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Relationships between parental sleep quality, fatigue, cognitions about infant sleep, and parental depression… Hall, Wendy A; Moynihan, Melissa; Bhagat, Radhika; Wooldridge, Joanne Apr 4, 2017

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RESEARCH ARTICLE Open AccessRelationships between parental sleepquality, fatigue, cognitions about infantsleep, and parental depression pre andpost-intervention for infant behavioralsleep problemsWendy A. Hall1*, Melissa Moynihan2, Radhika Bhagat3 and Joanne Wooldridge4AbstractBackground: Maternal and paternal depression has been associated with infants’ behavioral sleep problems. Behavioralsleep interventions, which alter parental cognitions about infant sleep, have improved infant sleep problems. This studyreports relationships between parental depression, fatigue, sleep quality, and cognitions about infant sleep pre andpost-intervention for a behavioral sleep problem.Methods: This secondary analysis of data from Canadian parents (n = 455), with healthy infants aged 6-to-8-monthsexposed to a behavioral sleep intervention, examined baseline data and follow-up data from 18 or 24 weeks postintervention (group teaching or printed material) exposure. Parents reported on sleep quality, fatigue, depression, andcognitions about infant sleep. Data were analyzed using Pearson’s r and stepwise regression analysis.Results: Parents’ fatigue, sleep quality, sleep cognitions, and depression scores were correlated at baseline and follow-up.At baseline, sleep quality (b = .52, 95% CI .19–.85), fatigue (b = .48, 95% CI .33–.63), doubt about managing infant sleep(b = .44, 95% CI .19–.69), and anger about infant sleep (b = .69, 95% CI .44–.94) were associated with mothers’ depression.At baseline, fathers’ depression related to sleep quality (b = .42, 95% CI .01–.83), fatigue (b = .47, 95% CI .32–.63), and doubtabout managing infant sleep (b = .50, 95% CI .24–.76). At follow-up, mothers’ depression was associated with sleep quality(b = .76, 95% CI .41–1.12), fatigue (b = .25, 95% CI .14–.37), doubt about managing infant sleep (b = .44, 95% CI .16–.73),sleep anger (b = .31, 95% CI .02–.59), and setting sleep limits (b = −.22, 95% CI -.41-[−.03]). At follow-up, fathers’ depressionrelated to sleep quality (b = .84, 95% CI .46–1.22), fatigue (b = .31, 95% CI .17–.45), sleep doubt (b = .34, 95% CI .05–.62), andsetting sleep limits (b = .25, 95% CI .01–.49).Conclusions: Mothers’ and fathers’ cognitions about infant sleep demonstrate complex relationships with their depressionscores. While mothers’ setting sleep limit scores are associated with decreased depression scores, fathers’ setting limitsscores are associated with increased depression scores. Parental doubts about managing infant sleep and difficulties withsetting sleep limits require attention in interventions.Keywords: Depression, Sleep cognitions, Infant, Sleep problems, Fatigue* Correspondence: wendy.hall@ubc.ca1University of British Columbia School of Nursing, T. 201, 2211 WesbrookMall, Vancouver, BC V6T 2B5, CanadaFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Hall et al. BMC Pregnancy and Childbirth  (2017) 17:104 DOI 10.1186/s12884-017-1284-xBackgroundParenting is a very complex area, particularly in the contextof parent-identified infant behavioral sleep problems.Twenty to 30% of young children have sleep disturbances[1]. Sleep problems can persist for about 30% of children,particularly infants [2]. Behavioral sleep problems are evi-dent when infants’ sleep time is shorter than age-appropriate norms and infants show evidence of sleep loss[3]. The presence of a behavioral sleep problem alsodepends on whether parents define infants’ sleep as a prob-lem [1]; parents commonly view frequent infant night wak-ing with crying beyond 6 months of age as a problem [4].Maternal stress, depressive symptoms, and poorer self-reported health [5], and poor paternal general health [6]and depressive symptoms have been associated withinfants’ behavioral sleep problems [7, 8]. Moreover, inmothers without a past history of depression, infantsleep problems have had a greater impact on mothers’severe psychological distress [6]. Fathers attending a ser-vice for early parenting difficulties reported higher levelsof distress when children had more severe sleep prob-lems [9]. Children’s sleep problems persisting frominfancy or recurring in preschoolers have been associ-ated with higher maternal depression scores [10].For parents, fatigue, sleep quality, and psychologicaldistress (including depression) are associated. Mothersand fathers have reported high levels of fatigue withparental sleep quality contributing to fatigue in the first6 months post birth [11]. Poorer sleep quality has alsobeen associated with higher parental fatigue levels infamilies with infants, toddlers, and preschoolers [9, 12].Fatigue in the postnatal period accounted for 59% of thevariance in mothers’ depression scores [13]. Maternal fa-tigue at 12 months post-birth predicted depressionscores at 