Internet-Based Therapy And Understanding Toddler Sleep Problems

Toddlers are often prone to sleep challenges, which can be challenging for parents and caregivers. Sleep is essential to health and wellness, so supporting your child’s rest is often part of maintaining their mental and physical health.

Medical attention can be required for sleep problems caused by physical conditions like sleep apnea. However, behavioral interventions may also be effective in improving toddlers’ and parents’ sleep habits, and internet-based therapy interventions are a way to receive accessible mental healthcare.

If you’re interested in professional support for insomnia or other common sleep issues, including night terrors, sleep talking, or separation anxiety, online therapy can offer a way to receive care from home at a time that works for you.

Sleep trouble: A common behavioral issue in toddlers

If you are struggling to help your toddler get to sleep and stay asleep, you are not alone. Sleep problems can be common in young children, with around 20% to 30% of infants and toddlers having trouble falling asleep and staying asleep, symptoms of a sleep disorder called insomnia.

Sleep trouble can be a common behavioral challenge for which parents seek the advice of primary care or family medicine providers. Dysregulated sleep may lead to increased difficulties with mood control, focus, and alertness during daily activities. While ages can experience these symptoms, young children, in particular, are susceptible to the detrimental effects of sleep deprivation, as their quickly developing bodies can require a greater amount of sleep. The Centers for Disease Control and Prevention (CDC) reports that infants and toddlers require 11 to 17 hours of sleep daily.

Because of the nature of toddler sleep problems, they often correlate with parental sleep and well-being. By helping young children develop healthy sleeping practices, such as appropriate sleep hygiene before bed and a regular bedtime routine, parents can help their children sleep through the night, improve their own sleep quality, and potentially increase their measures of focus, happiness, and emotional control.

Research on sleep and toddler health

The American Academy of Sleep Medicine indicates that sleep trouble can often be successfully treated through behavioral interventions. While these behavioral interventions have been conducted over face-to-face sessions in previous years, the increased integration of technology into society has led researchers to explore whether internet-based interventions have the potential to reduce or eliminate sleep disturbances for toddlers to build a solid sleep foundation.

Studies looking at the efficacy of internet-based therapy to improve sleep issues have been positive. Results show that insomnia symptoms have been effectively decreased, reducing the number of sleepless nights for individuals. In addition, the effects often remained steady at the six-month follow-up. While these results can indicate the benefits of sleep for adults, studies have also been explicitly conducted on toddlers.

In one study, where 264 families were recruited with children between the ages of six months to three years, two weeks of behavioral interventions were shown to have beneficial effects on the children's sleep quality. Despite initial studies showing positive effects on sleep quality, previous studies had a follow-up period of six months or less. To look at longer-term measures, researchers conducted the study to find the effects of internet-based sleep intervention for toddlers after one year.

Study set-up

The study aimed to examine the effects of intervention methods on sleep problems, specifically in children, and note the difference in these effects when bedtime routines were manipulated based on intervention. Though child sleep concerns were the primary topic, this study focused specifically on toddler sleep.

Two hundred sixty-four mothers and young children aged six months to 36 months were recruited for this study. These families were then randomly assigned to one of three groups: the internet-based intervention group, the internet-based intervention plus routine group, and the control group, which did not complete the intervention.

For those included in the internet-based intervention group, the mothers were instructed to finish the internet-based intervention at home and follow the individualized recommendations with their children when they go to bed. The internet-based intervention plus routine group did the same things as the intervention group plus a three-step bedtime routine. This routine included a warm bath, lotion with a massage, and quiet activities. Materials for these activities were provided. The control group kept their children's normal bedtime routine. This intervention lasted for three weeks.

Study methods

A Customized Sleep Profile (CSP) was created for each child through an algorithm developed by Mindell and Sadeh, and it used the parent’s or caregiver's responses to various questions to assess needs in three core areas. The algorithm then gave individualized recommendations and information across three areas:

• Comparison of the child's sleep to other children of a similar age

• A rating of the child's sleep quality

• Customized advice on how caregivers could help improve their child's sleep at night

These recommendations were often based on the child's age and could include age-specific recommendations, such as those related to nursing or other feeding activities, room setup, and nap time routines.

