Brief Report: A ‘‘Storybook’’ Ending to Children’s Bedtime
Problems—The Use of a Rewarding Social Story to
Reduce Bedtime Resistance and Frequent Night Waking
Raymond V. Burke,1 PHD, Brett R. Kuhn,2 PHD, and Jane L. Peterson,3 MS
1
Girls and Boys Town, Nebraska, and University of Nebraska, Lincoln; 2Munroe-Meyer Institute,
University of Nebraska Medical Center; and 3Behave’n Day Center
Objective To evaluate the efficacy and acceptability of a social story with tangible rewards to
reduce children’s disruptive bedtime behavior and frequent night waking. Method Four
children (ages 2 to 7), with clinically significant disruptive bedtime behavior, received the
intervention, which consisted of a social story (The Sleep Fairy) that sets forth (a) parental
expectations for appropriate bedtime behavior and (b) rewards for meeting those
expectations. Results Parent sleep diaries indicated that children had a 78% average
decrease in frequency of disruptive bedtime behaviors from baseline to intervention, with
another 7% decrease at 3-month follow-up. Night wakings, a problem for 2 children during
baseline, were not a problem during intervention and follow-up. Parents reported improved
daytime behavior for 3 of the 4 children. Parents gave the intervention high acceptability ratings
and maintained a high level of treatment fidelity. Conclusions Use of a social story helped
parents implement a multicomponent intervention using a familiar bedtime routine, thereby
increasing the likelihood that implementation and effects occurred. The book format makes this
intervention widely available to parents and professionals, with minimal costs and
inconvenience.
Key words bedtime; behavior; children; reinforcement; sleep; sleep disorders; social story.
For many parents, the task of putting a young child to
bed is met with great reluctance. Pediatric sleep
disturbance in the form of bedtime difficulties and
frequent night awakenings affects about 25% of all
children between the ages of 1 and 5 (Armstrong,
Quinn, & Dadds, 1994). Poor sleep consistently is
among the most common concerns presented in clinical
settings for children (Arndorfer, Allen, & Aljazireh,
1999; Keren, Feldman, & Tyano, 2001; Lavigne et al.,
1999; Mindell, Moline, Zendell, Brown, & Fry, 1994).
Recent evidence indicates that a good night’s sleep plays
a critical role in early brain development, learning, and
memory consolidation (Frank, Issa, & Stryker, 2001;
Stickgold, James, & Hobson, 2000), whereas disrupted
sleep has been linked to behavior problems and poor
emotional regulation (Dahl, 1996; Sadeh, Gruber, &
Raviv, 2002).
For years, the most widely recommended treatment
for bedtime tantrums and night waking has been
extinction, or one of its variants (Christopherson, &
Mortsweet, 2001; Ferber, 1985; Owens, Palermo, &
Rosen, 2002; Spock, 1978). Extinction and graduated
extinction form two of the three well-established
effective interventions in the field (Kuhn & Elliott,
2003). Extinction has been criticized heavily by many
consumers, resulting in poor acceptability (Kuhn, Elliot,
Lund, & Pfeifer, 2003). The use of extinction often
results in an initial increase in crying or tantrum
Address correspondence to Raymond V. Burke, 14100 Crawford Street, Boys Town, NE 68010. E-mail: R. Burke,
[email protected]; B. Kuhn, [email protected]; J. Peterson, [email protected].
Journal of Pediatric Psychology 29(5) pp. 389–396, 2004
DOI: 10.1093/jpepsy/jsh042
Journal of Pediatric Psychology vol. 29 no. 5 Q Society of Pediatric Psychology 2004; all rights reserved.
390
Burke, Kuhn, and Peterson
behavior, which many parents find difficult to tolerate. If
parents react by deviating from the prescribed procedure, their treatment efforts may fail. Extinction has
also been criticized on the grounds that it fails to teach
and reinforce appropriate child replacement behaviors
(Milan, Mitchell, Berger, & Pierson, 1981).
The purpose of the current study is to evaluate the
efficacy and acceptability of a rewarding social story to
reduce children’s disruptive bedtime behavior and night
wakings. Social stories typically describe social situations, relevant cues, and desired responses to a given
situation (Gray & Garand, 1993). While used successfully as a teaching tool for children with autism (e.g.,
Thiemann & Goldstein, 2001), social stories present an
untapped potential for typically developing children
with persistent behavior problems. Our social story
consists of a children’s storybook that tells the tale of
the ‘‘Sleep Fairy,’’ who leaves a small tangible reward
under children’s pillows when they demonstrate
clearly described appropriate bedtime and nighttime
behaviors.