18 months post-birth [14]. In early parenthood,poor sleep quality contributed to variance in fathers’anxiety and stress but not depression scores [15]; be-cause parental sleep quality, fatigue, and parental dis-tress, including depression, are linked, it is important toexamine contributions of parents’ sleep quality and fa-tigue to depression. This is particularly important forfathers who have received minimal research attention.Parental cognitions (expectations and attitudes) aboutinfant sleep, in particular doubts about managing infantsleep, difficulty with setting sleep limits, and anger at in-fants’ demands around sleep, have consistently been as-sociated with infant behavioral sleep problems [16–19].When maternal cognitions about sleep and depressionfor mothers of 31 children with behavioral sleep prob-lems and 170 control mothers were compared, mothersof children with sleep problems reported more doubtsabout managing infant sleep, anger at infants’ demandsaround sleep, and depressive symptoms than controls[20]. Mothers with higher levels of depressive symptomshave reported more infant night waking and morematernal worries (cognitions) about adequately respond-ing to their infants' needs at night [21].Because parental cognitions drive parents’ behaviorsaround infant sleep, modifying their cognitions is amajor element in behavioral interventions to improve in-fants’ sleep [1]. Regardless of whether maternal depres-sion precedes infant sleep problems or infant sleepproblems precede depression, an area of great debate inthe literature, [22] interventions to resolve infant behav-ioral sleep problems have improved infant night waking[4, 23, 24] and maternal and paternal depression scorespost intervention [8, 25–27]. Moreover, mothers of in-fants exposed to a preventative sleep interventionreported lower depression scores and fewer doubts (cog-nition) about managing their infants’ sleep problemsthan a control group [28].Parental depression has implications for many parentinginteractions with infants. Caregiving by mothers with de-pression can involve more intrusive or withdrawn interac-tions, less preventative health care visits (immunization),and less satisfaction with breastfeeding [29]. Maternalpostnatal depression has been associated with increasedpaternal depression and parenting stress, and less optimalfather-infant interactions [30]. Paternal depressive symp-toms have been linked with children’s internalizing andexternalizing behaviors in early childhood [31].Relationships between parental depression scores, fa-tigue, sleep quality, and infant sleep cognitions requireexamination. Using baseline data (prior to group assign-ment and intervention exposure) and follow-up data(post intervention exposure) from mothers and fathersof healthy 6–8 month-old-infants with behavioral sleepproblems, this secondary analysis aimed to: 1) identifyproportions of mothers and fathers reporting high andclinically significant depressive symptoms at baselineand follow-up; 2) identify mothers’ and fathers’ meansand standard deviations for depression, sleep quality, fa-tigue, and sleep cognitions (baseline, follow-up andchange scores); 3) examine relationships betweenmothers’ and fathers’ depression, sleep quality, fatigue,and sleep cognitions scores at baseline and follow-up; 4)explore the variance in mothers’ and fathers’ depressionscores explained by sleep quality, fatigue, and sleep cog-nitions scores at baseline and follow-up; and 5) explorethe variance in mothers’ and fathers’ change in depres-sion scores explained by changes in sleep quality, fatigue,and sleep cognition scores from baseline to follow-up.MethodsThe study, from which these data are drawn for second-ary analysis, was a randomized controlled trial to evalu-ate a cognitive-behavioural sleep intervention for healthy6-to-8-months-old infants based on improvement inHall et al. BMC Pregnancy and Childbirth  (2017) 17:104 Page 2 of 10parental perceptions of infant sleep problems and re-duced infant night waking at 6 weeks post-intervention[8]. The study sample was recruited between September2009 and March 2011. Parents, who reported a diagnosisof depression or receiving treatment for depression (anti-depressant medications or cognitive therapy), had diag-nosed sleep problems, or worked permanent night shifts,were excluded. An infant sleep problem was defined as aninfant waking two or more times per night and/or wakeslasting more than 20 min, occurring at least four nightsper week for a minimum of 3 weeks [32]. Two hundredand thirty-five families (including 8 single-parent families)provided baseline data and 188 families provided follow-up data. This secondary analysis reports combined controland intervention group data from baseline (beforerandomization) and outcomes assessed at 18–24 weekspost-intervention exposure (follow-up).A brief summary of the trial follows; details about thetrial have been published elsewhere [8]. The primaryoutcome measure was significant infant sleep disturbance:parent report of a severe sleep problem or