In this Papers Podcast, Professor Sooyeon (Aly) Suh discusses her co-authored JCPP paper ‘Validation of the Parental Understanding and Misperceptions about BAby’s Sleep Questionnaire using auto-videosomnography’ (https://doi.org/10.1111/jcpp.13797).
There is an overview of the paper, methodology, key findings, and implications for practice.
Discussion points include.
- How prevalent paediatric sleep disorders are and how these sleep problems impact children.
- The association between parental cognition and children’s sleep.
- How the questionnaire was developed and the cultural differences in sleep patterns.
- The importance of re-examining parental beliefs and attitudes about their child’s sleep.
- Implications of the findings for researchers & how the findings might be translated into practice to support CAMH professionals and clinicians.
In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are The Journal of Child Psychology and Psychiatry (JCPP); The Child and Adolescent Mental Health (CAMH) journal; and JCPP Advances.
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Professor Sooyeon “Aly” Suh is a clinical psychology professor at Sungshin Women’s University in Seoul, Korea. Professor Suh’s research focuses on behavioral sleep medicine, including applying non-pharmacological interventions of insomnia to specific populations, such as PTSD patients, shift workers, and patients in primary care. Her secondary research interest includes incorporating digital technology into sleep research, such as wearables, auto-videosomnography, and digital apps. She has authored or co-authored several papers and chapters on these topics.
Transcript
[00:00:07.520] Jo Carlowe: Hello, welcome to the Papers Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlowe, a Freelance Journalist with a specialism in psychology. In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are the Journal of Child Psychology and Psychiatry, commonly known as JCPP, the Child and Adolescent Mental Health, known as CAMH, and JCPP Advances.
Today, I’m interviewing Dr. Sooyeon Suh, Associate Professor at the Department of Psychology at Sungshin Women’s University in Seoul, Korea. Sooyeon, who also goes by “Aly,” is a co-author of the paper, “Validation of the Parental Understanding and Misperceptions About BAby’s Sleep Questionnaire Using Auto-videosomnography,” recently published in the JCPP. This paper will be the focus of today’s podcast. If you’re a fan of our Papers Podcast series, please subscribe on your preferred streaming platform, let us know how we did, with a rating or review, and do share with friends and colleagues.
Aly, welcome, thank you for joining me. Can you start with an introduction about who you are and what you do?
[00:01:16.570] Professor Sooyeon “Aly” Suh: Thank you so much for having me and giving me this opportunity to share my research. I’m a Clinical Health Psychologist by training and I’m something of what you would call a Sleep Psychologist or a behavioural sleep medicine specialist. So, what I do is I do a lot of treatment and research around, kind of, the psychological aspects of sleep.
[00:01:38.830] Jo Carlowe: Excellent, thank you. So, today, we’re going to look at your paper. This is, “Validation of the Parental Understanding and Misperceptions About BAby’s Sleep Questionnaire Using Auto-videosomnography,” recently published in the JCPP. To help set the scene for us, Aly, can you tell us how prevalent paediatric sleep disorders are and how these sleep problems impact children?
[00:02:01.119] Professor Sooyeon “Aly” Suh: So, when we talk about paediatric sleep problems, there’s usually three that we mainly talk about. The first one is taking a long time to fall asleep, which we call sleep onset problems, or having the child wake up in the middle of the night and not being able to fall back asleep without any type of parental intervention. Or something called limit setting problems, which means the child deliberately continues to make requests with the intention of postponing bedtime, like, you know, they need another glass of water, they need to go to the bathroom, etc. And research shows that in children ages six to 36 months, about 25 to 40% of children do report having sleep problems, or their parents do, and so, that’s about one in three children, so it’s quite a lot.
[00:02:45.980] Jo Carlowe: Hmmm, strange.
[00:02:46.980] Professor Sooyeon “Aly” Suh: And yeah, whilst some children’s sleep problems might naturally remit, it’s been shown through research that most paediatric sleep problems are likely to persist without – if they’re not treated. And these untreated sleep problems may subsequently have a negative effect on the child’s development, such as resulting in a higher prevalence of child psychiatric disorders or having more aggressive behaviour and interfering with health and learning outcomes.
