CIO, sleep training, and evidence or the lack thereof

The sleep training debate has, to no-one's great surprise, popped up again in Parentland.  In the red corner, Rosa Brooks: hell, yeah, stick in those earplugs, sling 'em in the cot and let 'em howl!  What harm could it possibly do?  In the green corner, Hathor, the Cow Goddess Of Attachment Parenting: heresy!  Don't you realise this will traumatise your child and damage his or her trust?  What caring mother could ever do such a thing?

I've commented previously on my opinions on both sleep training in particular and OneTrueWayism in parenting in general, but, as it happens, what drew me into the debate this time was another favourite bugbear of mine - the spot-the-difference game between what the evidence on a contentious topic says and what people with strong opinions on the topic claim it says.  What Hathor claimed, you see, is that her anti-CIO stance had been proved right by scientific research.  Years of study and reams of inquiry, she assured us, all consistently maintain that it is harmful to force your child to cry it out.  Indeed, Ferber himself had been proved wrong on the subject and had recanted his claims as a result.

Now, I can totally understand being anti-CIO - even its strongest proponents admit that it can be a pretty unpleasant experience for everyone concerned.  I'm a lot more sceptical about the belief that it's likely to cause long-term emotional damage - personally, I think babies are a lot more resilient than some of us give them credit for, and I don't think a child who's getting plenty of affection in his life overall is going to suffer permanent trauma as a result of a few bedtimes and naptimes crying alone - but it's a big old world and there's room for a lot of different opinions out there.  But claiming that there's scientific evidence for the supposed harmfulness of CIO - well, that's where things leave the realm of opinion and get into the realm of ascertainable fact.  Or, as it may be, fiction.

I've spent a lot of time looking at what different parenting forums and websites have to say about CIO, including a lot of the CIO-is-the-work-of-the-devil sites, and I've often come across this claim before.  Invariably, the 'evidence' presented (when the person making the claim actually does present any evidence instead of just assuming that the existence of evidence is so obvious as to need no further comment) falls into one or more of three categories:

1. Opinion.

2. Anecdote (often of cases where a number of other things were changed in a child's life at the same time.  "This two-month-old baby was left to cry herself to sleep and her parents stopped spending as much time with her during the day and she was fed less often and, guess what, she didn't thrive.  Obviously the sleep training!")

3. Actual research that isn't actually into CIO. There is a huge amount of research out there to show that regular positive attention and affection is crucially important for children's emotional development, and one of the few issues in parenting that just about anyone with any glimmer of a clue can actually agree on is that prolonged, regular neglect during childhood is liable to cause children problems; sometimes huge problems.  However, sleep training isn't prolonged, regular neglect.  It involves leaving children for short periods at specific times, while giving them just as much loving care as normal at other times (possibly more, since responding lovingly and affectionately to another person tends to be rather easier if you're not going insane with sleep deprivation).  Pointing to studies on the desperate harm suffered by Romanian orphans left abandoned in their cribs all day and every day as evidence of what a Bad Thing sleep training is is about as valid as pointing to studies on starving, malnourished children in the Third World and using them as support for a claim that you're doing your child terrible damage by expecting her to wait an extra twenty minutes for her dinner now and again.

Since no-one from the anti-CIO-for-sleep-training brigade ever seemed to cite any actual studies on the use of CIO for sleep training, I searched Medline to whether any such studies had ever actually been done.  (The technical term is "extinction", if you want to do the same thing.)  There are no long-term studies that I could find, but I did find two studies that looked at the psychological status of children shortly after sleep training.  Both of these seem to have passed unnoticed by the very people who are supposedly most fascinated by the psychological status of children following sleep training.  Call me cynical, but am I wrong in thinking that this might possibly have something to do with the fact that both studies actually showed children to be, if anything, somewhat more secure following CIO?

So, I replied to Hathor's claim with a quick summary of the above.  Since the list of references she gave in reply was fairly typical of the kind of stuff that gets presented as evidence in these debates, I'll go through them.

