In Science We Trust

SleepingBabyIf you were a newbie mum relying on baby wars you find on internet forums to review and assess different sleep strategies for your babies, you would quickly find that most forums made up of mother-experts are strongly against sleep training of any kind, including self-settling and cry-it-out. I have a suspicion that the reason for this apparent bias against sleep training, and the opposition to the idea that babies can be trained to sleep better, is because the parents who have had success with sleep training have moved on with their lives and aren’t on the forums anymore; because their babies are good sleepers, they themselves are getting plenty of sleep and they therefore no longer feel the need to lurk on online baby advice forums looking for sleep advice and decrying any method that they deem to be ‘wrong’. But since I have decided to train my baby to self-settle, and I know of parents who have had success with this method, while others have resorted to controlled-crying or cry-it-out and also found success, I was interested to see what the scientific community conclude about sleep training to see if the mother-experts are correct when they say that these strategies don’t work and are possibly harmful for my child’s emotional development.

I have a strong personal preference towards peer reviewed scientific results because in science I trust. I do understand, however, that it’s very easy to either purposely or accidentally cherry pick scientific results to suit your pre-conceived opinions. But luckily, when I went looking for it, I managed to find a study that can’t be accused of being cherry picked, because it’s a review of 52 other studies into sleep training methods, or treatments, for baby and children’s sleep. This study titled ‘Behavioral treatment of bedtime problems and night wakings in infants and young children’ was carried out by researchers from the American Academy of Sleep Medicine. You can download the full paper here. But to save you reading it, I’ll do my best to summarise the outcomes.

The first thing of note is the scary statement that ‘longitudinal studies have demonstrated that sleep problems first presenting in infancy may persist into the preschool and school-aged years and become chronic’. The other scary conclusion is that, if left untreated, chronic sleep problems have been found to have detrimental consequences on a child’s cognitive development, health, mood regulation, attention, behaviour and quality of life. This makes sense to me, as I know how hopeless I am at remembering anything, maintaining a sunny disposition, being attentive and feeling healthy when I am sleep deprived. Not surprisingly, the studies have also apparently revealed the secondary side-effects of children’s chronic sleep problems as being detrimental to family life, including increasing the risk of maternal depression. Of course, the description of ‘chronic sleep problems’ is much more than my current problem of failing to get Lottie to sleep in her cot in the morning, so I’m not panicking just yet! But right off the bat, the paper gave me all the motivation I need to get Lottie’s sleeping habits sorted as soon as possible and backed up my theory that baby’s sleep intake is possibly equally as important as baby’s food intake.

After reviewing the prevalence of sleep disorders in children, the study went on to review studies of the efficacy of different sleep training methods, including Extinction, Graduated Extinction, Positive Routines/Faded Bedtime with Response Cost, Scheduled Awakening and the method I am practicing currently; Parent Education/Prevention. A summary of the results of the studies into each of these methods is as follows

Extinction and Graduated Extinction
Extinction and Graduated Extinction are scientific descriptions for the controversial ‘cry-it-out’ or ‘controlled-crying’ method of sleep training. As described in the paper, ‘Unmodified extinction procedures for sleep problems involve having the parents put the child to bed at a designated bedtime and then ignoring the child until a set time the next morning (although parents continue to monitor for illness, injury, etc)’. This ‘cry-it-out’ method is described as being most difficult for the parents, and as such, Graduated Extinction, or ‘controlled crying’ methods are often used instead; described as being when ‘parents are instructed to ignore bedtime crying and tantrums for specified periods. The duration or interval between check-ins with the child is often tailored to the child’s age and temperament, as well as the parents’ judgment of how long they [the parents] can tolerate the child’s crying’…‘The goal of Graduated Extinction is to enable a child to develop “self-soothing” skills in order for the child to fall asleep independently without undesirable sleep associations (e.g., nursing, drinking from a bottle, rocking by parent).’

So the big question is, do these cry-it-out methods work to improve a child’s sleep habits? Quoting from the paper that reviewed studies into the success of Extinction sleep training methods: ‘Extinction has a strong record of accomplishment, now having been evaluated in 19 separate research studies involving 552 participants. With the exception of 2 studies, in 17 studies the procedure has proven highly effective in eliminating bedtime problems and night wakings, and improving sleep continuity’. 17 out of 19 is a tick of approval in my opinion. And for Graduated Extinction, ‘All 14 [studies] reported positive treatment outcomes as indicated by a reduction in bedtime problems and/or night wakings’. So full marks.

Positive Routines/Faded Bedtime with Response Cost
‘Positive Routines’ is simply described as ‘the parents developing a set bedtime routine characterized by quiet activities that the child enjoys’. This is one method I am trying to employ, particularly for the night-time routine. But unfortunately, it’s not a method that has been specifically studied, as explained in the paper: ‘Having an infant or young child participate in a nightly Standardized Bedtime Routine has become a universal, “common sense” recommendation. This intervention component was included in no fewer than 14 of the selected studies. However, it was always included as part of a multi-component treatment package, and has yet to be systematically evaluated as a stand-alone intervention.’