[00:03:12.930] Jo Carlowe: Thank you, yeah, so extremely impactful. Before we go into the details of the paper itself, can you tell us what is known about the association between parental cognition and children’s sleep?
[00:03:24.810] Professor Sooyeon “Aly” Suh: Parental cognition can seem a little bit of a big word and I, kind of, wanted to clarify first what we meant by that. Parental cognition about child’s sleep refers to, kind of, the beliefs and attitudes that a parent has about how their child should sleep. So, it’s, kind of, the expectations surrounding, and then, oftentimes, these beliefs can, kind of, shape and influence how the parent behaves associated with the child’s sleep. So, they might frequently check in more or sleep with the child right next to them, things like that. And these behaviours, such as frequently checking in to see that – if the child is sleeping, or immediately running to tend to the child, even with the slightest bit of noise, can ultimately, affect the quantity and quality of both the child’s and the parent’s sleep. So, we really wanted to look at this, kind of, unseen variable that really has a huge impact on how the parent behaves and ultimately, how the child sleep.
[00:04:18.769] Jo Carlowe: So, sort of, a bidirectional relationship. Let’s turn to the paper, then. Can you give us an overview, what did you look at and why?
[00:04:26.630] Professor Sooyeon “Aly” Suh: So, this paper is a validation paper and we really wanted to develop a questionnaire focusing on the role of parental cognitions about the child’s sleep. And what we really wanted to, kind of, get out of the paper was coming up with and developing a paper that was culturally inclusive. So, we did this with a thought in mind that we wanted to show the impact of how paediatric sleep difficulties extended to how the parents actually slept, as well. So, we looked at both in this study.
So, kind of, telling you a little bit about how we developed the questionnaire. One challenge that we ran into when we started the research was that most of the questionnaires that have already been used in the field were really centred towards Western culture. And I don’t know if you know anything about Korea, but I’m from Korea, where sleeping culture drastically, really differs from many Western cultures. So, for example, there’s a lot more co-sleeping going on and oftentimes, whole families sleep together in the same room until the child is quite grown-up. And this is sometimes, you know, just a cultural thing. It’s not necessarily a, kind of, a sleep problem.
So, there are all these different cultures that revolve around sleep, and some of the questionnaires that we reviewed, that we wanted to use in future studies to look at parental cognition, kind of, seemed a little bit more unfit for paediatric sleep research in cultures like Korea. So, what we did was, we, kind of, took a little bit more of a bottom-up approach. We interviewed ten Korean women who were currently experiencing sleep difficulties with their child, and then, kind of, compiled a list of statements that reflected the beliefs and attitudes that they had towards their child’s sleep.
So, while we did that, we also asked a group of world-renowned sleep experts to review the items that we had come up with and add their own expertise from it, and we came up with this questionnaire, that’s called a “Parental Understanding and Misperceptions About BAby’s Sleep Questionnaire,” which is also named PUMBA-Q. Our study was called SIMBA, so we, kind of, had a little bit of a Disney theme going on there. And then, after we, kind of, had these questions, we wanted to make sure statistically, that it was, kind of, sound to use, and we call this process validation.
And so, what we did was we had the absolute pleasure of partnering with a US-based company called Nanit, and this company specialises in a device called auto-videosomnography. So, this device is specifically designed to monitor infants’ sleep in their own natural environment, and it also, objectively measures sleep. And one of the things that was very unique about this is that a lot of the studies that have already been done with paediatric sleep research is that they, kind of, took more parental reports, so paper and pencil measures, to measure infants’ sleep. Whereas this was measuring, so, infants’ sleep in their own natural environment for multiple nights. And so, I think that was, kind of, a unique objective piece of it. And so, we did all the statistical analyses and we found that there were four sub-scales that, kind of, came up in the questionnaire.
[00:07:26.490] Jo Carlowe: Just to go back to the – to making it culturally inclusive, the bias towards Western attitudes and cultures towards sleep would promote much more independent sleeping, so…
[00:07:38.150] Professor Sooyeon “Aly” Suh: Right. So, a lot of the Western cultures, if you look at, kind of, how they measure parental cognition, it, kind of, assumes that solitary sleeping is, kind of, the norm. Kind of, sleeping separate from their parents is the norm, and that is really not the case for a lot of Asian countries.