One reference to a speech by James McKenna in which he cited primate studies into short-term mother-infant separation.  Now, I can't comment directly on how these studies might or might not relate to CIO, because direct references weren't given in Hathor's quote or anywhere else on the 'Net that I could find.  However, a Medline search on "mother-infant separation" shows that, while lengthy separations do indeed appear to be harmful to infants, infants separated from their mothers for brief periods of time only were actually less fazed by separation when older than primates who hadn't undergone such separations.

One newspaper article about Margot Sunderland's new book, The Science Of Parenting.  I haven't read the whole book, as yet, but I've read the section on sleep training.  No references to studies on CIO.

Two articles about the infamous Commons and Miller paper.  I call it infamous because it gets mentioned in tones of reverence all the time in CIO debates.  It is, according to popular legend about it, a study by two Harvard psychiatrists that showed CIO to be harmful.  The only part of that that's correct is that the authors do indeed work at Harvard. 

The Commons and Miller paper wasn't a study and wasn't about CIO.  (And the authors are psychologists, not psychiatrists.)  It was a discussion of the many ways in which child-rearing practices differ in two different societies (the USA and the Gusii tribe of Kenya) and what kind of long-term effects this might have on children reared in the two societies.  It's a fascinating paper, but it isn't a study.

One reference to a study stating that all of 186 hunter-gatherer societies looked at in one study practiced co-sleeping.  Which tells us, um, precisely zero about the effects of CIO.

One webpage on the general evils of leaving babies to cry, devoid of any actual references.

And one article about a study showing that infant rats who received plenty of affection from their mothers were more secure than infant rats who received little maternal attention.  Which, as I discussed above, adds to the already sizeable body of evidence that giving your child little attention overall is A Bad Thing, but tells us nothing about the effects of a specific short-term intervention such as CIO.

My dissent on the issue of whether this constituted adequate evidence of the evils of CIO caused, as you can imagine, some debate.  Since there are now quite a number of questions for me in the second comment thread still awaiting a reply, I decided to move the discussion over here and answer them in this post.

What exactly are you looking for for something to be a study?

Well, not wanting to sound tautologous or anything, but a study involves studying something.  When someone says that CIO is harmful but doesn‘t actually provide any evidence to back this up, that’s an opinion.  When someone speculates on whether CIO may be harmful, that’s a theory.  When someone makes an attempt to assess the state of children following CIO, that’s a study.  (Whether or not it’s a good study is, of course, a whole separate and important question.)

Or to have compelling information for you to see that CIO is not a good thing for babies?

I’m not trying to claim it’s a “good thing” (although I believe that, for some babies, it’s a better thing than the alternative).  I’m objecting to the claim that research has proved it to be a harmful thing.  But, to answer your question: if well-conducted studies into the psychological state of children following sleep training showed them to be psychologically worse off after CIO, then that would be compelling evidence.

If I may be so bold as to ask, what exactly are you doing on a site that is pro co-sleeping trying to defend CIO?

Objecting to misinformation.  I don’t object to people being anti-CIO; I do object to people claiming the evidence states something that it doesn’t.

Or at least trying to say that there needs to be studies to prove that co-sleeping is benificial (sic)?

I haven’t said that.

I guess it all comes down to doing what works best for your family, taking into consideration that babies/children are people too, and that they have needs that they can not meet themselves do to their age.

Doing what works best for your family is exactly my philosophy, as well.  However, my experience is that when that statement is followed by that sort of qualifier in this sort of debate, what it actually means is that you don’t believe CIO is ever going to be what works best for anyone's family.  And, having read a lot of different stories from different people with different experiences, I can’t agree with that.

There are may ways to help a child learn to sleep that do not involve them having to cry for extended periods of time.

And I’d like to see them much more widely known (by which I do not just mean the blanket “Co-sleeping will solve all your problems!  What more could you possibly need to know?” recommendation that seems to be all that some attachment parenting advocates have to offer).  I’d also, however, like to see it more widely recognised that - like everything else in parenting - they aren’t universal solutions that work for all children and all families.