We hypothesized that the introduction of a social
story to convey clear bedtime expectations, with the
presentation of a reward for appropriate bedtime
behavior, would result in (1) a reduction in disruptive
bedtime behavior and night waking, (2) a reduction
in sleep onset time, (3) an increase in sleep duration,
(4) a decrease in children’s problem behavior during
waking hours, and (5) high levels of treatment acceptability and fidelity.
Method
Participants
Participation in the study was made available to children
between 2 and 7 years of age who met relatively stringent
selection criteria (previously established by Mindell &
Durand, 1993):
1. Medical etiologies were not believed to
contribute to the sleep disturbance.
2. For a minimum of three nights per week, the
child resisted going to bed, fell asleep in a location
other than his or her bed, or required parental
intervention or presence to return to sleep.
3. The parents indicated to the clinician a desire for
the child to fall asleep independently and sleep in
his or her own bed throughout the night.
4. The sleep problems had been occurring for
a minimum duration of 4 weeks.
Agreeing to participate in the study were the parents
of four respective children who were referred by
physicians to a sleep clinic in a centrally located
Midwestern city and who met the selection criteria.
During the intake process, parents of one participant
noted that the referred child’s sibling also met the
selection criteria and was included in the study, for
a total of five participants. Four of the children and their
parents completed the study. Parents of the fifth child
were unwilling to complete data collection and withdrew
from the study. They were offered standard clinical care
at the sleep clinic.
The participants included a 5-year-old Caucasian
male ( Jeff ); a 7-year-old Hispanic male (Hector); and
two sibling Caucasian females, age 7 (Michele) and age 2
(Susan; all names are fictitious). All but one child
(Susan) participated in behavioral health services
throughout the study. Parents of all 4 children described
a lengthy history of disruptive bedtime behaviors. For
example, Jeff’s parents reported that his bedtime
problems included severe tantrums, hitting and kicking
parents and siblings, destruction of property (e.g.,
beating the wall, breaking a window, urinating on floor),
and frequent episodes of leaving the bedroom after being
put to bed for the night. Hector’s sleep history was
remarkable for frequent night waking and difficulty
initiating and maintaining sleep without parental
presence. According to Michele and Susan’s mother,
the girls’ behavior problems included fighting with each
other, refusing to get ready for bed, arguing, crying and
screaming once in bed, and waking and entering their
parents’ bed during the night.
Procedure
A university institutional review board approved the
study. During the intake interview, parents completed
consent forms and received a photocopy of the book The
Sleep Fairy (Peterson & Peterson, 2003) but received no
stipend for participation.
A single-subject design was chosen, because this is
an initial evaluation of a previously untested intervention (Drotar, La Greca, Lemanek, & Kazak, 1995). The
initial intent was to use an ABAB withdrawal experimental design (Kazdin, 1998); however, the first
participant’s parents were reluctant to complete the
withdrawal phase, expressing concerns that they did not
wish to revert to baseline conditions (i.e., stop reading
the book at bedtime) after their child experienced
success with the intervention. As a result, the authors
Children’s Bedtime Problems
decided to use a multiple-baseline design across
participants (Kazdin, 1998) for the next 3 children.
Follow-up data were collected at 3 months after the
conclusion of the treatment condition.
Intervention
Parents were asked to read The Sleep Fairy (Peterson &
Peterson, 2003) at the conclusion of the child’s nightly
bedtime routine. The book, which includes colorful
illustrations and 14 pages of text, involves a social story
about two children who overcome their bedtime
problems and learn how to get ready for bed and how
to stay in bed without difficulty. A poem embedded in
the story specifies appropriate bedtime behaviors and
describes how the Sleep Fairy will leave a treat (a
positive reward) for children who follow bedtime
routines and fall asleep without problems.
And if you’re very still and quiet, and if you stay in
bed.
[The Sleep Fairy] lifts your pillow to place a gift
beneath your head.
But she only leaves a present if you stay in bed
all night.
So don’t yell or cry or leave your bed. Don’t pout
or whine or fight. (p. 15)
Two introductory pages provide parents with brief
instructions on how to:
1. set clear bedtime expectations;
2. use reinforcement contingent on children’s
appropriate bedtime behavior—for example,
‘‘When your children stay in bed and are sleeping
peacefully, place a small prize, treat, or charm
under their pillow’’; and
3. select reinforcers that are simple and safe for
children—for example, ‘‘such as a bookmark,
sticker, hair ribbon, or small plastic dinosaur.’’
