Postbirth
Prenatal Week 1 Week 2 Week 3 Follow-up
Measure
(by group) M SD M SD M SD M SD M SD

Infant sleep
Total sleep (in min)
Training — — 390.5 41.6 402.9 43.6 416.1 33.0 451.9 25.2
Control — — 385.3 50.8 393.0 45.1 400.8 43.7 437.7 32.0
No. of sleep episodes
Training — — 1.68 0.44 1.45 0.48 1.35 0.36 1.15 0.25
Control — — 1.85 0.61 1.80 0.63 1.83 0.71 1.48 0.59
Longest sleep episode (in min)
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Training — — 350.5 55.9 375.9 60.3 396.0 45.0 439.5 45.5

This document is copyrighted by the American Psychological Association or one of its allied publishers.

Control — — 307.1 79.7 322.2 86.4 330.3 90.3 403.3 61.1

Slept > 300 min"
Training — — 5.32 1.59 5.85 1.73 6.16 1.38 6.64 0.95
Control — — 3.93 2.36 4.21 2.47 4.52 2.42 5.78 1.42
No. of waking episodes
Training — — 1.20 0.54 0.81 0.50 0.68 0.47 0.55 0.56
Control — — 1.25 0.73 1.27 0.70 1.20 0.76 0.69 0.64
No. of feedings
Training — — 1.08 0.49 0.89 0.55 0.74 0.46 0.27 0.35
Control — — 1.24 0.73 1.30 0.73 1.18 0.81 0.47 0.45
Parent Behaviors
No. of parent awakenings'"
Training 0.87 1.00 0.49 0.75 0.35 0.47 0.40 0.44
Control 1.38 1.14 1.22 1.35 0.94 1.07 0.82 1.02
No. of times parent responded11
Training 0.56 0.48 0.44 0.59 0.18 0.25 0.25 0.34
Control 1.05 0.72 0.90 0.88 0.77 0.76 0.61 0.86
Parents' stress and efficacy
Frequency hassles
Training 19.40 8.22 17.10 6.36 18.62 10.00
Control 15.66 9.10 24.37 16.95 22.88 13.55
Frequency uplifts
Training 37.26 11.88 31.09 11.03 34.76 12.98
Control 37.87 20.40 38.55 20.40 37.35 19.85
Parental efficacy
Training 69.48 8.86 86.46 6.38
Control 68.86 7.27 79.79 7.90
Note. Dash = measure not administered.
b
• Number of nights in week infant slept for longer than 300 min at one time. Either parent.

6.98, p < .001. However, no significant Condition X Time ef-
fects were demonstrated, F(18, 29) = 1.55. Univariate tests of
the time effect revealed significant linear increases for all six
sleep variables: number of sleep episodes, F(l, 46) = 42.52, p <
.001; number of nights slept continuously for more than 300
min, F(l, 46) = 18.72, p< .001; total sleep, F(l, 46) = 63.69, p <
.001; number of waking episodes, F(l, 46) = 25.25, p < .001;
longest sleep episode, F(\, 46) = 81.03, p < .001; and number of
feedings, F(l, 46) = 71.58, p < .001. The means in Table 2
demonstrate that the infants in both conditions were sleeping
for fewer and longer individual sleep episodes, slept more nights
for 300 min or more without awakening, and had decreasing
number of episodes and fewer findings during the night. Qua-
dratic and cubic trends were nonsignificant for all six variables.
Researchers (e.g., Kendall & Grove, 1988) have suggested the
importance of providing an index of clinical significance in
addition to statistical significance. Not only did the parent
training provide results of statistical significance, it also pro-
duced results of clinical merit. To parents, the most practical
criterion of desirable infant sleep is having a baby sleep through
the night. Researchers define sleeping through the night as sleep-
ing for a continuous period of at least 300 min during the night-
time hours. Table 3 displays the percentage of infants who met
this criterion on 5 and on 6 nights during each of the postbirth
weeks and at follow-up.