Participant follow-up

Of the 264 families who participated, 171 were present at the one-year check-in. Families were first contacted through an automated phone call, followed by an email link to a safe website. Participants then completed an online survey and received a five-dollar stipend for their participation.

After one year, the intervention group was given a 13-question questionnaire to measure each child's sleep quality. The intervention plus routine group was given a 14-question questionnaire. The control group was given a 10-question questionnaire. The questionnaires included eight core questions developed from the expanded Brief Infant Sleep Questionnaire. These questions covered topics such as:

• Sleep onset latency
• Perception of bedtime difficulty
• Number of night wakings
• Duration of night waking
• The longest stretch of sleep
• Total sleep during the daytime and night
• Perception of sleep problems

In addition to these questions, maternal sleep quality was assessed through a question from the Pittsburgh Sleep Quality Index and maternal confidence in managing their child's sleep. Relevant groups were also asked questions on maternal perception of internet-based sleep interventions and whether they continued to follow the intervention recommendations.

In the statistical analysis, descriptive analyses, such as means and frequencies, were used to analyze the demographic and sleep variables. One-way analyses of variance were used separately for each control and intervention group variable.

Results of the study

The study results supported the notion that internet-based therapy can significantly improve toddler sleep directly after the intervention and a year following treatment. For most study participants, improvements made directly after the study were still valid a year later. These results included fewer concrete measures, such as the parents' perceptions of whether their child's sleep had improved and how significantly the child's sleep had been affected.

While the improvements in the internet-based intervention groups tend to support the use of the intervention, the control group also saw minor improvement levels. While the effects were slight, improvement may have been due to normal developmental changes. Previous studies have shown that sleep disturbances in young children can resolve over time. However, up to one-third of infants with trouble sleeping through the night between the ages of five months and 17 months have been found to still have these problems at 29 months. This result indicates that sleep problems may not always resolve with age, and internet-based interventions can potentially effectively lessen sleep trouble in children.

A positive finding of the study was the difference in sleep quality for toddlers and the effects of sleep problems in children before and after the intervention. Sleep wakings tended to decrease by over 50%, and there was a significant increase in how often the children slept for over two hours. The mothers' sleep quality also tended to improve.

Researchers recommend that parents are on board and confident that the intervention may benefit their child. In the study, over two-thirds of the parents found the sleep recommendations helpful, and almost 70% were still using the recommendations after one year. The sleep recommendations were often specific to the child's age, so after one year, some recommendations may not have been as relevant.

Overall, parents found the bedtime routine helpful. One year later, almost 90% followed the routine at least half of the time, and over 50% followed the recommendations most of the time.

Study limitations

In peer-reviewed studies, researchers examine potential limitations to provide an objective view of the results. A possible limitation of the study was determined to be the fact that there were no objective measures of the child's or parent's sleep quality, such as actigraphy. The reports were based on subjective measures and perceptions. In addition, some participants did not finish the follow-up survey. However, no correlation was found between those who did and those who did not finish the survey.

The last reported limitation is that parents were not asked at the follow-up if they sought medical sleep treatment over the year following the study. Some of these parents may have sought outside support, and their treatment may have affected their sleep improvement. In addition, the study was unclear about whether the participants’ children had been diagnosed with sleep disorders or if these sleep disorders in children affected the study.

Support options

As telemedicine grows in popularity, internet-based behavioral interventions continue to show positive effects on mental health and sleep in adults and children. If you’re experiencing insomnia or other sleep challenges or want parenting advice regarding your child’s sleeping habits, online therapy through a platform like BetterHelp may be advantageous.  

Online therapy may be more accessible for busy parents or those with financial challenges. By signing up for an online therapy platform, you may connect with a licensed mental health professional from home without having to set up childcare or drive to a therapist’s office. In addition, online therapy allows you to set your preferences when signing up to get matched with a therapist with experience in your area of concern.

Studies have found that online cognitive-behavioral therapy (CBT) for sleep problems can effectively increase sleep efficiency, refreshment, soundness of sleep, and quality of life while also decreasing sleep onset latency, number of awakenings, and depression and anxiety symptoms. A therapist may also be able to recommend strategies for improving a child’s sleep, such as allowing them to self-soothe, play quietly before bed, avoid screen time, and engage in soothing activities.