When parents identified night waking as a targeted problem during the initial interview, they were asked to place
the reward under the child’s pillow in the morning, before
the child awoke. The introduction instructs parents to
continue reading The Sleep Fairy until the child demonstrates success for 2 weeks. At that point, it instructs them
on how to transition to intermittent use of the book.
Measures
Sleep diaries. Sleep diaries are the most widely used
measure of sleep in clinical settings. They have reason-
able validity, high internal consistency, and good
agreement with videotapes and actigraph measures of
children’s sleep (Corkum, Tannock, Moldofsky, HoggJohnson, & Humphries, 2001; Mindell & Durand,
1993). In this study, parents used a bedtime data form
to structure their sleep diary entries, track the time of
bedtime events, and record the frequency of disruptive
bedtime behaviors during bedtime preparation and from
the time the child was put to bed (i.e., night wakings).
Disruptive bedtime behaviors included, but were not
limited to, stalling, noncompliance, vocal protests,
calling out for the parent, crying, screaming, tantrums,
complaining, demanding, and aggression. Night waking
was operationally defined as any time the child aroused
a parent and required him or her to do something to
settle the child (Adair, Zuckerman, Bauchner, Philipp, &
Levenson, 1992). Sleep onset was defined as the time
from when the child was in bed with lights out until the
time a parent observed the child asleep. Data collected
by parents were used as dependent measures of the
combined total number of observed disruptive bedtime
behavior problems (DBB); the number of night wakings
(NW); sleep onset time (SOT); and total sleep time (TST).
Reliability. Consistent with prior studies (e.g., Durand
& Mindell, 1999), an author called parents and reminded them to complete the reliability check sheet on
28% of randomly selected dates across baseline and
intervention phases. Two methods were used to check
reliability. For two of the families, the parent who did
not manage the bedtime routine was asked to record
reliability data on a separate bedtime data form, without
collaborating with the other parent. In the third family,
a second parent was not available for data collection;
therefore, the third author called the mother on
randomly selected mornings and asked her to report
DBB and NW frequency for the prior night. These
telephone reports were later compared formally with the
parent’s completed bedtime data form (Durand &
Mindell, 1999).
Data for DBB and NW events were considered reliable
if parents’ frequency counts varied by no more than one
point—or, for the parent collecting the data by herself, if
the difference between reported and recorded frequencies varied by no more than one point. SOT and TST data
were considered reliable if they varied by no more than
15 min. Reliability was computed by summing each of
the total number of possible disruptive events or minutes
and the total number of disruptive events or minutes
reported during the reliability check, dividing the latter
number by the former and multiplying by 100.
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Burke, Kuhn, and Peterson
Figure 2.
Figure 1.
Total disruptive bedtime behaviors (DBB).
Interrater agreement between Jeff’s parents was 91%
for disruptive behaviors and 100% for sleep onset and
sleep duration. Telephone reliability data for Hector
matched the parent-recorded bedtime data forms on
100% of the occasions. Interrater agreement was 92% for
Michele and Susan’s parents (i.e., agreement occurred on
11 of 12 selected nights).
Treatment fidelity. During treatment phases, parents
recorded the time at which they read The Sleep Fairy.
Records indicated that the intervention was implemented on 26 of 27 (96%) treatment dates with Jeff, all
36 nights with Hector, 19 of 20 (95%) nights with
Michele, and 14 of 15 (93%) nights with Susan.
Child Behavior Checklist (CBCL). The CBCL (Achenbach, 1991) is a widely used, standardized measure of
behavioral–emotional problems in children. Parents
indicate the extent to which each item describes their
child’s behavior within the past 2 months (for 2- to 3year-olds) or 6 months (for 4- to 18-year-olds). The
CBCL yields a Total Problem T score and two broadband
factors: an Internalizing scale (e.g., social withdrawal,
depression) and an Externalizing scale (e.g., aggression,
delinquent behaviors). The Sleep Problems subscale on
the 2- to 3-year-old version has been shown to be
sensitive to treatment effects (Reid, Walter, & O’Leary,
1999). For purposes of this study, the CBCL’s Internalizing and Externalizing composite T scores and
Total night waking (NW) events.
Total T scores were used. The Sleep Problems subscale of
the 2- to 3-year-old version was used for the one child
(Susan) who fell within this age range.
