Sleep that knits up the ravell’d sleeve of care,
The death of each day’s life, sore labour’s bath,
Balm of hurt minds, great nature’s second course,
Chief nourisher in life’s feast,–
– Macbeth, Act II, Scene II
Since we’ve been discussing sleep training, why not look at one of the big reasons parents use it: sleep deprivation. As I’ve said before, there seems to me an underlying idea in many AP circles that parents (especially moms) should just suck it up and deal with sleep deprivation. Actually, to an extent I think it’s true. When you bring home a newborn, your life is turned upside down for a while, and because a new baby’s needs are so vital, you do need to learn to cope with sleep interruptions for a bit. In the first few months, babies need to nurse every 2-3 hours, with perhaps one slightly longer period at night, if you’re lucky. Formula takes slightly longer to digest, but a baby’s stomach is approximately the size of his fist – no matter what you’re putting in, you’re not going to provide 8 hours of nutrition in one feeding. So someone will be waking up with the baby. And of course, they tend to poop frequently, get belly pain as their digestive system learns to cope with life outside mom, and generally need lots of help to organize themselves physically and neurologically.
During this time, moms and dads are encouraged to lower their housekeeping standards, rely on their social network for help with meals and household responsibilities, nap when they can, and trade off night time duties to allow each other at least one reasonably lengthy block of uninterrupted sleep. During this time, keeping the baby in the parents’ room is not only powerfully protective against SIDS, it eases the burden of waking up to take care of the baby’s needs. Most often, babies develop something of a routine, and begin sleeping for longer blocks of time as they mature.
But what happens if that doesn’t occur? Or if a baby sleeps better for a while, then begins waking more and more often at night? After four, five, or six months, most of the social support from friends, church members, and neighbors will have evaporated. Parental leave and vacation days have been used up, and people no longer cut parents the same slack they did when their baby was new. From perusing some parenting boards, I see that some babies (who probably slept for a few hours at a time as newborns) degrade to sleeping only 45, 60, or 90 minutes at a time, all night long. While waking up with the baby twice a night might be a bit wearing, one can usually cope with it, and even get a total of about 8 hours of rest. But waking up 5-10 times a night? How do you cope with that – for months?
“Lower your standards.” There is a point at which lower would be too low for the health and safety of you and your baby.
“Sleep when the baby sleeps.” This is awesome advice – for stay-at-home moms with no older children, that is.
“Bed share!” A lot of moms will take the AAP admonition against this at face value. Others can’t bed share for a variety of reasons even James McKenna “authorizes” as legitimate. Also, to judge by the bedsharing sections of The No Cry Sleep Solution and Solve Your Child’s Sleep Problems, bedsharing by no means guarantees a good night’s sleep.
In the whole Narvaez debate, I’m seeing quite a few people saying, “Those selfish mothers – I can’t believe someone would leave a baby to cry just so they won’t be inconvenienced!” Now, I agree that parents shouldn’t put their convenience above their baby’s needs. (Heck, I’m taking apart Babywise with just this attitude – the book so far seems to be based on the idea that babies shouldn’t inconvenience their parents). To think that you can be responsible for all the needs of a helpless human being, 24/7, and not have major changes in your life is absurd. However, when inconvenience develops into major cognitive impairment and huge health risks, some balancing of needs is called for. To all those Judgy McJudgersons decrying lazy parents who can’t stand some inconvenience, I invite you to set your alarm to go off every 60 minutes at night, for just a week. Then get back to us about how inconvenient you find it when you develop depression, can’t make decisions or concentrate, forget simple things, get in a car crash, or even develop high blood pressure or diabetes.
There’s a reason for all the controversy over the U.S. government using sleep deprivation methods on prisoners. It is considered by many to be a form of torture, and is indisputably an effective means of breaking someone down psychologically. So maybe, just maybe, you AP advocates could cut those “evil, lazy, selfish” parents who consider sleep training a little bit of slack. Especially if you were lucky enough only to have moderate sleep deprivation, or you’re among the 5% of people who do OK on less sleep, or if you’re an “expert” who has never had children.
(By the way, I was looking for a good picture of a tired mom, and all the images were of happy moms holding sleeping babies, or moms asleep with a gentle smile on their faces. To find an image expressive of true mom-sleep-deprivation, I finally did an image search for “zombie” – there we go, perfect.)
The Dangers of Being Insulting and Misleading
Darcia Narvaez, PhD, launched quite the volley two days ago with her Psychology Today article, “The Dangers of ‘Crying it Out’: Damaging children and their relationships for the longterm.” Now, if you’re a reader of this blog, your first question might be, “Gee, that seems rather incendiary. Does this person have a real PhD?” Given that she’s a psychology professor at Notre Dame, I’m thinking yes. But that doesn’t disqualify her from being a judgmental ideologue who has only passing acquaintance with honesty!