A z-score test of differences between proportions assessed
the extent to which the treatment and control groups equally
met this criteria. Significant differences were demonstrated in
 46 A. WOLFSON, P. LACKS, AND A. FUTTERMAN
Table 3
Percentage of Infants Who Slept Continuously
for 300 Minutes or More
Postbirth Follow-up
No. of nights
(by group) Weekl Week 2 Week 3 Week 1
5 or more
Training 68 74 92 96
Control 57 59 55 74
6 or more
Training 54 67 72 88
Control 27 31 48 67
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the proportions of treatment and control group infants who met
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the 5-night criteria (averaging across the 3 postbirth weeks), z =
1.79, p < .05. The average proportion of training group infants
was 78% over the 3 postbirth weeks versus only 57% for the
control group infants. The difference between proportions of
training group infants and control group infants who met the
6-night criteria was even more marked, z = 2.35, p < .01. The
average percentage of training group infants for the 3 postbirth
weeks was 64% versus 35% for the control group infants.
At follow-up, significant differences were demonstrated be-
tween the proportions of training group and control group in-
fants meeting both the 5- and 6-night criteria: 5-night criteria,
z = 2.54, p= .01;and 6-night criteria, z= 2.03, p = .05. As Table
3 indicates, training group infants met this criteria much more
frequently than did control group infants.
Parent Behaviors
Means and standard deviations for the total number of times
a parent awakened and the number of times a parent responded
are displayed in Table 2. During the postbirth period, these 2
variables were highly correlated (r = .83). In general, training
group parents awakened less often than the control group par-
ents, F(l, 43) = 5.79, p < .05, and responded less frequently to
their infant's wakefulness, F(l, 43) = 8.41, p< .01. Significant
differences in parent awakenings and responses to the baby
during the night were found between the two groups at post-
birth (age, 6-9 weeks), F(2, 48) = 5.30, p < .01. Group differ-
ences at this time are due to the number of times a parent
awakened, F(\, 49) = 5.89, p< .05, and to the number of times a
parent responded, F(\, 49) = 10.31, p < .01. The beneficial
effects were not maintained as there were no differences be-
tween the two parent groups at follow-up, F(2,42) = 3.60.
Although both groups demonstrated significant change in
parent awakening and responding across time, F(6,38) = 3.50,
p < .01, the Condition X Time effect was not significant, F(6,
38) = .56. The linear trends for both variables (awakening and
responding) were significant: parent awakening, F(\, 43) =
8.13, p < .05; parent responding, F(\, 43) = 8.37, p < .05. The
means in Table 2 show that the parents in both conditions were
awakening less often and responding less frequently over time.
Parents' Stress
No differences between mothers and fathers' ratings of
hassles were found, F(l, 59) = .28. Similarly, there were no
differences between mothers and fathers on frequency of
uplifts, F(l, 59) = .35. Frequency of hassles and uplifts scores of
mothers and fathers were averaged together (see Table 2). The
effect of condition for frequency of hassles was not significant,
F(l, 56) = 1.32. However, a Condition X Time effect was demon-
strated, F(2, 55) = 9.64, p < .001. Training group and control
group parents changed differently in their frequency of hassles
from prenatal to postbirth, F(l, 56) = 10.38, p < .01, and from
postbirth to follow-up, F(\, 56) = 3.81, p < .05.
Training group parents demonstrated nonsignificant change
in frequency of reported hassles, F(2,27) = 2.18 (mean frequen-
cies of reported hassles at prenatal, postbirth, and follow-up
were as follows: 19.40, 17.10, 18.62, respectively). In contrast,
the control group reported significantly more hassles over time,
F(2, 27) = 9.08, p < .001. This overall change was attributed
primarily to a significant change in the control group's self-re-
ported hassles from prenatal to postbirth F(\, 28) = 11.40, p <
.01; nonsignificant change was observed in the control group
from postbirth to follow-up, F(\, 28) = 2.17 (M = 15.76, 24.28,
22.88, prenatal, postbirth, and follow-up, respectively).
An overall change in number of hassles in both parent groups
was observed across time, F(2, 55) = 4.73, p < .01. This time
effect is attributed to a change in frequency of hassles from
prenatal to postbirth, F(\, 56) = 6.70, p < .05, and not from
postbirth to follow-up, F(\, 56) = .75. No significant effects
were found in reported uplifts, Fs < 1.0.