Treatment acceptability. The Treatment Evaluation Inventory-Short Form (TEI-SF; Kelley, Heffer, Gresham, &
Elliott, 1989), a shortened and simplified version of the
Treatment Evaluation Inventory (TEI; Kazdin, 1980),
was used to assess parental judgments of treatment
acceptability and perceived efficacy. This widely used
instrument consists of nine items scored on a 5-point
scale (15 strongly disagree; 5 5 strongly agree). Total
scores ranged from 9 to 45, with higher scores indicating
greater acceptance of the treatment. The TEI-SF has been
shown to be an internally consistent and valid instrument
that effectively discriminates between alternative treatments (Kelley et al.; Miller & Kelley, 1992).
Results
Problems Across Bedtime Preparation
and Sleep Periods
Results show that introduction of The Sleep Fairy social
story produced rapid and sustained reductions in the
frequency of the children’s targeted disruptive bedtime
behaviors (DBB; Jeff, Michele, and Susan; see Figure 1)
and night wakings (NW; Hector and Michele; see Figure
2). These improvements were maintained at 3-month
follow-up.
During the intervention, Jeff’s mean number of DBB
dropped substantially, from 20.3 per night (SD 5 16.2)
to 1.0 per night (SD 5 2.0). At 3-month follow-up, the
frequency increased slightly, to 3.8 (SD 5 3.5). Jeff’s
total DBB jumped to 23 during an unplanned withdrawal, clearly exceeding the mean DBB during the treatment phase. While the DBB rate did not reach the
frequency seen during the planned reversal (M 5 3.6),
Children’s Bedtime Problems
the rate was still more than five times the observed rate of
DBB during the intervention phases (M 5 .67).
Michele and Susan’s mother reported a combined
average of 35 DBB during baseline (M 5 17.4 and 17.6,
respectively). During the intervention, the mean DBB
was .71 and 1.2 per night for Michele and Susan,
respectively—a 96% and 93% reduction (Figure 1). At 3month follow-up, the DBB rate dropped to an average of
.3 events per night for each child. Susan, who averaged
slightly less than one NW during baseline, had no NW
during intervention and follow-up conditions (Figure 2).
Although The Sleep Fairy instructions encourage
parents to have the ‘‘Sleep Fairy’’ leave a reward when
targeted behaviors occur from the bedtime routine
through morning, Hector’s mother independently chose
to target only a single criteria (i.e., night waking) during
the intervention phase, which explains the less noticeable effect on total DBB (Figure 1). However, her chosen
criteria, night waking (NW), reduced from 2.4 events
per night during baseline to .5 per night during
treatment with no NW occurring at 3-month followup. The duration of NW improved from 28 min during
baseline to less than 4 min during treatment. This
reduction in NW appeared to have a positive concurrent
effect on the frequency of DBB. Hector averaged 21.0
problems per night during baseline, 9.0 problems per
night during intervention (a reduction of 57%), and 3.6
problems per night at 3-month follow-up (Figure 1).
Sleep Onset
Sleep onset improved consistently for Jeff, from an
average of 56 min, during baseline and withdrawal
phases; to 32 min, across treatment phases; and 29 min,
at 3-month follow-up. Sleep onset improved substantially for Hector, Michele, and Susan (M 5 50 min
during baseline; M 5 29 min during intervention) before
reverting to near baseline levels (M 5 48) at follow-up.
Total Sleep Time
The Sleep Fairy appeared to produce varying effects on
the children’s total sleep time (TST). For example, Jeff’s
TST did not improve immediately, but by the 3-month
follow-up, he was sleeping an average of 16 min more
each night (average TST of 601 min). Hector showed
steady increases in TST, with an average increase of 23
min per night by follow-up. TST for Michele and Susan
did not change a great deal. However, their TSTs were
within the normal developmental range (Weissbluth et
al., 1981) at pretreatment, so we did not expect an
increase for these children.
Child Behavior Checklist
Results from the CBCL indicated that the Total Problem
scores were in the clinical range for all 4 children at
baseline. At posttreatment, scores were in the normal
range for Jeff and Susan, were improved for Michele, and
were unchanged for Hector. For Susan, the Sleep
Problems subscale on the 2- to 3-year-old version of the
CBCL improved from the clinical range (T 5 68) at pretreatment to the normal range (T 5 57) at posttreatment.
Treatment Acceptability
Parents rated The Sleep Fairy to be a highly acceptable
intervention for their children’s sleep problems, as
indicated by the parents’ TEI-SF total scores of 44, 33,
44, and 40, out of a possible 45 points (Kelley et al.,
1989).