actigraphicwakes of greater than two per night averaged over fivenights. Secondary outcomes were improvements inparents’ perceptions of their mood, fatigue, and sleepquality, and the quality of their cognitions about infantsleep. Following randomization into intervention and con-trol groups, both groups received a 2-h teaching sessionand 2 weeks of bi-weekly telephone support calls. Theintervention group received information about managinginfant sleep problems and the control group received in-formation about managing infant safety risks. Trial out-comes were assessed at 6 weeks post-teaching session.Following that assessment, the sleep group received apamphlet summarizing the safety information and thesafety group received a pamphlet reproducing the infor-mation taught in the sleep intervention training session.At baseline and follow-up, parents completed ques-tionnaires which included demographic questions, andmeasures of parental sleep quality, fatigue, depression,and cognitions about infant sleep. Parents providedfollow-up data at 24 weeks post-intervention exposure(sleep and safety training); however, because the controlgroup was exposed to the sleep intervention (printedmaterial) at 6 weeks post-intervention their data collec-tion occurred at 18 weeks post sleep intervention.In the study database, parental designation was by pri-mary and secondary caregiver because one caregivertook the lead for the intervention. In only one two-parent family, the primary caregiver was male and allsingle parents were females; therefore, we refer tomothers (primary caregivers) and fathers (secondarycaregivers) in this paper. One family self-identified as alesbian couple. At follow-up, 188 mothers and 171fathers responded with questionnaire data. Because thisis a secondary analysis of data obtained for a trial, powercalculations were not undertaken for examining relation-ships among psychological variables.MeasuresAt baseline, data were collected on parents’ age, marital/partner status, years of formal education, number ofchildren, work status and hours of work, family income,rating of infant sleep problem severity, and ethnicity.Data were also collected on infant gender, birth order,age, breast feeding status, and co-sleeping. At follow-up,only data about parents’ age, length of relationship, high-est level of education, and ethnicity and infant genderwere not collected again.The Centre for Epidemiologic Studies DepressionScale (CESD) was used to measure depressive symptoms[33]. Higher scores indicated higher levels of symptoms,with a score of ≥16 being used as the cut-off point forhigh depressive symptoms and ≥22 being used to indi-cate clinically significant depression. The CESD hasdemonstrated reliability and validity when used withchildbearing populations [34]. In a quasi-experimentalintervention study for infants’ behavioral sleep problems,the measure indicated a significant improvement inmood following the intervention (p = .001) [25]. In thisstudy, Cronbach’s alpha ranged from 0.89 to 0.90. Theuse of the term depression in this paper is not intendedto indicate a diagnosis of clinical depression.The Pittsburgh Sleep Quality Index (PSQI) was usedto assess parents’ sleep quality [35]. Higher scores indi-cate worse sleep quality. The PSQI has demonstratedrelationships between lifestyle regularity and sleep qual-ity in healthy subjects [36]. In a quasi-experimentalstudy of an intervention for parents with infants withbehavioral sleep problems, sleep quality improved sig-nificantly post-intervention (p < .001) [25]. In this study,Cronbach’s alpha ranged from 0.53 to 0.69.The Multidimensional Assessment of Fatigue Scale(MAF) Global Fatigue Index (GFI) was used to assessfatigue [37]. Higher scores equal more fatigue. Reliabilityand validity of the measure was supported with two largecohorts of postnatal women [38]. In a quasi-experimentalstudy of an intervention to manage an infant sleep prob-lem, MAF scores demonstrated significant reductions inparental fatigue post-intervention (p < .001) [25]. In thisstudy, Cronbach’s alpha ranged from 0.94 to 0.95.The Maternal Cognitions about Infant Sleep Question-naire (MCISQ) was used to measure parents’ thoughtsabout managing infant sleep [16]. The questionnairecomprises 20 items with five subscales including: limitsetting around infant sleep, anger about sleep, doubtabout managing infant sleep, the necessity of feedinginfants at night, and infant sleep safety. Higher scores in-dicate more difficulty with managing sleep. The MCISQHall et al. BMC Pregnancy and Childbirth  (2017) 17:104 Page 3 of 10has predicted settling strategies and infant sleep prob-lems [17, 39] and differentiated infants with poor andgood sleep quality using parental difficulty with limit set-ting [18]. In a small quasi-experimental study using theMCISQ, parents’ cognitions improved after a sleep inter-vention for infant behavioral sleep problems including:setting sleep limits (p < .001, d = 1), anger about sleepproblems (p < .001, d = 0.7), doubt about handling sleepproblems (p < .001, d = 0.7), and necessity for night feed-ing (p < .001, d = 1) [25]. In this study, Cronbach’s alphafor the subscales ranged from 0.5-0.75.Parental perceptions about infant sleep were measuredusing the Child Sleep Question from the LongitudinalStudy of Australian Children (LSAC). The measure hasbeen used in a number of studies to indicate the extentto which parents perceived their child to have a sleepproblem (no, mild, moderate, or severe) [40–43].Statistical analysisFor baseline and follow-up, we calculated univariatedescriptive statistics (means, standard deviations) andnormality statistics for continuous, demographic, andsubscale data, and percentages for categorical data. Weexamined changes in proportions of parents with de-pressive symptomatology and clinically depressive symp-tomatology based on cut-off scores on the CESD. Wecalculated change scores (follow-up - baseline) for all ofthe variables and used Pearson’s r to examine correla-tions among continuous variables.To examine mothers’ and fathers’ predictors of depres-sion, we undertook six forward stepwise multiple regres-sion analyses, two at baseline, two at follow-up and twousing change scores to determine the best combinationof sleep quality, fatigue, and cognitions about infantsleep for predicting depression. To control for interven-tion/control group allocation, group assignment wasentered as an independent variable in all of the models;we used change scores for one model. We entered alleight of the independent variables (group, fatigue, sleepquality, sleep doubts, sleep limits, sleep anger, sleepsafety, and sleep and feeding) simultaneously. When thebackward method was used the results were the same.The assumptions were met for performing multiple re-gression analysis. No two independent variables includedin the models had an association of r ≥ 0.60, minimizingpotential for multi-collinearity. Checks of assumptionsyielded no indicators of multicollinearity. The outcomevariables at follow-up were slightly heteroscedastic. Weused IBM SPSS Statistics for Windows, version 24 (IBMCorp, Armonk, N.Y., USA) and considered p-values<0.05 as statistically significant. Correlation analyseswere two-sided. We compared observed proportions ofparents reporting none-mild sleep problems using aFisher’s exact test with adjustment for baseline severityusing the Mantel-Haenszel test, including corresponding95% confidence intervals for differences in proportions. Weused ANOVA to examine change of scores between base-line and follow-up for primary and secondary caregivers.ResultsDemographic data at baseline and follow-up demonstratesimilar characteristics (See Tables 1 and 2). By follow-up,most mothers had returned to paid employment. Giventhe infants’ ages were between 11 and 16 months atfollow-up the proportion of infants still breastfeeding wasvery high (55.2%). At follow-up, most mothers identifiedinfant sleep as not a problem or a mild problem (72.3%)compared with baseline where the majority identified amoderate to severe problem (81%). A minority of parents(26.2%) were co-sleeping at follow-up. We used Chi-Square to compare parents by missing data on their CESDscores at follow-up based on their demographic character-istics at baseline; there were no significant differences onfamily income, education, parents’ age, partner status,sleep problem rating, or cultural identity.At baseline, mothers’ mean depression scores exceededthe cut-off for the CESD for high depressive symptomsbut the fathers’ mean scores did not (See Table 3). Themean change scores indicated that all of the variables(higher scores =more difficulties) changed in the desireddirection. Mothers’ and fathers’ means on the CESDwere equivalent at follow-up.Table 1 Mother and father baseline demographic variablesMothersn = 232Fathersn = 223Age in years, [M (SD)], range 34.4 (4.5), (22, 54) 36.5 (5.9), (22, 60)Years of education, [M (SD)], range 17.5 (2.7), (10, 30) 17.1 (2.9), (4, 27)Highest level of education, n (%)Some high school 0 (0) 1 (0.4)High school completed 4 (1.7) 8 (3.6)Some college 13 (5.6) 24 (10.8)College completed 25 (10.8) 28 (12.6)University courses 10 (4.3) 15 (6.7)University degree 107 (46.1) 85 (38.1)Post-graduate degree 73 (31.5) 62 (27.8)Cultural identitya, n (%)American 2 (0.9) 7 (3.2)Asian 27 (11.6) 14 (6.3)Canadian 121 (52.2) 113 (50.9)Chinese 19 (8.2) 23 (10.4)European 24 (10.3) 32 (14.4)Central or South American 5 (2.2) 3 (1.4)Other 34 (14.6) 30 (13.5)aFathers n = 222Hall et al. BMC Pregnancy and Childbirth  (2017) 17:104 Page 4 of 10At baseline, 47.8% (n = 111) of mothers and 34.5%(n = 76) of fathers reported CESD scores ≥16. Atfollow-up, only 18.1% (n = 34) of mothers and 14.6%(n = 25) of fathers reported CESD scores of ≥16. Atbaseline, 29.7% (n = 69) of mothers and 18.6% (n = 41)of fathers reported CESD scores ≥22, while, at follow-up, only 8.5% (n = 16) of mothers and 7.6% (n = 13) offathers reported CESD scores of ≥22.At baseline (n = 455, mothers and fathers) and follow-up (n = 359, mothers and fathers), parental fatigue, sleepquality, doubts