One of the most controversial topics in parenting groups is sleep training. Why is this such a hot topic? Mostly because it results in a child crying, which some parents and professionals believe is harmful or traumatic to the child. However, there is no evidence to support this claim and quite the contrary. Please read on for more information.
Q. I've heard the word "attachment", but what does this mean exactly?
Attachment is the emotional bond that forms between a child and caregiver. Attachment occurs during the first several months of life when a baby sends out a signal of need (e.g., crying) and the caregiver appropriately reads the signal and responds to it. Attachment can go awry for many reasons, but those reasons are beyond the scope of this blog.
Q. Does sleep training impact the attachment or bond between a child and caregiver?
A. No, quite the opposite. A secure attachment develops when a caregiver consistently and predictably responds to the baby's signals with attunement, responsiveness, and engagement.
A sleep-deprived child becomes fussier and needier, demanding additional attention and care from the caregiver. Naturally, a sleep-deprived caregiver will struggle to meet the child's needs and respond appropriately to the baby's signals.
Due to fatigue, the caregiver is more prone to respond inconsistently (e.g., sometimes ignoring the cries) and unpredictably (e.g., responding with irritability). Naturally, things go better when the child and caregiver are well-rested resulting in greater connection.
Q. I thought sleep training meant you let the baby just "cry it out", which implies not responding to the baby's signals. How is attachment not impacted?
A. There is no single agreed-upon definition of sleep training in the literature. For example, lying a baby down in his crib drowsy but awake can be considered sleep training. However, typically what makes sleep training controversial is when one of the following 3 main interventions are used.
*It's important to note that these interventions should not be used in isolation and should be part of a comprehensive sleep intervention based on the results of a thorough sleep assessment.
1. Extinction, also called cry it out (CIO), involves ignoring the cries of the child as she learns to soothe herself to sleep.
2. Graduated Extinction (aka the Ferber method) which I refer to as time-based visiting, involves waiting a certain amount of time before briefly and lovingly responding to the child’s cry.
3. Parental Presence, also known as camping out, involves the parent/caregiver remaining close to the bed/crib until the child falls asleep and slowly overtime, the parent moves further away from the child.
There are other interventions used to treat sleep challenges, however, these are the primary interventions used to fade out sleep dependencies, such as being rocked to sleep. Depending on the child and family that I’m working with, I typically suggest using graduated extinction or parental presence. With these interventions, the parent is responding to the child by checking in or being present; however, the parent is setting a healthy boundary by sending the message, "I'm sorry, but I can no longer rock you to sleep every time you wake up".
Q. I heard that sleep training leads to a lot of crying, which could be stressful and even potentially traumatic to the child. How does this excessive crying not impact attachment or cause trauma?
A. Consistent and predictable interactions between the caregiver and baby leads to stable and secure relationships. Each day there are hundreds of opportunities to respond to the baby signaling the need for comfort, food, thirst, warmth, attention, etc.
Sleep training is one small part of the day in which the child’s specific want, not need, is no longer being provided. For example, a baby will cry because she wants to be held and rocked to sleep because this is how she has learned to fall asleep. Sleep training involves teaching the child to fall asleep on her own, in her own crib or bed. Because this is a big change, she will cry and protest. Children cry when they don’t get what they want.
During the day, we can redirect children to an alternative or distract them with something else, making the crying short-lived and less intense. At night, we can’t redirect them or distract them because we want them to lay down and fall asleep; therefore, the crying will be more intense and last longer. With sleep training, the caregiver will have a specific plan on how to respond to the crying which will lead to a consistent and predictable, and loving, way to respond to the baby.
Additionally, there’s a difference between tolerable stress and toxic, ongoing stress. Short term, mild to moderate stress can be positive and leads to resilience. The stress involved in sleep training is short term.