She starts out by poisoning the well, linking “Cry it out” with discredited 19th century exhortations not to touch babies, to withhold love, not to be too kind, and the sentiment that watching and entertaining a baby is a waste of time. She refers to “Cry it out” without defining the term and also talks about “letting babies cry.” This vagueness about the very heart of her argument isn’t helpful to her case. What does she mean by CIO? Ferber? Weissbluth? Ezzo? “Letting babies cry” for how long? Does letting a baby cry for 5 minutes on one occasion “damage children and their relational capacities in many ways for the long term” and make the baby “less intelligent, less healthy but more anxious, uncooperative and alienated”? Note she doesn’t give any citation as she lobs these firebombs. She simply says “With neuroscience we can confirm [them].” This is the debating equivalent of saying, “Increase the Flash Gordon noise and put more science stuff around!” She’s trying to dress her philosophical opinion piece with science-y trappings without doing, you know, actual science.
Citing . . . herself, she declares that babies only grow when being held, and that basically you should never put your baby down, never mind sleeping apart from them. Then she states, “There are many longterm effects of undercare or need-neglect in babies.” While the terms “longterm,” “effects,” “undercare,” and “need-neglect” are left undefined, she has finally, in the fourteenth paragraph of her article about the risks of CIO, cited a scientific study that allegedly demonstrates the risks of CIO. Well, it’s not an actual study. It’s a survey of research used to make a public policy argument for early intervention “to provide an optimal environment in the first years of life.”
“There are many longterm effects of undercare or need-neglect in babies”
The article by Dawson, Ashman, and Carter, does discuss postnatal stress as an influence on child development. However, it’s difficult to pin down what is included in the term “stress.” The authors discuss animal studies where “separation from the mother” causes a surge in cortisol and other hormones. Unfortunately, some study abstracts don’t tell how long a separation they’re studying (and I can’t afford to buy all the studies!). And of course that would have a big impact on our concern about the risks of CIO. However, this one and this one used a 24 hour separation, and this one used isolation for 6 hours daily during postnatal days 2-20. The human studies of postnatal stress discuss the level of attachment exhibited by children, compared with their behavior and cortisol levels, but don’t inquire into what might cause poor attachment. The most damning statement I could come up with was “later attachment security was related to greater maternal responsiveness and lower cortisol baselines,” i.e., maternal responsiveness, as measured during clinic visits, was associated with children showing greater attachment security when they returned for follow-up testing. Needless to say, mothers who scored high on responsiveness during the day at the clinic might or might not have used CIO in some form at night, at some point.
When they discuss specific circumstances that cause stress for babies, Dawson et. al refer to babies in Romanian orphanages, and those with clinically depressed mothers. Note that these are serious, long-term, global stressors, not simply a short period of stress, confined to a certain part of the day, for a limited duration. Other circumstances they cite as influencing child development for the worse are fetal exposure to drugs and alcohol, developmental disabilities such as autism, poor nutrition, and violence. So by “stress,” they seem to be referring to very long isolation from the mother, or significantly traumatic events and conditions. There’s no indication that sleep training rises to this level, and Dawson et. al. never make any reference to sleep training or long periods of crying.
Moreover, the Dawson article undermines Narvaez’s confident doom-saying by noting that “the contribution of parenting factors to the development of self-regulatory brain mechanisms that have been hypothesized to relate to affective and attentional disorders is still poorly understood,” and “It needs to be determined whether psycho-biological measures such as neuropsychological performance, cortisol levels, autonomic responses, and brain electrical activity will be useful in identifying children at risk for psychopathology.”
So let’s go back to the statement she linked with this article: “There are many longterm effects of undercare or need-neglect in babies.” It might more accurately reflect the article to say, “There may be many long-term effects of lengthy separation from the mother, maternal mental illness, and chronic deprivation in an institutional setting, but we’re not yet sure what those effects are, and while we are guessing that certain brain mechanisms relate to emotional and attention disorders, we’re not sure about the details, and we don’t know if or how much parenting affects such mechanisms.”
“What does ‘crying it out’ actually do to the baby and to the dyad?”
We’re told that “neurons die” due to “the toxic hormone cortisol.” You know, that “toxin” that is needed for proper glucose metabolism, regulation of blood pressure, blood sugar maintenance, immune function, and inflammatory response. Is it more charitable to assume that Dr. Narvaez is ignorant, thinking that cortisol is unremittingly evil, or that she’s disingenuous, purposely ignoring the beneficial, normal function of cortisol while focusing solely on its effects in cases of chronic stress, when the body is not given the chance to return to baseline after a stressful event? I’m going to have to go with the latter, seeing as she follows up with the brazenly speculative cry, “Who knows what neurons are not being connected or being wiped out during times of extreme stress?” (That’s a fun game – I’m going to play. “Who knows how many of my neurons have been wiped out due to reading Dr. N’s screed?” “Who knows whether contact with her article might have given me an STD?” “There’s no telling how much my credit score has fallen due to such extensive contact with this text!” “Who can tell whether you’ll receive a pot of leprechaun gold if you write an angry letter to Psychology Today?”)