about managing infant sleep, difficultieswith sleep and feeding, anger about infant sleep, sleepsafety, and difficulties setting sleep limits for infantswere significantly positively correlated with depressionscores. The cognition scores were also significantly posi-tively correlated with parental sleep quality and fatigue.Sleep quality, fatigue and depression were moderatelycorrelated (See Table 4).At baseline, mothers’ depression was associated withsleep quality (b = .52), fatigue (b = .48), doubt aboutmanaging infant sleep (b = .44), and anger about infantsleep (b = .69). The model accounted for 47% of the vari-ance (see Table 5). At baseline, fathers’ depression re-lated to sleep quality (b = .42), fatigue (b = .47), anddoubt about managing infant sleep (b = .50). The modelaccounted for 39% of the variance (See Table 6).At follow-up, mothers’ depression was associated withsleep quality (b = .76), fatigue (b = .25), doubt about man-aging infant sleep (b = .44), sleep anger (b = .31), and set-ting sleep limits (b = −.22). The model accounted for 39%of the variance (see Table 5). At follow-up, fathers’ depres-sion was linked to sleep quality (b = .84), fatigue (b = .31),sleep doubt (b = .34), and setting sleep limits (b = .25). Themodel accounted for 48% of the variance (see Table 6).When change scores were examined change in fatigue(b = .25), sleep anger (b = .59), sleep quality (b = .53),and sleep doubt (b = .38) was associated with change inmaternal depression scores, with the model accountingfor 33% of the variance. Fathers’ change in depressionscores related to changes in fatigue (b = .36), sleep safety(b = .89), and sleep anger scores (b = .37), with the modelaccounting for 35% of the variance (See Table 7).DiscussionOur results demonstrated reductions in parents’ levels ofhigh and clinically significant depression scores frombaseline to follow-up. All of the change scores reportedindicated reductions in fatigue, poor sleep quality,depression, and problematic parental cognitions aboutinfant sleep from baseline to follow-up. The variables alldemonstrated small to moderate statistically significantcorrelations. At baseline and follow-up, maternal depres-sion was associated with fatigue, sleep quality, doubtabout managing infant sleep, and sleep anger. At follow-up, setting sleep limits had a statistically significantnegative relationship with maternal depression. At base-line and follow-up, paternal depression was related tofatigue, sleep quality, and doubt about managing infantsleep. At follow-up only, paternal depression was associ-ated with setting sleep limits. To control for baseline, wealso examined variables associated with mothers’ andfathers’ change in depression scores from baseline tofollow-up. Mothers’ changes in depression followed asimilar pattern to variables associated with depressionscores. Changes in maternal fatigue, sleep quality, sleepanger and doubt about managing infant sleep related tochange in maternal depression. For fathers, the patternwas quite different because changes in fatigue, sleepanger, and infant safety during sleep were associatedwith changes in paternal depression.Our findings demonstrated moderate correlationsamong depression scores and fatigue and sleep qualityscores in a sample of men and women who had not beendiagnosed with or treated for depression prior to studyTable 2 Parent, infant, and family variables at baseline andfollow-upBaseline Follow-upMothers n = 232 n = 188Paid employment, n (%) 40 (17.2) 122 (64.9)Sleep problem rating, n (%)Not a problem 1 (0.4) 72 (38.3)Mild 43 (18.5) 64 (34.0)Moderate 148 (63.8) 48 (25.5)Severe 40 (17.2) 4 (2.1)Fathers n = 223 n = 171Paid employment, n (%) 205 (91.9) 159 (93.0)Sleep problem rating, n (%)Not a problem 8 (3.6) 63 (36.8)Mild 42 (18.8) 58 (33.9)Moderate 139 (62.3) 48 (28.1)Severe 34 (15.2) 2 (1.2)Infantsa n = 455 n = 359Age in months, [M (SD)], range 6.7 (0.9), (5, 10) 12.9 (1.1), (11, 16)Breastfed, n (%) 410 (90.1) 198 (55.2)Co-sleeping, n (%) 275 (60.4) 94 (26.2)Familya n = 440 n = 350Income, n (%)$10,000 – 29,999 20 (4.5) 16 (4.6)$30,000 – 59,999 64 (14.5) 47 (13.4)$60,000 – 89,999 81 (18.4) 72 (20.6)$90,000 – 109,999 91 (20.7) 64 (18.3)More than $110,000 184 (41.8) 151 (43.1)aResponses from both mothers and fathersHall et al. BMC Pregnancy and Childbirth  (2017) 17:104 Page 5 of 10Table 3 Means (SDs), ranges and change scores for key variables at baseline and follow-upMothers FathersM (SD) Range M (SD) RangeBaseline n = 231 n = 217CESD 16.4 (9.5) (0, 39) 13.0 (9.7) (0, 48)PSQI 9.7 (3.3) (2, 19) 6.5 (2.9) (1, 16)MAF 30.4 (7.2) (8.4, 43.4) 23.2 (8.7) (5, 41.2)Setting sleep limits 16.5 (4.5) (5, 25) 13.1 (4.9) (0, 25)Sleep doubts 8.0 (3.9) (0, 20) 6.1 (4.3) (0, 18)Sleep anger 7.0 (3.9) (0, 18) 6.9 (3.5) (1, 25)Sleep feeding 8.1 (3.5) (0, 15) 5.9 (3.5) (0, 15)Sleep safety 3.0 (2.4) (0, 10) 2.6 (2.4) (0, 10)Follow-up n = 185 n = 170CESD 9.2 (7.5) (0, 34) 9.2 (8.0) (0, 45)PSQI 5.8 (2.9) (0, 15) 5.2 (3.0) (0, 15)MAF 18.2 (9.0) (5.0, 38.5) 17.8 (8.7) (5.0, 42.7)Setting sleep limits 9.9 (4.9) (1, 25) 8.8 (4.3) (0, 25)Sleep doubts 4.1 (3.5) (0, 16) 3.5 (3.6) (0, 15)Sleep anger 5.0 (3.3) (0, 19) 4.9 (3.1) (0, 16)Sleep feeding 3.0 (3.3) (0, 14) 2.7 (3.1) (0, 14)Sleep safety 1.8 (2.0) (0, 8) 1.5 (2.0) (0, 10)Change scores n = 185 n = 169CESD −6.4 (9.1) (−33, 19) −3.1 (8.6) (−42, 19)PSQI −4.0 (3.5) (−13, 5) −1.4 (2.9) (−9, 8)MAF −11.8 (10.2) (−34.4, 21.9) −5.3 (10.0) (−27.2, 17.4)Setting sleep limits −6.4 (4.9) (−18, 5) −4.1 (4.7) (−19, 7)Sleep doubts −3.7 (4.1) (−15, 5) −2.4 (3.9) (−12, 15)Sleep anger −2.2 (3.6) (−14, 8) −2.1 (3.5) (−16, 9)Sleep feeding −4.9 (4.0) (−14, 6) −3.1 (3.7) (−11, 9)Sleep safety −1.1 (2.2) (−8, 4) −1.0 (2.2) (−7, 7)Abbreviations: CESD depression, PSQI sleep quality, MAF fatigueNote: Means and SDs values from descriptive statistics of regression models; range values from descriptive statistics; change scores calculated by subtractingbaseline from follow-up valuesTable 4 Correlations among variables for all participants at baseline and follow-upCorrelation coefficients baseline Correlation coefficients follow-up1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 81. SD 1 12. SF .42 1 .47 13. SL .48 .43 1 .44 .45 14. Ang .34 .20 .09* 1 .39 .35 .26 15. SS .41 .26 .23 .14 1 .47 .35 .29 .33 16. PSQI .28 .27 .26 .13 .16 1 .21 .24 .20 .24 .24 17. MAF .38 .29 .29 .19 .22 .62 1 .29 .33 .27 .36 .27 .58 18. CESD .43 .23 .23 .34 .27 .46 .58 1 .35 .31 .22 .33 .30 .53 .58 1Correlations p < 0.01, 2-tailed; * indicates p > 0.05Abbreviations: 1) SD Sleep Doubt; 2) SF Sleep & Feeding; 3) SL Setting Sleep Limits; 4) Ang Sleep Anger 5) SS Sleep Safety; 6) PSQI sleep quality; 7) MAF fatigue; 8)CESD depressionHall et al. BMC Pregnancy and Childbirth  (2017) 17:104 Page 6 of 10recruitment. Moreover, sleep quality and fatigue werenot only making significant contributions to depressionscores at baseline but also at 18 to 24 weeks follow-up,when our infants’ mean age was 12.9 months. Change indepression scores was associated with fatigue change formothers and fathers, although change in sleep qualitywas only significant for mothers. Our findings emphasizethe importance of Giallo and colleagues’ work demon-strating that maternal fatigue at 12 months post-birthpredicted depression scores at 18 months post-birth[14]. In other studies, infants’ sleep problems at 4 and 6months have been associated with increased paternal de-pression and poor personal sleep quantity and quality[7] suggesting fathers’ mental health is also suffering.High levels of parental fatigue have also been associatedwith lower parenting competence, greater stress, moreirritability in parent–child interactions, and poorer sleepquality [12].Parental cognitions have also been associated withinfant behavioral sleep problems [16–19] but effects ofparental cognitions on depression, in combination withparental fatigue and sleep quality, are rarely studied. Ourresults indicated that parental cognitions consistentlycontributed to variance associated with maternal andpaternal depression when sleep quality and fatigue werealso considered, in particular, parents’ doubts aboutmanaging infant sleep. Setting sleep limits contributedto variance in depression scores for mothers and fathersonly at follow-up and for mothers, the relationship wasnegative (less difficulty setting sleep limits associatedTable 5 Stepwise multiple regression analysis explaining mothers’ depression from sleep quality, fatigue, and sleep cognitionsUnstd B (SE) t Sig. 95% CI for B Cumulative R2Baseline (N = 231)Constant −11.63 (2.10) −5.53 <.001 [−15.77, −7.48]MAF .48 (.08) 6.28 <.001 [.33, .63] .31Sleep doubt .44 (.13) 3.49 .001 [.19, .69] .42PSQI .52 (.17) 3.12 .002 [.19, .85] .46Sleep anger .69 (.13) 5.52 <.001 [.44, .94] .48Follow-up (N = 185)Constant -.92 (1.26) -.73 .467 [−3.41, 1.57]MAF .25 (.06) 4.27 <.001 [.14, .37] .28PSQI .76 (.18) 4.26 <.001 [.41, 1.12] .34Sleep doubt .44 (.14) 3.08 .002 [.16, .73] .38Setting sleep limits -.22 (.10) −2.26 .025 [−.41, −.03] .39Sleep anger .31 (.15) 2.10 .037 [.02, .59] .41Abbreviations: CI confidence interval, PSQI sleep quality, MAF fatigueBaseline: R2 = .48, adjusted R2 = .47, F (4, 226) = 51.9, p < .001Follow-up: R2 = .41, adjusted R2 = .39, F (5, 179) = 24.6, p < .001Table 6 Stepwise multiple regression analysis explaining fathers’ depression from sleep quality, fatigue, and sleep cognitionsUnstd B (SE) t Sig. 95% CI for B Cumulative R2Baseline (N = 217)Constant −3.79 (1.57) −2.42 .017 [−6.88, −.70]MAF .47 (.08) 6.20 <.001 [.32, .63] .34Sleep doubt .50 (.13) 3.77 <.001 [.24, .76] .38PSQI .42 (.21) 2.00 .046 [.01, .83] .39Follow-up (N = 170)Constant −4.00 (1.25) −3.19 .002 [−6.47, −.1.53]MAF .31 (.07) 4.37 <.001 [.17, .45] .39PSQI .84 (.19) 4.39 <.001 [.46, 1.22] .44Sleep doubt .34 (.15) 2.29 .023 [.05, .62] .48Setting sleep limits .25 (.12) 2.06 .041 [.01, .49] .49Abbreviations: CI confidence interval, PSQI sleep quality, MAF fatigueBaseline: R2 = .39, adjusted R2 = .39, F (3, 213) = 46.1, p < .001Follow-up: R2 = .49, adjusted R2 = .48, F (4, 165) = 39.9, p < .001Hall et al. BMC Pregnancy and