But I think we need to remember that there are a lot of parents out there who might well have tried alternative solutions to sleep problems with their children if they’d known about them, but who didn’t know about them and thus tried some form of CIO.  Now, leaving these families thinking “Damn, if only I’d known about that at the time!  Could have saved us an unpleasant few evenings” is one thing; leaving them thinking “Oh, no!  There’s scientific evidence that the way I handled things was actually damaging for my child!“ is another.  If we’re going to do that to parents, we ought to be damn sure we have our facts straight first.  If there isn’t any actual evidence that CIO is harmful then we shouldn‘t be claiming that there is, no matter how vehement our personal opinions on the subject.

Touche on the Harvard study, I haven’t seen the actual paper the article was based on.

Well, if you want to, you can read it here.  Right where I said it would be, in fact.

But a comparative multi-disciplinary investigation of different societies is not necessarily less valid than lab-controlled experiments. It’s what anthropologists do.

It's a valid research method for some things, although I don't think it would be a good way of studying CIO - there are so many differences between different societies that it wouldn't be possible to single out one specific brief episode during childhood and pinpoint the effects of that.  However, the objection I was making is not that their paper is an anthropological study, but that it isn't a study at all.  It's a discussion of previous research into the topic, and it doesn't contain any actual information on how the different methods of child-rearing affect children.  It simply theorises on how the differences might affect children, and suggests this as a topic for further research.

These [the children in the first CIO study] are 6-24 month old children they studied. How would you guess they rated the security and anxiety of these children?

They used a modified version of a scale called the Flint Infant Security Scale, filled in by the parents.  The second study I cited used the same scale, and also visual analogue scales to measure the parents' impressions of how depressed and how anxious/insecure their children seemed.

I personally can’t see how being left alone to sleep can make anyone more secure.

I've found that dealing successfully with a situation I originally thought to be beyond me usually leaves me feeling more secure.  Knowing that I can deal with it leaves me with more confidence in my own abilities.

It's also worth remembering that children who have difficulty getting to sleep and wake frequently in the night are often sleep-deprived themselves.  If adults find it easier to cope with life's stresses when well-rested, why shouldn't the same be true of children?

To me this abstract is pretty unconvincing.

That's fine.  I'm not out to bang a CIO-is-wonderful drum here - that isn't the way I feel at all.  What I'm trying to point out is that the existing evidence doesn't show it to be harmful.

I don’t believe in CIO.  Sarah, you obviously do to some extent

What I believe in is finding solutions that work for individual families, individual children.  I believe that sometimes, that solution is going to be CIO.  And I believe that though another method could potentially have worked just as well or better in most (not all) cases where CIO is used, that doesn't mean that using CIO in those cases was actually harmful.

Anyway, people also used to widely believe in ’spare the rod spoil the child’ and were full of evidence of how spanking led to better children.

And stories like that don't tell you that we should be extremely careful about not claiming that the evidence supports a particular way of doing things purely because that's what it suits us to believe?

I just don’t see how a three or six month old baby for example can know the difference between just having been left in his safe nursery and having been abandoned completely.

Well, when his mother turns up again, I think he's going to figure out that it was the former.

And how do you really know that a three month old really isn’t hungry, or that something isn’t really bothering him?

In fact, I don't know any experts who advocate using sleep training for a baby as young as three months.  But, assuming that you didn't feel that to be the crucial point of your question: By knowing your child and by using common sense.  For example, if you've just nursed your child and he isn't taking any more milk then it's a fair bet that hunger isn't the problem.

And besides that, why are only physical needs valid when speaking about babies? Certainly judging by the numbers of relationship gurus out there, all the books, all the Dr. Phils and beyond, we in North America believe that we have emotional needs that deserve to be met.