[00:07:54.560] Jo Carlowe: And just in terms, again, like, an overview, can you just say why it was important, so important to look at this area?
[00:08:01.819] Professor Sooyeon “Aly” Suh: So, you know, a lot of the times, when you look at behavioural sleep interventions for infants, better known as sleep training, when you look at that, a lot of them have been really focused on changing the behaviour around the infant’s sleep or the parents’ sleeps.
One of the more well-known methods is something called Cry-It-Out method or Ferber method, where, you know, you just, kind of, like, let the child cry for a long period of time and the child, kind of, gets trained to sleep on their own. Which is fine, but I think what some of these methods really, kind of, overlook is that the parents that are all – that are driving the intervention, and if they can’t tolerate the training, or if they have these, kind of, fears of isolation or abandonment in their past, a lot of the time it’s going to be really hard for them to follow through, you know, days of crying. And a lot of the times, they fail. And we really need to figure out – you know, we have these great methods of behavioural sleep interventions that are scientifically sound.
They have a lot of good evidence around them, and they’re very safe, but we’re also seeing a pretty low implementation rate. And, you know, I think one of the key pieces to remember is that the way that the parents think about their child crying, or the way that they expect a child to sleep at a certain age, really does influence how they should really train their child to sleep.
[00:09:21.310] Jo Carlowe: Thank you. Let’s turn to the findings. Aly, what were the key – if you could highlight some of the key findings from the paper for us.
[00:09:29.480] Professor Sooyeon “Aly” Suh: Some of the key findings of the study was that we came up with a list of items and through a statistical method, something called factor analysis, the questionnaire, kind of, consisted of four categories of how the parents thought about their child’s sleep. So, the first one was the misperceptions that a parent might have specifically about the child’s sleep. So, an example item might be, “If I do not always know what my child needs when my child cries at night, it means I’m a bad parent.” So, really attributing all the fault to themselves.
A second category was how they should intervene when their child cries or wakes up at night. So, a sample item might be something like, “If I do not respond right away when my child cries, it will negatively affect his or her emotional development.” So, catastrophising some of the results of the child crying. And then, the third category was misperceptions about feeding. So, “If my child wakes up at night, it’s because he or she is hungry.” And then, the fourth category was, kind of, general anxiety of being a parent. Something like, “I am afraid my child might die unexpectedly if I sleep separately with him or her.”
So, these are the four categories that we found the questionnaire items to be, and when we looked at the item totals, so higher scores meant that they had more perceptions or dysfunctional beliefs about the child’s sleep. What we found was that it was also highly associated with insomnia symptoms for parents. So, parents who actually had more dysfunctional beliefs, actually had more insomnia symptoms. Very interestingly, it was also very strongly related with how much the baby actually slept.
So, I told you about this auto-videosomnography device called Nanit, and every day, it was recording how long the child was sleeping. And what we did was, we divided the children into three tertiles. So, you know, one third, one third, and one third, and if you, kind of, compare the top tertile and the bottom tertile, the top tertile infants slept 623 minutes. These were the parents who had the least number of dysfunctional cognitions, and they were sleeping 623 minutes. Whereas, the parents who had a lot of dysfunctional cognitions, their infants were sleeping 590 minutes. So, there was about a 30-minute difference between the top tertile and the bottom tertile.
And while this might – 30 minutes might not seem a lot to some people, you know, if you’re a parent, 30 minutes is a long time. So, actually, your child sleeping 30 minutes definitely means a lot to a lot of parents. So, I think this was a pretty big difference that we found and it really highlights that the way that you think about your child’s sleep really shapes your behaviour. And if it shapes your behaviour and how it intervenes, it’s going to, kind of, interfere with some of the practices that are more well-known, that may be more conducive to sleep, and that, ultimately, does have an impact on your child’s sleep, as well.
And really more interestingly, so, one of the other things that we measured was that the Nanit device, or the auto-videosomnography device, actually was capable of measuring how many times the parents came in, in the middle of the night and checked in on their infants. And what we found was that the parents who had higher scores on our questionnaire, actually showed more parental interventions during the night and reported less confidence in terms of their parentings. Also, we found that it was, kind of, shaping their behaviour, as well.