Childbirth  (2017) 17:104 Page 7 of 10with lower depression scores). In another study, whenmothers identified children as having behavioral sleepproblems, their cognitions about infant sleep were sig-nificantly positively correlated with their depressionscores; doubts about infant sleep, difficulties with limitsetting, and anger about infant sleep, and scores on thedepression measure were significantly higher in theinfant behavioral sleep problem group than in the feed-ing problem or control groups [20].At baseline, but not at follow-up, mothers’ anger aboutinfant sleep problems was contributing more variance totheir depression scores than sleep quality. Fathers’ angerdid not make a statistically significant contribution todepression variance at baseline or at follow-up but theirchange scores for sleep anger and fears about infantsafety contributed to their depression change score.Parents may be fearful of losing control and harmingtheir infants when experiencing anger about infant sleepproblems. Fathers have reported anger about infants’sleep problems at 4 and 6 months of age [7].In our study, the patterns in relationships betweencognitions and parental depression indicated that parents’doubts about managing infant sleep persisted in contribut-ing to depression score variance and fathers’ difficultieswith setting sleep limits had a positive relationship withdepression. Morrell linked infant night waking with prob-lematic parental cognitions about limit setting, doubt, andanger to over-intrusive and rejecting parental interactions[16]. Difficulties with setting limits can persist becausemothers’ difficulty setting limits for 12-months-old infantshas predicted objectively measured night waking problemswhen children are 4 years old [44]. When Teti and Crosbytested models correlating maternal depressive symptoms,‘dysfunctional cognitions (worries about infant needs andmaternal helplessness/loss of control)’, and infant nightwaking, for cohorts between 5 weeks and 25.3 months,they suggested that maternal depressive symptoms, night-time presence, and worries about infant night needs weredriving infant sleep problems [21]. They also acknowl-edged; however, that chronic infant night waking anddistress could elicit maternal interventions that increasematernal distress. Rather than endless academic specula-tion about whether parental depression is driving infantsleep problems or infant sleep problems are driving paren-tal depression it is important to offer parents interventionsto manage infant sleep problems.In our study, there was a marked improvement in par-ents’ depression from levels at baseline to 18–24 weekfollow-up; there was a reduction in proportions ofmothers and fathers scoring above cut-offs on the CESDfor depressive symptomatology by between 11 and 30%.The literature has demonstrated that, not only have infantbehavioral sleep problems been consistently associatedwith maternal depression scores [5, 8, 26, 27] and, underthe rare circumstances where fathers are assessed, withpaternal depression scores [7, 8, 25], but also that inter-ventions for infant behavioral sleep problems haveimproved infant night waking [4, 8, 23] and maternal andpaternal depression scores [8, 25–27]. A recent trial byGradisar and colleagues reported that graduated extinc-tion (also called controlled comforting) improved infantsleep and decreased infant cortisol levels and maternalstress compared with controls (sleep education) [24].LimitationsThis secondary analysis of the trial data relies on a sam-ple of convenience. Although we did not detect anydemographic differences on missing CESD scores it ispossible that retention bias could have been operating.Requiring commitment by both parents to the studyTable 7 Stepwise multiple regression analysis explaining caregivers' change in depression from changes in sleep quality, fatigue,and sleep cognitionsUnstd B (SE) t Sig. 95% CI for B Cumulative R2Mothers (N = 185)Constant 1.26 (.98) 1.28 .201 [−.68, 3.21]MAF change .25 (.06) 3.83 <.001 [.12, .37] .22Sleep anger change .59 (.16) 3.74 <.001 [.28, .90] .28PSQI change .53 (.18) 2.90 .004 [.17, .89] .32Sleep doubt change .38 (.14) 2.74 .007 [.11, .65] .34Fathers (N = 169)Constant .43 (.67) .64 .521 [−.89, 1.74]MAF change .36 (.06) 5.97 <.001 [.24, .47] .29Sleep safety change .89 (.26) 3.45 .001 [.38, 1.40] .34Sleep anger change .37 (.16) 2.28 .024 [.05, .70] .36Abbreviations: CI confidence interval, PSQI sleep quality, MAF fatigueMothers: R2 = .34, adjusted R2 = .33, F (4, 180) = 23.5, p < .001Fathers: R2 = .36, adjusted R2 = .35, F (3, 165) = 31.4, p < .001Hall et al. BMC Pregnancy and Childbirth  (2017) 17:104 Page 8 of 10reduced the likelihood of parents experiencing maritalor parenting conflict participating in the study. We ex-cluded parents with diagnosed depression or receivingtreatment for depression because pre-existing chronicdepression would be unlikely to be sensitive to changesin infants’ night waking but excluding those parentslimits the generalizability of our findings. We combinedthe control group and