Parents' Sense of Efficacy
Table 2 displays the means and standard deviations for the
parental efficacy measured for training and control parents at
prenatal and follow-up. The internal consistency (Cronbach's
alpha) for the 10 self-efficacy items was .77 (for mothers) at the
prenatal period. Interitem correlations ranged from .05 to .53,
median equaled .30. The alpha on the same 10 items for fathers
was .72. Interitem correlations ranged from .01 to .60, median
equaled .24. In keeping with Bandura et al.'s (1980) approach,
mean self-efficacy ratings for the 10 items were computed for
each parent. Gender differences in mean self-efficacy were not
found, F(l, 59) = .06.
Differences in parental efficacy were found between training
and control conditions, F(l, 54) = 6.33, p < .05. Moreover, a
Condition X Time effect was found for parental efficacy (prena-
tal, follow-up), F(l, 54) = 7.43, p < .01. Simple effects tests were
conducted to explain this Condition X Time interaction. At the
prenatal period, there were no differences between training
parents' and control parents' ratings of self-efficacy, F(l, 59) =
.09. Later, at follow-up, the training group reported a signifi-
cantly greater sense of efficacy than the control group, F(\,
59) = 12.25, p < .01. Over time (prenatal to follow-up), parents
in both groups reported an increasing sense of competence,
F(l, 54) =159.88, p<. 001.
Discussion
The main purpose of this research was to determine whether
first-time parents who receive brief, specific training can influ-
ence the sleep patterns of their infants. Results suggest that
parent training was effective in helping the infants establish
 PARENT TRAINING OF INFANT SLEEPING PATTERNS
early, stable sleeping patterns. At postbirth, training infants
demonstrated better sleeping patterns than did control infants.
However, at follow-up the training group infants no longer evi-
denced significantly better sleeping patterns than the control
group.
Previous research (e.g., Rickert & Johnson, 1988; Schaefer,
1987) has documented that parents given brief training are able
to reverse maladaptive sleep problems (e.g., middle-of-night
waking) in their young children. However, this study is the first
to use a preventive design showing that parents can help their
newborn babies to establish early, stable, and nonproblematic
sleep patterns. That is, parent training can be beneficial before
children develop difficulties.
Other researchers have reported that parent behaviors could
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
be altered to affect the sleep-wake schedule of infants (Ferber,
This document is copyrighted by the American Psychological Association or one of its allied publishers.
1985; Paret, 1983). In our study, when the infants were 6-9
weeks, training parents were awakened less often by their in-
fants and responded less often to their infants' wakefulness.
There are two reasonable explanations for this finding. The
first is that the parents actually learned their lessons: They
awakened fewer times, and when they awakened, they re-
sponded less frequently. A second possible explanation is that
the parents' responsiveness is merely a reflection of the babies'
improved sleeping pattern and as such reflects treatment out-
come rather than parents' conscious influence on infant sleep.
Our findings of changes in parent behavior that parallel im-
proved sleep in infants confirm the work of Paret (1983). She
examined the association between night waking and mother-
infant interaction in 9-month-olds. She found that good
sleepers could soothe themselves to sleep after waking up,
whereas night wakers required the mother's physical presence
(e.g., nursing) to return to sleep. Paret also found that mothers of
night wakers responded more quickly and more often during
the day than did mothers of good sleepers. In general, the more
independent and self-reliant infant was more likely to sleep
through the night.
Parent behaviors that promote independence in the infant
have raised questions for some about broader parent-infant at-
tachment issues. Will not allowing a baby the security of falling
asleep in its parent's arms or being left to fuss without quick
parent attention interfere in any way with attachment, forma-
tion of trust, or parent-child reciprocity? Research has shown
that maternal sensitivity to the infant's signals during feeding,
face-to-face play, physical contact, and distress episodes in the
first 3 months were predictive of the quality of the relationship
at 9-12 months. Maternal responsiveness to infant crying in the
first 3 months was not related to later crying (Tracy & Ains-
worth, 1981). However, it may be the amount of these interac-
tions that is important to development rather than the time of
day they are provided. Parents of newborns have ample oppor-
tunity during daytime hours to interact with their baby—to
interact more effectively if they, the parents, are not sleep-de-
prived.