Certainly.  But that doesn't mean that someone has to be available to meet them every minute throughout the day and night.  I don't expect my partner to drop absolutely everything he's doing to talk to me whenever the fancy takes me, even if it's 4 a.m. and he's in a sound sleep.  I know that he has other things to do that are important; and I know that that doesn't detract from his love for me or his ability to be supportive and available to me overall.

Why is it less valid for a baby to be lonely than it is for an adult to be lonely?

It isn't.  But, similarly, why should it be so much more valid?  If a friend staying with you was regularly expecting you to come and keep her company regardless of what hour of the day and night it was or what else you might need to do, how long would it be before you started saying no some of the time?

I mean no offense by this, but I don’t really need you to answer these questions. I know what the answers are for me.

Which is good.  The point at which I start having a problem with these sorts of discussions is when people start deciding that they know what the answers are for everybody else.

I think ultimately all there is to this topic is to follow your heart, as Julinda and Serendipity said above.

And if your heart leads you to the conclusion that CIO is the right answer for your baby?

I hope these articles make people think about this issue a little bit more, to reconsider, to tune into their heart and see what is right for *them*.

I'd love it if there were more articles that did that, but I don't think either Rosa Brooks' or Hathor's had that aim.  What Hathor, like Brooks, really wants other people to do is to tune into her heart and do things the way she thinks is right.  That's the problem I have with this issue, as with so much else in parenting; so many people think they've got the one right way that's going to work for all children, just as though children weren't individuals as much as the rest of us.

But that's not why I wrote the reply I did to Hathor's post.  I replied to it because I believe that she was not correct in claiming that the existing scientific evidence proves CIO to be harmful.  And I hope I'd have had the guts to say so even if I was passionately anti-CIO on a personal level.  Judging the evidence on the basis of what we want it to show is a temptation that's impossible to avoid altogether - but we should be willing to be as honest as we can be about what it actually shows.

Comments

[Emily]

All my friends at our post-natal group approached sleeping solutions in different ways. I decided on the cry it out method. But I only had one night of about 40 mins of crying and the next night of 10 and then slept soundly and I've been really lucky on the sleep front.

My friend J has had a terrible time. Her marriage ended when her daughter was 9 months old. Sleeping has never been the same again. She hasn't had a decent night's sleep for more than a year. Her daughter cries if she is in the same room, if she is in J's bed...just basically all night. The last few months it is better but she gets out of her own bed at about 3am and sleeps in J's bed. J has been out of her mind, on prozac and tried to get any help she can. They are finanlly talking about a sleep unit. Her health visitor recommended crying it out but the daughter throws up if she cries to long and hard. Clearing up sick five times a night is just too much for a single parent to handle I think.

Like with most parenting choices, how you get your child to sleep is your business. Whether you teach the crying out (which hopefully only lasts a couple of nights) stuff or go for co-sleeping.

I like to think that a stable homelife and caring parenting that provides attention and love would be enough to offset any 40 mins of screaming while trying to get them to learn a bedtime routine. Aferall, are we also damaging our children when in full throws of toddler tantrums with timeout and the naughty step? What about when they are teenagers and trying every trick in the book? When is the right time to lay down acceptable boundaries for behaviour?

Interesting debates on all sides as you've linked to. I agree though, I don't like anyone using data incorrectly to serve an agenda (as we saw with the breastfeeding stuff recently).

[Beanie Baby]

Thank you for the link.

What I find most interesting about the CIO debate is actually how, during the day, most parents realize that sometimes you have to let your children cry. You take them for shots, or you strap them in their carseat, or you snatch them away from that intersting looking knife they found, and they scream in protest, and you let them. It's true that the kids don't know that the needles aren't full of acid, the carseat isn't actually a rack, and the knife could hurt them, and they might conclude that their parents hate them or are trying to hurt them, but we don't stop and let them do whatever they want so they won't have to cry. We tell ourselves that the child doesn't understand but the parent does, and it's for the best, so the crying will simply have to be weathered. But then it's night-time, and the baby cries, and--hold everything! Do anything you can to stop it! No crying can be tolerated at any time! If the baby cries, you are scarring them for life! It makes no sense at all.