Discussion
The use of a social story that specifies and reinforces
appropriate bedtime and nighttime behavior produced
a substantial reduction in disruptive bedtime behavior
(DBB) and night waking (NW) for the 4 children in this
study. Results were consistent and robust across
participants and compared favorably with interventions
that parents deemed effective but less acceptable (see
Kuhn & Weidinger, 2000). Positive effects of the social
story were maintained at 3-month follow-up, when
parents were using the story and rewards intermittently.
Although many studies in the pediatric sleep
literature have targeted bedtime behavior, the current
study is unique because it reports intervention effects on
relevant sleep variables—including a standardized sleep
scale, sleep onset time, total sleep time, and frequency of
night waking—while also monitoring daytime behavior,
treatment acceptability, and fidelity by parents. Unlike
many pediatric sleep studies, our study did not exclude
children with daytime behavior problems; in fact, all 4
participants displayed clinically significant daytime
behavior problems upon entry. Results on the CBCL
indicate that The Sleep Fairy had a positive effect on
daytime behavior problems for 3 of the 4 participants.
Effects of The Sleep Fairy on sleep onset and total
sleep time varied across children. The most noticeable
improvement occurred with Jeff, whose sleep onset was
reduced by almost half. Increases in TST from baseline to
posttreatment were evident most with Jeff (an average
increase of 16 min per night) and Hector (an average
increase of 23 min per night). Despite the variable effects
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Burke, Kuhn, and Peterson
on sleep time, parents reported maintenance of treatment effects with children’s DBB and NW.
An important but often overlooked aspect in
treatment outcome research has been the acceptability
and fidelity of the intervention (Kazdin, 1998). This has
been the Achilles’ heel for interventions designed to
address children’s sleep problems. For example, Kuhn
and Weidinger’s (2000) review of pharmacological and
behavioral interventions for sleep disturbances suggests
that, despite the proven efficacy of behavioral treatments, parents are unwilling to follow through with
many of these interventions, hence jeopardizing treatment effectiveness. Reid, Walter, and O’Leary (1999)
mentioned that nearly 20% of the parents who participated in a comparison of graduated or standard ignoring
interventions dropped out of the study because they
were unwilling to allow their young children to cry
without attending. In contrast, behavioral diaries from
parents who used The Sleep Fairy reported no adverse
effects with implementation (e.g., extinction burst).
They rated the Sleep Fairy intervention to be a highly
acceptable approach to their children’s sleep disturbances and implemented the treatment with a high degree of
fidelity. The average acceptability (TEI-SF) score of 40.3
compares quite favorably to parental ratings for positive
reinforcement (M 5 34.2), response cost (M 5 33.4),
and time-out (M 5 32.6) for children’s disruptive
behavior problems ( Jones, Eyberg, Adams, & Boggs,
1998). The Sleep Fairy also received higher treatment
acceptability ratings than other empirically based
interventions for pediatric sleep disturbance, including
extinction (M 5 28.9), graduated extinction (M 5
33.4), and sedative medication (M 5 18.2; Kuhn et al.,
2003). These data are consistent with existing research
indicating that techniques designed to increase deficit
behaviors (e.g., rewards, attends) are evaluated by
consumers to be more acceptable than techniques
designed to decrease behavioral excesses (e.g., timeout, ignoring).
Although these results are promising, they represent
an initial evaluation of 4 subjects. Further research is
needed, with a larger sample of children experiencing
a wider variety of bedtime problems. A randomized
control group study is underway to help identify which
components of the intervention (i.e., establishing a bedtime routine, personal attention from parents, social
story, positive reinforcement) contribute to the overall
positive effects of The Sleep Fairy. Like most existing
research targeting children’s bedtime behavior, this study
relied on parent-completed diaries and standardized
measures. Future studies might incorporate objective
measures of sleep (e.g., actigraphy), operationally define
when the child is asleep (e.g., Piazza & Fisher, 1991),
and use partial-interval time sampling to more accurately
measure disruptive bedtime and nighttime behaviors
(e.g., Sanders, Bor, & Dadds, 1984).
In summary, use of a social story helped parents to
effectively address child disruptive bedtime behavior
and night waking via a simple and acceptable intervention. The book format, which is parents’ preferred
source of assistance for children with sleep problems
( Johnson, 1991), makes this intervention widely available to the public, with minimal cost and inconvenience.
For professionals, The Sleep Fairy provides an addition
to their tool kit of effective interventions for pediatric
sleep disturbance.
Acknowledgments
The authors thank Holly Filcheck and Ron Thompson for
their critiques of earlier drafts of this paper, the editor and
reviewers for their thoughtful recommendations, and the
parents and children who participated in the study.
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