Regarding parental stress, the present research demonstrates
that parents, indeed, do benefit from training. For example, the
training group parents reported fewer hassles than the control
group when their infants were about 6-9 weeks of age. Also,
parents who attended the training sessions maintained about
the same level of hassles at prenatal, postbirth, and follow-up,
47
whereas the control parents reported an increasingly greater
number of hassles during the early months of parenthood.
Markman and Kadushin (1987) demonstrated that interven-
tions (e.g, Lamaze classes) during the transition to parenthood
can prevent much of the stress entailed with assuming this new
role. All of the parents in our study attended Lamaze childbirth
preparation classes; however, the parents who were also in our
training group(s) reported fewer hassles and no significant
change in frequency of hassles over the course of the first 4-5
months of parenthood (e.g., infants 6-9 weeks and 16-20
weeks). Because the months following childbirth are consid-
ered a very stressful time of life, interventions that decrease
stress or prevent increased stress during the postnatal months
seem worth pursuing.
A second parent benefit was that the training group reported
greater parental efficacy in managing their baby's sleep than
did the control group. A number of factors are likely to have
contributed to this enhanced sense of self-confidence and com-
petence as a parent. Parents in this program were given educa-
tion about sleep, a structure and philosophy to guide the man-
agement of their babies' sleep, and a good deal of support.
These parents were also able to change some of their own behav-
iors in response to their babies.
Although we have reason to be encouraged by our findings,
certain caveats pertain. For example, we did not control for the
expectations of success that were raised with the training group.
The next study should include an attention-placebo control
group. The lack of a placebo control group diminishes, to some
extent, the infant sleep results. However, the parallel changes in
the behaviors and attitudes of the training parents following
intervention does provide construct validation of the infant
sleep findings.
The results of this study are based entirely on parent self-re-
port. Parent diaries have some limitations (e.g., it is difficult for
parents to keep records in the middle of the night; parents are
not always certain whether their infant is asleep or lying awake).
Keener et al. (1988) reported that infants in their study had
silent awakenings during which they did not signal their parents
when they awakened. Future research should include some
kind of additional assessment such as time-lapse video record-
ings or other objective sleep measure.
In the present study, the interval between the infants' ages in
the final postbirth week and the follow-up week differed
slightly between the training and control conditions (10.7 weeks
vs. 9.0 weeks). This difference may be important in that the
control infants might have progressed further in their sleeping
patterns if the follow-up measurement had been administered
later. This may have resulted in reduced group differences at
follow up. However, previous studies (e.g., Anders & Keener,
1985; Coons & Guilleminault, 1982) have not looked closely at
infant sleep development between individual weeks at age 4-5
months (i.e., Weeks 18-20). Moreover, the 4- 5-month follow-up
used in this study was relatively brief. Future research should
extend this period to 1 or 2 years, especially because many
studies suggest an increase in nighttime waking in the second 6
months of life and during other developmental stages.
This field is still in its "infancy," and there are many areas for
future research. Although our study shows that clinicians can
provide effective support and practical training to expectant
 48 A. WOLFSON, P LACKS, AND A. FUTTERMAN
parents, our research involved mostly well-educated, middle-
class, married couples. Babies were screened to be full term and
healthy, and training was given in small groups. One future
direction would be to assess the effectiveness of these methods
under less ideal circumstances (e.g., work with the parents of
babies who have colic). Our protocol was based on suggestions
from Cuthbertson and Schevill's book, Helping Your Child
Sleep Through the Night (1985). Future research could compare
parents who read the book on their own with those given the
training. Such a design would clarify whether it was the group
format, the material presented, or some combination that af-
fected the infants' sleep patterns. Longitudinal research to de-
termine how these changes in infants' sleep affect their future
sleep patterns would be very valuable.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
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Received July 20,1990
Revision received April 30,1991
Accepted May 8,1991 •