ABCs of Child Psychiatry

Real info about children's mental health

Infant Sleep and the Crying-It-Out Debate

What happens when a classic parenting question is unanswered
Darcia Narvaez
This post is a response to Parents Misled by Cry-It-Out Sleep Training Reports by Darcia Narvaez, Ph.D.

What parents should do when an infant repeatedly wakes up and cries at night has been a passionate and timeless debate.  Behavioral sleep interventions, which can vary from relatively milder techniques like camping out (in which a parent gradually moves farther and farther away from the crib over time after putting the baby down until the parent is no longer in the room) to the infamous “crying-it-out” method in which a parent simply stops responding to the baby’s nighttime crying, have generated intense discussion.  In her most recent PT blog, Dr. Narvaez provides a stern rebuke of an article in Parents magazine (which I admittedly haven’t read) that reportedly tells the public that any type of sleep intervention is fine and will not cause any psychological damage based on the results of study recently published in the prominent journal Pediatrics.

To put my own current opinion on this issue up front, I will say that I do believe that behavioral sleeping techniques such as controlled crying or camping out can be highly effective (often in a matter of days) and do not cause developmental problems.  That said, I don’t have any quibble with parents who choose to go comfort children at each awakening or those who choose to share a bed with their kids (especially if over 6 months old).  I also don’t advocate that parents continue to plug away with behavioral techniques indefinitely if they aren’t working.

This post makes some strong points, especially about the way that the media and, in turn, the public can make wild conclusions that go far beyond what science actually tells us.  Unfortunately, Dr. Narvaez does exactly the same thing in her counter arguments.

The study in question took an Australian sample of 7-month-old infants with sleep problems and their mothers and instructed half of them on behavioral sleep interventions such as the camping out technique.  The other half were left to fend for themselves, and none of the subjects were taught or suggested to use the pure crying-it-out method.  While an earlier study when the children were younger found some benefits of the behavioral techniques in terms of sleep and maternal mental health (less depressive symptoms), this study examined how the kids and mothers were doing 5 years later.  The bottom line, according to the authors, was that the families who did and did not get the instructions were not statistically different from each other no matter what was examined (sleep, behavioral problems, parental health, parenting and bonding measures, etc.).   The authors concluded that there was no evidence that these techniques caused harm and thus could be recommended to help with the short-term sleeping problems during infancy.

In my view, Dr. Narvaez is rightly concerned about media coverage that arrives at sweeping conclusions not supported by scientific study.  This study in no way argues that pure crying it out is safe and effective because that is not what the study tested.  Even the well-known Dr. Ferber was not a fan of pure crying-it-out, despite the fact that his name was virtually synonymous with the technique. 

The post also does point out some valid limitations of the study.  The instructions on the sleep techniques were brief and whether or not parents actually used them (in either the intervention or control group) was not assessed, as is customary in most intervention studies.   However, it is worth pointing out that group differences were found in the earlier study, suggesting that it is likely that the group receiving the instruction did apply these techniques more than those who did not, as was the study’s intention. 

My biggest qualm with this post, however, are the many cataclysmic and over-reaching statements Dr. Narvaez makes herself  against sleep interventions that also, in my view, go miles beyond what we actually have shown.  The gravity of some of these statements are enhanced by the use of a reference, but with a little scrutiny these references are quite an extrapolation from the sentence they are supposedly supporting.   In a sentence that would be alarming for any parent to read, for example, she states that “over 2 million Parents readers have just been told that leaving babies to cry to the point of distress and beyond—to the point of potential neurological damage-has been proven safe and even that it’s proper childrearing.”  While one might logically think that the citation given for this claim of neuronal damage would be related to human babies, it actually refers to a study of adult monkeys given the stress hormone cortisol to drink for a month.   Later in the post, there is the sentence “the younger or more sensitive temperamentally the baby is, the faster and higher the stress level will rise when suddenly left alone to sleep, and the greater damage done to the child’s developing brain.”  The reference here is actually a study about rat mothers’ licking and grooming behavior.  Finally there is the sentence, “Infants can experience PTSD, toxic distress, depression and dissociation in response to crying-it-out.”  Here the link is not to a study that demonstrates this (because there isn’t any) but to a review article by a psychiatrist who has marketed an approach to traumatized children that itself has been criticized for not being adequately researched before being sold to the public.

Certainly, animal data is not irrelevant to humans, but to make such specific and provocative claims such as those made here and then cite rat licking as the primary source is needlessly alarming and heavily misleading.

Ironically, Ferber used to claim that NOT applying behavioral sleep techniques would cause psychological damage because a child would never learn how to soothe him or herself.  He has backed off on this assertion because of a lack of evidence. 

The truth is that this is a complicated issue and it is a huge failure that we have so few studies on which to base opinions for one of the most classic parental debates in history.  To me it is quite possible that these techniques when applied the right way at the right time do not result in damage.  Further, if it does create some stress, it is also possible that these effects are overcompensated for by the positive benefits of these techniques in the form of awake, alert parents ready to supply that priceless positive energy that kids thrive upon.   All of us would be well to remember that scientific evidence is there to inform our opinions, not justify them. 

@copyright by David Rettew, MD

Image courtesy of Serge Bertasius Photography and FreeDigitalPhotos.net

David Rettew is author of Child Temperament: New Thinking About the Boundary Between Traits and Illness and a child psychiatrist in the psychiatry and pediatrics departments at the University of Vermont College of Medicine.

Follow him at @PediPsych and like PediPsych on Facebook.

David Rettew, M.D., is a child psychiatrist at the University of Vermont and author of Child Temperament: New Thinking about the Boundary between Traits and Illness.

more...

Subscribe to ABCs of Child Psychiatry

Current Issue

Just Say It

When and how should we open up to loved ones?