[00:12:52.279] Jo Carlowe: Yeah, it’s fascinating. So, it’s almost a bit, sort of, self-perpetuating. So, the more anxiety laden the parent is about – around their beliefs around sleep, the greater the chances that their child will sleep less well, or less long, or…?
[00:13:05.060] Professor Sooyeon “Aly” Suh: Yes, and then, that also has an impact on their own sleep, because, you know, their child’s not sleeping as much, they’re not sleeping as much. And, you know, the chi – the parent’s not sleeping as much, I mean, we didn’t really measure this in our study, but research has shown that parents not getting sufficient sleep really does have an impact on their parenting practices. They’re less sensitive to their child’s emotions, you know, they might be more irritable. You know, sleep has been very strongly tied with emotion regulation, so they might be a little bit more short with their spouse or their child. I mean, there’s a lot of different consequences that you could think of that would be impacted by their child not sleeping very well.
[00:13:42.380] Jo Carlowe: So, hugely impactful findings, actually. Aly, what are the implications of your findings for Researchers?
[00:13:49.180] Professor Sooyeon “Aly” Suh: Well, we really wanted to, kind of, highlight and focus on the importance of re-examining the beliefs and attitudes that parents might have about their child’s sleep. It’s really been under-researched. A lot of it is just focusing on some of the behaviour, and some of these beliefs and thoughts, or attitudes, were probably passed on to you by your parents. So, there is a little bit of a history there, and some were probably acquired through your own life. But without close examination, there may be some beliefs that are really interfering with child’s sleep and counterintuitive to sleep science, that you may not even know about. So, really focusing on this as a field, I think, will be very helpful in boosting some of the treatment effects that we already have and also, helping parents think about their own history and thinking about why they’re doing some things around their child’s sleep.
I mean, the bigger message is that paediatric sleep problems not only affects the child negatively, but extends to the parents’ wellbeing, as well, and you know, we really don’t have a lot of discussion about how stressful parenting can be. And, you know, I mentioned earlier that I used to be a Clinical Health Psychologist. I started out my research career in stress research, and there were these two Stress Researchers called Holmes and Rahe, and what they did was they, kind of, compiled a list of all the stressful things that could happen to a person and could rank them. And what they found was that getting pregnant and having a child was actually more stressful than going bankrupt or losing a close friend. And so…
[00:15:17.200] Jo Carlowe: Ah.
[00:15:18.200] Professor Sooyeon “Aly” Suh: …you could think that, you know, being a parent is stressful and we’d really talk a lot about some of the more positive aspects about it, but I think sleep is one the, kind of, areas that is most stressful to some parents. And, you know, I don’t think we really realise that enough and really talk about it enough. So, hopefully, this will open a little bit more dialogue about how this is a stressful area for a lot of parents and also, how there are some things that really can be done about it.
[00:15:43.899] Jo Carlowe: Well, turning to the things that can be done about it, you mentioned treatment earlier. How might your findings be translated into practice to support CAMH professionals and Clinicians who work with families experiencing paediatric sleep problems?
[00:15:57.930] Professor Sooyeon “Aly” Suh: Most of the sleep interventions in the field for children are mainly focused on behaviours and behavioural interventions. So, some of these things are sleep routines or, you know, Crying-It-Out, the Ferber method, are pretty well-known, and there’s really been little to no focus on parental cognitions as a target for treatment. We really don’t examine that, and it is really a big barrier in terms of implementing some of the more well-known evidence-based interventions. And also, the really good news is that parental cognitions are a modifiable factor that can serve as a really good target for interventions in sleep disorders in children. And so, we have, you know, we have cognitive behavioural therapy, which is a very powerful and effective type of therapy, and, kind of, adding this cognitive aspect into some of the behavioural interventions that have already been established, I think will be very helpful.
One of the other interesting things about the paper was that parents who had misperceptions and dysfunctional beliefs about their child’s sleep also had more higher scores about – on dysfunctional beliefs about their own sleep, as well. So, it just might be like a general sleep issue. They probably have had sleep issues in the past and it, kind of, gets passed down and perpetuates as a generational thing. I thought that was, kind of, an interesting piece that maybe should be discussed a little bit further.