Next up, we’re told that “disordered stress reactivity can be established as a pattern for life.” Again, both citations refer to extreme stress such as child physical and sexual abuse, psychiatric illness, and PTSD. I admit I’m reading these late at night, but I’m pretty sure neither included “crying for 10 minutes” in their list of catastrophic stressors.
Likewise, when she argues that self-regulation is undermined, she cites a study that does indeed say “Stress during infancy that is severe enough to create insecure attachment has a dissociative effect,” but the stress they’re discussing involves experiences so severe they induce PTSD.
Next she argues that “trust is undermined,” referring to the philosophical work of Erik Erikson and delineating her personal belief that a baby left to cry (presumably for any period) learns to mistrust his caregivers, and the world at large. Piling fantastic speculation on wild conjecture, she sums up, “And self-confidence is undermined. The child may spend a lifetime trying to fill the inner emptiness.” Or, not. Either guess is equally valid.
She is also concerned that “caregiver sensitivity may be harmed.” Again, this is speculation. It’s not totally nonsensical – it makes sense that becoming inured to your child’s cries in one instance could make you generally more insensitive. On the other hand, every mom I’ve talked to who’s tried sleep training has agonized over her baby’s crying, and it’s equally plausible that empathy and good old mom guilt might make a sleep training mother more responsive, doting, and loving at all other times. It would also make sense that a fatigued mother would be less responsive, while a well-rested mother would have more resources for engagement with her baby. We’re dealing purely with “what-if” scenarios here, and Narvaez seems to acknowledge that by including the uncharacteristic equivocation “may,” and omitting any citations.
“But isn’t it normal for babies to cry?”
Here Narvaez really lays into parents, setting an impossible standard. She states that if your baby cries, or even “displays discomfort,” it’s clearly because you are depriving them of something they need. And she makes sure to remind you that your baby is rapidly growing – implying that your callous deprivation is particularly disastrous and cruel!
She continues, stating that any parent whose baby cries a lot is inexperienced and ignorant. If only you stupid incompetent parents had researched how to properly soothe a colicky, fussy, or high-needs baby, your infants would hardly cry at all. Get on that, would you?
Why Narvaez’s article is a double-scoop of obnoxious.
To sum up, this article really irritates me because it combines two things I hate. First of all, you guys know it irks me when people abuse citations. What’s billed as a research study supporting their assertion turns out to be an opinion piece or simply doesn’t say what the citing party says it does. I’m annoyed that to get a real picture of the supposed “science” here, I had to spend hours combing through abstracts and pony up $6 to rent an article. Narvaez no doubt has greater access to scientific publications than we lowly parents do – is it too much to ask that she not misrepresent what the studies say?
The second thing that makes me twitch is her intrusive, judgmental tone. I’ll be the first person to present the evidence showing formula feeding is statistically more risky than breastfeeding, or even to opine that routine infant circumcision is unethical. But I don’t charge into someone’s facebook status about their son’s bris screaming that they’re child abusers. I don’t post here intimating that formula is “junk food” and accusing bottle-feeding moms of not loving their kids enough, or being ignorant and callous. I acknowledge that people can choose parenting options that may be demonstrably inferior, all things being equal. But I don’t live their lives, and I don’t know what factors are interacting to ensure that all things aren’t equal. I just know that all things aren’t equal for most people, most of the time. The vast majority of parents love their kids like no tomorrow, and make the best decisions they can given their unique circumstances. The last thing they need is someone twisting the facts in an effort to make them look uncaring and stupid.
(By the way, that “formula is junk food” concept comes from another of Narvaez’s articles, which inspired a PhD in Parenting post saying that Narvaez was judgmental, vague, ignorant, and lacking scientific support for her statements, and that she “gives greater legitimacy to the argument that lactivists are cold-hearted, uncaring, uncompassionate, ‘Breastfeeding Nazis.'” Whoa. When a distinguished lactivist like Annie says you’re exemplary of the meme that lactivists are jerks, you know you’ve gone way overboard with the AP zeal!)
Cry-it-out, Ferber, and balancing risk
Look at most attachment parenting resources, breastfeeding-friendly forums, or crunchy mom refuges, and you’ll likely see people decrying “Cry-it-out” sleep training (“CIO”) for babies. While deliberately letting baby cry in distress is not a great approach to parenting when all things are equal, there are a couple problems with the knee-jerk hate this idea inspires.
