Fri, 10 Apr 2020 16:53:49 -0700WeeblyFri, 27 May 2016 05:20:09 GMThttp://infantsleep.org/blog/study-says-trying-to-get-your-baby-to-sleep-let-them-cry-it-outreallyThe Pediatrics study (not fully published until June 2016) hit the headlines today proclaiming in no uncertain terms that crying it out (CIO) --- also called extinction or graduated extinction --- was effective and without harm for infants.

I'm just going to say it: yes, CIO works. We know it works. Many, many studies have told us: it works. HOWEVER, once you start really looking at the body of research, you will see that it continues to ask and answer the same question: does it work?

There are many things we still don't know about CIO: who doesn't it work for? Are there interventions that also work and don't require so much solitary crying? Does CIO work differently at different ages? How much crying is too much at those ages?

So, here's a little of what we DON'T know:
1. What else also works? CIO is rarely compared to other, less difficult interventions. In the recent Pediatrics study, CIO was compared to "fading" and to a control group that received a brochure on sleep. "Fading" refers to pushing the infant's bedtime later by 15 minutes until you find a time that facilitates the infant being sleepier/more ready for bed. The problem with this is that very often, a later bedtime in an of itself results in more nightwaking. In this study, then, the deck was sort of stacked in CIO's favor. It tells you that leaving your baby to cry works better than putting off bedtime.

2. How does CIO affect infants at various ages? A majority of research on CIO wasn't actually conducted on infants, and those that are, rarely parcel out results by age. As a result, you may have a sample of children (e.g. aged 4-52 months) without showing outcomes by age. We can agree that a 6-month-old may tolerate CIO in a very different way than a toddler (or preschooler). This lack of developmental awareness tells us little about how the infants in the study did.

3. How are "negative effects" measured? The evaluation of negative effects is often limited to parental report about the child's behavior. While parents are experts on their own child, it's possible that after they've done CIO, they may be inclined reporting positive outcomes. Also, it's likely that a parent who wasn't sleeping and now is sleeping sees everything in a more positive light. To my knowledge no studies used objective observations of either the infant or the parent-child interaction. The current Pediatrics study did take cortisol (stress hormone) measurements and assessed attachment and reported no negative effects. Another study, however, found spikes in cortisol among CIO infants even after they stopped waking and crying (Middlemiss et al., 2012). 

The question really is not "are there negative effects" in general, but are there negative effects for some infants?

By looking at averages and groups of infants, we know little about the infants for whom CIO doesn't work. Spirited/intense/high needs infants or those with underlying sensory or other health issues are those that may not respond well to prolonged crying. We know nothing about how CIO might impact these infants (and their parents).

4. Research fails to take parental preferences into account. The fact is that most parents HATE crying it out. I'd like to see a survey that asked parents: if there were an approach to sleep that was a little slower than CIO, but had less crying, would you prefer it? My hunch is yes...overwhelmingly yes. Research tends to see parental resistance as a little puzzling. One scientist was surprised at the rates of parent drop-out from a study where they had a chance of being randomly assigned to the CIO group. Parents need to be talked into doing CIO. Why is this? Why do we need so much scientific effort put into talking parents out of their resistance? Because CIO goes against so many hard-wired parental instincts to respond that we tell parents is a good thing during the day.

Other points:

• Just because there's less research on an intervention, doesn't mean it doesn't work. CIO is relatively easy to study. Other interventions that are customized or have more components are complicated to measure. Positive routines, parental psychotherapy, social support, even white noise have been shown to improve bedtime and reduce nightwakings.
• Sleep is not merely a behavioral event, it is a relational event and involves the infant's biology, temperament and development, the parents' temperament, needs, values, and goals and the family's needs. Interventions that boil nighttime interactions down to an interplay of trainable behaviors overlooks the complexity of parenting and the parent-infant relationship.
  
• It is possible that all of the advice about sleep has merely made parents more worried and anxious about the job they are doing. A survey of parents' use of advice and their perceptions about it found that parents were more worried about how well they were managing their infant's sleep than they were about the wakefulness itself. Parents deserve information that empowers them and validates their values and goals for their child.
  

​Parents deserve to be supported with good information about a variety of approaches to good sleep. Research needs to begin asking different questions so that parents can choose an option that fits them, not adjust their mindset to fit the intervention.

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