‘Faded Bedtime with Response Cost’ is not a sleep training method I was familiar with before reading the paper, and is described as involving: ‘taking the child out of bed for prescribed periods of time when the child does not fall asleep. Bedtime is also delayed to ensure rapid sleep initiation and that appropriate cues for sleep onset are paired with positive parent-child interactions. Once the behavioral chain is well established and the child is falling asleep quickly, the bedtime is moved earlier by 15 to 30 minutes over successive nights until a pre-established bedtime goal is achieved. A scheduled wake time is established and daytime sleep is not allowed, with the exception of age-appropriate naps’. So this sounds to me like a way to enforce sleeping and waking routine times, however I would worry that getting the child out of bed when they are having trouble sleeping would lead to overtiredness. Nevertheless, letting the science judge rather than inexperienced me, the results of two studies into this sleep training method showed ‘the procedure is rapid and effective’. So perhaps it’s something I should look into if my preferred method doesn’t work, maybe when Lottie is a bit older.

Scheduled Awakenings
Scheduled Awakenings is also a method I have not come across before. It is described as involving: ‘parents awakening and consoling their child approximately 15 to 30 minutes before a typical spontaneous awakening. This strategy begins with establishing a baseline of the number and time of spontaneous night-time awakenings. Pre-emptive awakenings are then scheduled. Parent-induced scheduled awakenings are typically followed by the parents’ usual response to a spontaneous awakening, such as rocking or nursing the child back to sleep. Scheduled awakenings are then faded out, by systematically increasing the time span between awakenings. These scheduled awakenings appear to increase the duration of consolidated sleep.’ This one sounds really complicated, because I have no idea how you know your child is likely to awaken in 15 to 30 minutes. The paper seems to agree with me that this method is more difficult to accomplish than other methods like Extinction as it explains that Scheduled Awakenings is ‘slightly more complicated to carry out, and studies suggest that results may take several weeks rather than several days’. Nevertheless, four studies of this method by a particular group of researchers indicate that the method affords ‘another treatment option for frequent night-time awakenings’.

Parent Education/Prevention
I took extra interest in the results of this method since it is the one I am currently trying. Who doesn’t love the idea of ‘prevention’ before problems become entrenched! The researchers describe this method as encompassing many forms of new parent or soon-to-be-parent education that ‘focus on early establishment of positive sleep habits’ which ‘typically target bedtime routines, developing a consistent sleep schedule, parental handling during sleep initiation, and parental response to night-time awakenings’. The description goes on to explain that ‘almost all programs have incorporated the recommendation that babies should be put to bed ‘drowsy but awake’ to help them develop independent sleep initiation skills at bedtime, and enabling them to return to sleep without intervention following naturally occurring night time arousals’. This is the self-settling method that I am trying to train Lottie to master which is advocated in Tizzy Hall’s book Save Our Sleep. Happily, this method was given an endorsement by the researchers who claim that five large scale studies show that it ‘may set the standard as the most economical and time efficient approach to behaviourally based paediatric sleep problems’. This endorsement is great motivation to keep going with the training. So far, my own early experience is proving that when Lottie is able to self-settle, the whole family is a happy place!

As a last word, it’s also worth investigating whether many of the mother-experts are correct when they say that cry-it-out and controlled-crying is harmful to a child’s emotional development and relationship with their parents. As this study shows, the cry-it-out method is successful in improving a child’s sleep habits and can fix problems, often over a few short but painful nights. From what I can tell, cry-it-out is usually used to undo sleep habits that parents have identified as being problematic, such as when parents want to transition a child from co-sleeping to their own cot, or when the child is reliant on parent intervention to get them to sleep and into the next sleep cycle, such as rocking, patting, feeding to sleep or my current morning sleep crutch – motion in a pram or the car. Improving a child’s sleep and solving chronic sleep problems is clearly an important end unto itself for the child’s long term development. However no parent wants to think they’re doing emotional damage to their child by letting them cry; in other words, there’s contention about whether the ends justifies the means. However, the good news is, an Australian peer reviewed study has shown the controlled-crying method (which in the paper I’ve reviewed is called Graduated Extinction and is often also called camping-out) doesn’t do any long-term damage to a child. By comparing the emotional strength and parental and child bond of 6 year olds, half of who were sleep trained using the controlled-crying method, and half who were not, the study concluded that there was no difference in the two groups, and nor was there any difference in the sleep habits of the 6 year olds. I also came across this article that reviews some of the science the anti-cry-it-out (anti-Extinction) faction use to claim this method damages your child and frankly, I agree that science should never be misrepresented to scare people into believing they are damaging their child. So those tempted to use either the Extinction or Graduated Extinction method, or who have already used it, fear not, it would seem your child will not hate you or be emotionally stunted!

So there we have it – science has proven that not only are healthy sleep habits important for the health of a child, but that there are sleep training methods available to parents to improve the sleep habits of their child and the sanity of the family. Hooray for science!

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