What I found with Frances, now that I reflect, is that all my attempts to "soothe" her at night and co-sleep were the exact opposite of what she needed. I was so busy listening to the (Sears et. al) books, so certain that if she cried at night it must be because she was lonely and scared and needed comforting, that I "comforted" her night after night after night. She would cry in my arms for hours as I walked her up and down. She would wake up every 45 minutes and cry while we co-slept. Then when I buckled down to CIO, having exhausted my family's emotional and physical resources utterly trying to do it "the right way," she whimpered for 18 minutes and slept for seven hours in her crib by herself (I know she slept for seven hours, because I didn't sleep a wink of them). Upon reflection, it's obvious that she needed to sleep by herself, and her crying was not a plea for comfort. My presence stimulated her and kept her from sleeping (obvious, when I consider that from two months of age she has not been able to sleep at all unless she's at home in a quiet room). All my attempts to "soothe her to sleep" were keeping her awake.

[Bec]

Good points, and I have another study somewhere that claims that despite CIO, babies are still secure. I think studies on cortisol levels would be better to refer to, or possibly blood pressure, brain scans, or other indicators of stress, to see if the method was harmful to babies brains / physiology. Since we can't ask babies, "is this stressing you out?" we can only be informed about ALL the research, and then decide for ourselves as parents.
Heres the problem... the CIO method in my country is the dominant method - that is - our child health nurses are told to teach parents this method (often from birth, and I was told to use it when my DD was 20 days old). So the method is in the MAJORITY here. I had to have access to the net (which many people don't have) and literacy skills and the confidence to search for evidence against the majority view. To me, this isn't really fair, and parents should have access to ALL parenting methods, so they can choose for themselves. (In Australia, CIO and ff is the majority for babies).
More studies need to be done, you're right!, but since no researcher is yet willing to study it directly for the long term, all we can do is examine all the evidence suggesting potential effects on babies brains.
I'd love to read your studies on sleep deprivation in babies, and I'd also love to read your review of Prof Margot Sunderlands book and her studies into the matter (I'm going to read it soon too I hope!)

[JK]

Great post and thanks for the link :-).

I want go back and add something to the post I wrote... I'll probably do an addendum to it... (I hope that my post comes across as only being what worked for us, as telling my story, and sharing why I think CIO isn't the work of the Devil, not as me advocating CIO or LTSOYO... I mean I am advocating to try LTSOYO and see if it works or not if your current sleep solution isn't working. I'm all about if it aint broke, don't fix it. Does that make sense?)

But anyway, I love the fact that you don't believe in the OneTrueWay (TM). It's so frustrating when people can't see the other possible sides just because something what worked for them.

As I get older and learn more and more, I become more fuzzy, and skeptical at the same time.

Individual difference do matter. I was trained as a psychologist to look at "the average" and that's just wrong. I really like to think of life and all of its participants as a normal distribution (which psychology does teach you about) but then during research, researchers only think about the average and how to help the average or to try and understand everyone given the AVERAGE results.

Anyway... I will read and write more when I can. I am swamped with work today (developing some stuff for some individuals, not averages ;-).

Thanks for writing and I look forward to reading more.

[Heather]

Well, since you decided to use some of my comments from Hathor's site to rebuttle here I thought I might pop over and comment.
I do, as a matter of fact, believe if I have a problem in the middle of the night that my dear husband should get up and help me deal with it, just as I do for him. Whether it be a nightmare, cramp, or what not. I believe that that is what it mean to be married to someone. I also believe that it is the duty of parents to support their babies... all night long.
Just remember that babies are only helpless for so long. In the grand picture, some one can live 90 years and really only need their parents to sleep with them for 3 or 5. Pretty short time. Plus why is it that two adults can sleep together all night long, but a baby gets the boot?
And you never answered my question reguarding what would you like to be done to you if you were a helpless adult. Would you really want to be left alone, all night??