Q. I heard sleep training increases the stress hormone, cortisol. Is this true?
A. In one study, Middlemiss et al. reported that the infant’s cortisol levels were elevated after sleep training even though there was no baseline of the cortisol level, and the increase was not statistically significant. Gradisar et al. reported salivary cortisol levels indicated small-to-moderate declines in stress for the sleep training group as well as the mothers' stress also decreased in the first month for these groups. Additionally, at the 12-month follow-up, there were no significant differences in emotional and behavioral problems or attachment between the intervention (i.e., graduated extinction and bedtime fading) and control groups (i.e., general information about sleep).
Q. How many nights does it take of sleep training to see benefits?
A. Every child is different, however, parents often report that by the 3rd day they see their child falling asleep quicker, staying asleep longer, and waking up less often at night.
Q. At what age is it appropriate to start sleep training?
A. Depending on what sleep training method is used, sleep professionals say anytime between the ages of 4-6 months. I typically like to wait until 6 months and focus on educating parents about infant sleep in general, encouraging parents to place the baby in the crib drowsy but wake, along with creating a consistent and predictable bedtime routine, and a consistent sleep/wake schedule. I typically do not start with using the intervention procedures outlined above until the baby is a little older.
Q. In your opinion, what are the benefits of sleep training?
A. Simply put, everyone sleeps better! I often hear parents say, "WOW! I have a new kid!", "She's talking more!", "He's less fussy and less needy", "Her play skills have improved!", "He's able to sit and complete a puzzle!", "I'm seeing less temper tantrums!", and on and on. Additionally, parents are more attuned, responsive and engaged which promotes attachment and leads to better social and emotional outcomes for the child. This is why I'm so passionate about helping families get the sleep they need.
Q. What does the research say about sleep training?
A. Price et al. investigated the long-term effects of behavioral sleep interventions for infants. The researchers conducted a five-year follow-up of a randomized trial involving 326 children with sleep problems. They aimed to assess potential harms and benefits on child, child-parent, and maternal outcomes.
The study found no evidence of long-term negative effects on children's emotional development, mental health, or the child-parent relationship.
There were no significant differences between the intervention and control groups in terms of children's behavior, sleep problems, psychosocial functioning, or stress regulation.
Similarly, there were no significant differences in maternal mental health or parenting styles between the two groups.
Overall, the study suggests that behavioral sleep interventions are safe and do not have long-lasting negative impacts on children or their parents
Bottom Line
In summary, sleep training, when done with consistent and predictable responses, does not negatively impact the attachment between a child and caregiver. Instead, it can help form a secure bond by ensuring both the child and caregiver get the rest they need. While methods like Extinction, Graduated Extinction, and Parental Presence may involve some crying, this short-term stress is manageable and can lead to long-term benefits, including better sleep for the entire family. Studies have shown that sleep training does not cause long-term emotional or behavioral issues, and many parents see improvements within a short amount of time. By understanding and implementing these techniques, caregivers can support their child's development and well-being effectively. It's a win win for the entire family!
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References:
Gradisar, M., Jackson, K., Spurrier, N. J., Gibson, J., Whitham, J., Williams, A. S., . . . Kennaway, D. J. (2016). Behavioral Interventions for Infant Sleep Problems: A Randomized Controlled Trial. Pediatrics, 137(6). doi:10.1542/peds.2015-1486
Hiscock, Harriet, et al. "Long-term mother and child mental health effects of a population-based infant sleep intervention: cluster-randomized, controlled trial." Pediatrics 122.3 (2008): e621-e627. https://publications.aap.org/pediatrics/article-abstract/122/3/e621/72287/Long-term-Mother-and-Child-Mental-Health-Effects
Middlemiss, W., Granger, D. A., Goldberg, W. A., & Nathans, L. (2012). Asynchrony of mother–infant hypothalamic–pituitary–adrenal axis activity following extinction of infant crying responses induced during the transition to sleep. Early human development, 88(4), 227-232. https://doi.org/10.1016/j.earlhumdev.2011.08.010
Price, Anna MH, et al. "Five-year follow-up of harms and benefits of behavioral infant sleep intervention: randomized trial." Pediatrics 130.4 (2012): 643-651. https://doi.org/10.1542/peds.2011-3467
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