intervention group study partici-pants because, at follow-up, there were no significantdifferences between groups on depression, fatigue, orsleep scores, combining the groups increased the studypower, and we wanted to examine relationships betweenparental cognitions and depression following interven-tions for infants’ behavioral sleep problems.It is a limitation that parents were exposed to differentforms of the intervention (face-to-face as opposed to writ-ten materials) at different time points. The control groupreceived intervention materials 6 weeks later than the inter-vention group, which could influence the utility of theintervention. Other researchers have reported that compar-isons of face-to-face treatment and exposure to written ma-terials revealed no differences in efficacy post-intervention[45, 46]. When we compared intervention and controlgroups at follow-up, there were no significant differenceson any of the measures except for parents’ perceptions ofthe severity of the infant sleep problem of none-mild(96.3% intervention versus 86% control, p < .001, 95% CI2.8%–17.8%) and a significant improvement in interventiongroup fathers’ sleep doubt (F(1,171) = 5.6, p = 0.02) andcomfort with sleep and feeding (F(1,171) = 8.8, p = 0.004)compared with the control group. It may be possible thatfewer fathers in the control group were exposed to thesleep intervention through reading the written material.StrengthsWe used the comparison of baseline and follow-up datato explore changes in parents’ psychological variables for alarge sample of parents with infants in a narrow age range(i.e., developmentally similar). We used tools with evi-dence for reliability and validity for parents’ psychologicalmeasures. Our inclusion of fathers is an important stepforward in understanding parents’ patterns of cognitions.ConclusionOur study demonstrates complex associations betweenmothers’ and fathers’ depression scores, sleep quality, fa-tigue, and sleep cognitions. Findings suggest it is importantto provide parents with ongoing support to attend to fa-thers’ comfort with setting limits about infant sleep andmothers’ anger about infant sleep. Additional support toreduce doubts about managing infant sleep and furtherstudy of differences in mothers’ and fathers’ cognitive re-sponses to children’s sleep problems would improve theeffectiveness of sleep interventions.AbbreviationsCESD: Center for Epidemiologic Studies Depression Measure;MAF: Multidimensional Assessment of Fatigue Scale; MCISQ: Maternal(parental) Cognitions about Infant Sleep Questionnaire; PSQI: PittsburghSleep Quality IndexAcknowledgementsWe acknowledge the families who participated in the study and shared theirexperiences with us. We also gratefully acknowledge the assistance of Dr. J.Berkowitz, Sauder School of Business, University of British Columbia.FundingThis work was funded by a Canadian Institutes of Health Research grant (noMCT – 94836) awarded to Dr. Hall. The researchers designed and conductedthe study and analyzed and interpreted the data with complete independencefrom the Canadian Institutes of Health Research. The funding body was notinvolved in the writing of the manuscript.Availability of data and materialsThe data for this study will not be shared. Ethical approval for data sharingwas not obtained from participants.Authors’ contributionsWH conceptualized and designed the study, obtained funding, directedimplementation, participated in data analysis and interpretation, wrote thedraft manuscript, and is guarantor. MM assisted with the data analysis andinterpretation, and manuscript preparation. RB and JW participated in studydesign and manuscript preparation. All authors read and approved the finalmanuscript.Authors’ informationWH provides voluntary support to a large number of families who seekassistance for infant sleep problems and community groups requestinginformation about healthy sleep for children and strategies to promotehealthy sleep. MM has expertise in numerous statistical techniques andundertakes research with vulnerable populations. RB is a public healthnursing leader. JW leads regional policy and protocol development formaternal and child health.Competing interestsThe authors declare that they have no competing interests.Consent for publicationNot applicable.Ethics approval and consent to participateAll parents provided informed consent after obtaining written and oral studyinformation. The University of British Columbia (H09-00757) and VancouverCoastal Health (#CS09-076) Research Ethics Boards approved the trial.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1University of British Columbia School of Nursing, T. 201, 2211 WesbrookMall, Vancouver, BC V6T 2B5, Canada. 2School of Nursing, University of BritishColumbia, Vancouver, BC, Canada. 3South Community Health Centre,Vancouver Coastal Health, Vancouver, BC, Canada. 4Maternal Child Program,Vancouver Coastal Health, Vancouver, BC, Canada.Received: 25 June 2016 Accepted: 18 March 2017References1. 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