H

[Mollie]

Loved this piece on CIO.

Especially because you are hitting on my precise problem with mothering groups both online and in the real world. Lots of dogmatic belief in various parenting styles and methods with no real evidence to back up passionate opinions and attempts to *evangelize.*

When you call many of these women on their lack of evidence, they feel that you are criticizing their personal choices. No, you can make your own choices as you see fit. I just want people to use real sources, real data, not inflammatory clap-trap. They all say they want women to make up their own minds on topics like CIO and circumcision-- well then give them real, hard information on both sides of the arguments, not just propaganda!

Vent over!
Mollie

[Annie]

There are no studies on the actual use of CIO, because that would be unethical. We know that excessive crying can be harmful to infants, there are studies that prove that. However, we cannot pinpoint the exact amount of crying that is too much and under what circumstances or for what babies it would be too much.

This is similar to drinking alcohol while pregnant. We know that some women that drink alcohol while pregnant have babies with Fetal Alcohol Syndrome (FAS). Some don't. We can't explain exactly why and under what circumstances FAS appears. So we recommend that women abstain from drinking alcohol during pregnancy because it would not be advisable to get a bunch of women to drink varying amounts while pregnant to test the outcome.

Same thing with excessive crying. Some kids cry a lot, but are somehow resilient and turn out to be wonderful and successful well adjusted human beings. Other kids that are left to cry a lot suffer from depression, lower IQs, slower development, etc. Since we cannot pinpoint exactly how much crying is okay for exactly what kids, it is best to say that parents should be responsive to their babies cries. Period.

More on this here: http://phdinparenting.wordpress.com/2008/08/11/cry-it-out-cio-is-it-harmful-or-helpful/

[Donna]

You wrote:
I just don’t see how a three or six month old baby for example can know the difference between just having been left in his safe nursery and having been abandoned completely.
Well, when his mother turns up again, I think he's going to figure out that it was the former.

The answer to this has to do with the stage of development of the brain. An infant simply does not have the ability to understand or to 'know' that mother is coming back, even when she does. They know only 'now'. There is no object permanence and there is no 'cause and effect' ability, therefore, when a baby is abandoned, even if it is during the night only, they very well may be going through absolute terror. Their instincts tell them they will not survive unless they are with their caregiver.

You may find more information about brain development from Daniel Seigel's "The Developing Mind".

There certainly ARE babies who want to sleep alone. This doesn't necessarily mean 'alone in another room' as that is certainly not in the infant's best interests (with SIDS and all), but there are babies who simply can not sleep in proximity to someone else, for whatever reason. These babies are not the norm, but I think it shows that it is up to the parent to truly know their child and to figure out what it is the child needs.

[Donna]

Another interesting observation is this: If we were talking about a dependent adult who is disabled or an elderly person who is crying out in the middle of the night for help, no one would be saying 'let them cry it out', 'they need to learn that I have needs, too'. Is it the fact that these people usually can talk and tell us what they need that makes it different somehow? All babies can do is cry to communicate a need, but they are still trying to communicate something. Why is it not okay to ignore the pleas of an adult, but it is okay, even recommended by some, to ignore the pleas of an infant? What does this say about a society? I'm not sure. Just asking. One more observation is the correlation that was made between crying it out and crying in general situations (like getting into a car seat or preventing harm to a child by taking away a coveted knife and such) is not really the same thing. In one situation, the child is completely alone - abandoned. In the other situations, the child knows the caring parent is there because they can see them. Again, the stage of development is key.

[Liz]

You say:
"while lengthy separations do indeed appear to be harmful to infants, infants separated from their mothers for brief periods of time..."
How long is "brief"?

And how does "separated from their mothers" equal to "being left alone when crying"?

I'd not be at all surprised if infants who spend time happily playing in someone else's arms are more open to going from mom later on. I'm skeptical about an assertion that infants who are left alone and crying are equally relaxed about future separations.