[00:17:16.679] Jo Carlowe: Are you planning any follow-up research, or is there anything else in the pipeline that you would like to share with us?
[00:17:22.630] Professor Sooyeon “Aly” Suh: I’m so glad you asked that question, because the reason why we actually developed this questionnaire was we were actually really interested in designing an intervention that was mainly cognitive. And so, we just didn’t like any of the measures that we found, so, we developed this questionnaire first. It was one of the first steps, and now, we’re, kind of, in the middle of our clinical trial, where we’re comparing cognitive intervention to an active control group.
And what we’re doing is we’re really trying to make it more conducive to parenting. Where, you know, we’re meeting with parents who have some downtime during their naptime, and then, we’ll meet with them and we’ll, kind of, talk a little bit about the misperceptions they have about their child’s sleep. And also, making it, really, a cognitive intervention, where we do, kind of, the more traditional cognitive behavioural therapy where we fill out thought logs, we really closely examine some of the cognitive assumptions that they might have about child sleep and maybe some of that is faulty. And so, we, kind of, take a very much cognitive approach to that intervention.
And everything is online, so we meet with them through our telehealth means, as opposed to traditional face-to-face interventions, which is a lot more doable for some parents who are at home with their child and can’t leave. And sometimes, you know, we’ll have moms who have their child on their lap, and we’ll still do therapy. So, it is trying to be a little bit more deliverable to, and accessible to these parents. So, that’s in the pipelines and we’re in the middle. We’ve just recruited about half of the sample, so hopefully, we’ll be talking to you again about our exciting results about the intervention.
[00:18:58.440] Jo Carlowe: It sounds really exciting, thank you. Aly, finally, what is your take home message for our listeners?
[00:19:04.190] Professor Sooyeon “Aly” Suh: Well, I think, as I mentioned before, you know, being a parent is a very stressful event for many people. I mean, I’m sure there are also very joyful aspects of it, but also, you know, we really should think about how parental sleep is really important in the context of infant sleep. They’re, kind of, really tied together, and if your child doesn’t sleep, the parent doesn’t sleep, and if the parent doesn’t sleep, there are a lot of implications to how you’re going to treat your child and how you’re going to parent your child. And so, if you’re not getting enough sleep, you should really, you know, see a sleep professional.
If your child’s not getting enough sleep, or if child is having some sleep difficulties, there are some wonderful, wonderful evidence-based sleep interventions out there that can help you, that have been really established as safe and long-term and have good maintenance and good effect sizes. So, definitely don’t hesitate to, kind of, seek help if you feel you need it.
[00:19:57.550] Jo Carlowe: Thank you ever so much. Are there any particular interventions that you want to mention?
[00:20:02.429] Professor Sooyeon “Aly” Suh: So, the three interventions that have been recommended by the American Academy of Sleep Medicine are – one is called ‘standard extinction’, which is, I think, more well-known as you just leave your child there and you, kind of, let them cry it out a little bit. I think it’s a little bit unpopular with a lot of parents, because they don’t – really don’t like to hear their child cry. So, that’s the first approach.
The second one is called ‘graduated extinction’, where it’s a little bit more of a modified approach to the standard extinction, where you, kind of, you know, space out the time that you go in to check in with your child, and I think that one is a little bit more popular and also, effective. And then, the third one is called ‘camping out’, where you’re still in the room and there is still a parental presence until your child falls asleep, and that’s definitely a lot more modified.
So, I think, you know, with all these interventions, I know there’s a lot of controversy around it, but it’s really finding the right balance between how much limit-setting you can do and what your anxiety level is. There’s not a one size fits all for anyone. Everyone’s child is different. Everyone’s child is going to react differently to the different interventions, and also, the parents are different. So, you just have to find the right intervention for you, that’s effective, and my only main message is that you shouldn’t suffer.
[00:21:16.700] Jo Carlowe: Aly, thank you ever so much. Thanks for sharing more details about your research with us. For more details on Dr. Sooyeon Suh, please visit the ACAMH website, www.acamh.org, and Twitter @ACAMH. ACAMH is spelt A-C-A-M-H, and don’t forget to follow us on your preferred streaming platform, let us know if you enjoy the podcast, with a rating or review, and do share with friends and colleagues.