First of all, when someone says, “CIO is terrible for babies,” what do they mean by CIO? My sense is they’re picturing parents dumping their infant in his crib, shutting the door as they leave, and gritting their teeth as he cries for hours until falling asleep due to exhaustion. And while many people associate Dr. Richard Ferber with CIO, this isn’t at all what he advocates. I think a lot of concerned moms wind up demonizing Ferber when they should be reserving their strongest disapproval for Marc Weissbluth, who’s much closer to the “dump and ignore” method of sleep training. But even he doesn’t just say you should drop your kid and run – his suggestions incorporate everything from what to do when your baby wakes up in the morning to understanding normal sleep patterns and using them to establish routines supportive of good sleep.
Secondly, there’s not really much evidence that letting older babies cry as they adjust to falling asleep unaided causes lasting harm. It’s important to note that young infants need to wake during the night to drink milk. There is no consensus on when a baby can go the whole night without caloric input, but estimates range from 4-9 months. In older babies, there is speculation that sleep training involving crying may introduce some risk because the baby is experiencing stress, including elevated cortisol levels, during the crying. However, for babies whose cries are generally soothed, and whose physical and emotional needs are met on a regular basis, there’s just no evidence that a few days or weeks of nighttime sleep training causes any harm.
It is true that experts like William Sears and James McKenna have written about sleep training in very critical terms, indicating that it has been shown to cause lasting harm. However, their philosophical zeal seems to have colored their reading of the literature, as the studies they cite either involve children suffering severe abuse or neglect, or don’t actually support the arguments they’re cited to bolster.
For instance, in Sleeping with your Baby, McKenna states on page 38:
Some studies have suggested that elevated levels of cortisol in infancy can cause physical changes in the brain, prompting a greater vulnerability to social attachment disorders. At the very least, the energy lost in crying could be better put into growth or maintenance.
McKenna cites J Pediatr. 1988 Mar;112(3):457-61. “Effects of crying on cerebral blood volume and cytochrome aa3.” Brazy JE., which concludes “Thus crying alters cerebral blood volume in all neonates in a pattern consistent with cyclic obstruction to cerebral venous return; it decreases cerebral oxygenation in infants with respiratory problems.” No mention of cortisol, changes to brain structure, or social attachment disorders. (It’s also worth noting that the study involves only newborns, who should never be sleep trained anyway, and that the scary-sounding “cyclic obstruction” is a result of the Valsalva maneuver, which infants regularly perform when coughing or pooping as well as crying.)
Now, it’s perfectly valid to decide against sleep training that allows extended crying, just in case that stress could cause long-term problems. But you can’t honestly lambaste a parent who chooses sleep training with the threat that they’re causing permanent damage to their babies. There’s no foundation for that claim.
The other problem with blanket rejection of sleep training is that it doesn’t account for balancing of risks. My personal story is a good example. (Yes, I used sleep training, in case you hadn’t guessed!) When Claire was almost 6 months old, her sleep periods started to become shorter and shorter. Overnight, she was sleeping for mere 90 minute intervals, requiring our help to get back to sleep with each waking. As you can imagine, this sleep deprivation had extreme effects on my husband and me. I remember being totally unable to form a coherent sentence and convey what I was trying to say. My husband has always been regarded as a wizard at work, but suddenly he was screwing up even relatively simple tasks, and his bosses were taking notice. In addition, to attend to our responsibilities, both of us needed to drive, which is very dangerous when one is suffering sleep deprivation. Bed sharing was not an option for us due to several different issues. We decided that any risk to our baby from crying for 10 minutes at a time was less than the risk of having an unemployed father or getting in a wreck.
I’m not saying that I love the idea of letting babies cry, even for a few minutes at a time. But in our circumstances, it was the best solution to a bad situation. Note also that we did our own version of Ferber’s plan. Not only did I pat or talk to Claire between crying periods, I picked her up, nursed her, rocked her – did anything to soothe and calm her, just being careful not to put her to sleep. I also didn’t let her cry for longer than 10 minutes, because that was the limit of my personal comfort zone with letting my baby cry.
And that’s something I want to emphasize: I think philosophical beliefs are a fine basis for deciding against CIO. If you just think it’s wrong or can’t bear to leave your baby to cry, more power to you. Just as there’s no real evidence that sleep training causes permanent harm, there’s no real evidence that soothing your baby to sleep or bed sharing (safely!) cause any harm. If CIO doesn’t feel right to you, you shouldn’t do it. If you try it and it doesn’t seem to be working for your individual baby, you should feel comfortable stopping. For me, it’s not something I would choose as a first response, but only became a viable choice when our situation became extreme. Other parents will have different parameters. Thankfully, almost all our babies will do just fine.
(This post was written before I learned of a new anti-CIO article by Darcia Narvaez, Ph.D. Her article is far worse than the articles that I criticize here: hysterical, judgmental, and lacking in the research department. I will follow up this post with a critique of the full article.)