Few things pierce a mother's heart like her baby's cry. This is why so many parents hesitate to use sleep training methods. But take heart — sleep-trained kids do just fine later on.
That's the finding of a series of studies on a couple hundred children whose parents did or did not receive training on sleep behavioral techniques.
"Sleep training doesn't harm kids."
Ask a thousand parents what the most challenging part of parenting is during the first year, and you'll hear a lot of them say sleeping problems. The number of books published on infant sleep alone is testament to how difficult it can be for parents to find a method that enables them and their children to get the rest they need.
But choosing the "right" method to help your child sleep is also fraught with anxiety. Many parents worry that soothing their children to sleep will prevent the children from learning to fall asleep on their own. Or, they worry that the "cry-it-out" method will lead to emotional scarring.
The authors of the current Pediatrics study, a five-year follow-up to the first two studies, note this in their paper.
"Unproved concerns about their [sleep training techniques]) long-term harm are limiting their uptake and provoking vigorous debate," they write. The goal of their studies was to find out whether children of parents who use certain sleep training forms have any long-term negative outcomes.
So far, it appears they don't. And neither their parents nor their relationship with their parents appears to suffer either.
Two Sleep Training Methods
The study was led by Anna M. H. Price, PhD, of the Centre for Community Child Health at the Royal Children's Hospital in Australia, and it focused long-term effects of two types of behavioral sleep training.
The two types are "controlled comforting," also called "graduated extinction," and "camping out," also called "adult fading." In controlled comforting, "parents respond to their infant's cry at increasing time intervals to allow the child to learn to self-settle."
In camping out/adult fading, the "parents sit with the child as they learn to independently fall asleep, slowly removing their presence from the child's room." Both methods are different from the older "cry-it-out" method, which the authors noted is no longer recommended "because of the distress it causes parents and infants."
According to William Kohler, MD, director of Pediatric Sleep Services at Florida Hospital Tampa, both controlled comforting and camping out are "extinction" techniques, popularized by Richard Ferber. With cry-it-out, the child is left to cry all night without the parent coming in, and Dr. Kohler agreed it's not recommended.
Graduated extinction (controlled comforting), however, is recommended by the American Academy of Sleep Medicine, he said.
"Graduated extinction is an appropriate therapy for children that has been used effectively," Dr. Kohler said. He noted what a colleague, Judith Owens, MD, has said about the importance of finding a sleep technique that works for families.
"'A well-rested parent is going to be a better parent in the daytime,' she said, so we do want to encourage people to console their child," Dr. Kohler said. "We also want to encourage the use of graduated extinction so that the mother and other caregivers will get better rest after the child learns to get to sleep and stay asleep on their own."
The babies followed in this study were recruited from offices where parents took their children for well-child visits. All the parents of the children in the study reported that their children had sleep problems when their babies were 7 months old.
The study began with 326 children, and 225 families participated in the five-year follow-up. Of the original 326, 174 parents were part of the intervention group. This means they had the opportunity to hear about these two sleep training methods, though not all of them took advantage of that opportunity, and it's not clear how many used either or both methods.
In the five-year follow-up just published, 122 of the parents who had access to the behavioral interventions were included along with 103 who received usual care without behavioral intervention training.
"Sleep Training" Versus "Usual Care"
The original study was randomized in clusters, which means the clinics where nurses taught sleep training were randomly selected and were spread out geographically.
All the parents at one center received the intervention or else usual care. The researchers did not know which parents had received the training during the trial.
"Usual care" meant the parents could ask for sleep advice at their child's 8-month visit, but the nurses were not trained to teach the two specific sleep behavioral training techniques.
With the intervention families, nurses provided a brief description of the intervention, and the mothers could choose which strategies they would use (if any) or mix them. A total of 100 moms in the intervention group took advantage of hearing this information, and the other 74 did not.
The researchers did not note whether these 100 moms used one, both or neither of the sleep training methods taught. It's also not clear how many of these 100 mothers were part of the 122 intervention parents included in the follow-up study.
At the five-year follow-up, the researchers assessed the mental health, sleep patterns, social functioning and stress levels of the children, the relationship between the parent and the child and the mental health and parenting styles of the mothers. To measure the stress levels of the children, the parents took saliva samples (following specific instructions from the researchers), which the researchers then tested for cortisol, a hormone which can be used to assess the stress levels in a child.
What the Studies Found
Overall, the researchers found no significant differences between the group that received "usual care" and the group that received the sleep training intervention. This is good news for parents in both "camps" when it comes to sleep training. Basically, whether you choose to use one of these sleep training methods or not, your child does not appear to be different in terms of later stress or temperament.
However, there were differences along the way, so parents can consider the findings and use this to determine for themselves what route they wish to take.
- At 10 months, 56 percent of the parents who went to centers offering the behavioral interventions reported they were still experiencing sleep problems with their children, compared to 68 percent of the parents who received usual care.
- When the kids were 1 year old, 39 percent of the intervention center parents reported still having sleeping problems, compared to 55 percent of the non-intervention parents.
- At age 2, 27 percent of the children in the intervention group still had a sleep problem, compared to 33 percent of the children in the non-intervention group.
- At age 2, 15 percent of the mothers in the behavioral intervention group reported depression, compared to 26 percent of the mothers in the non-intervention group.
- At age 6, 9 percent of the children in the intervention group had sleep problems, compared to 7 percent who receive usual care.
- At age 6, 29 percent of the children in the intervention group had high stress levels (as measured with their cortisol hormone), compared to 22 percent of the kids in the non-intervention group.
- Among parents in the intervention group, 63 percent used an "authoritative parenting" style, compared to 59 percent of the families in the non-intervention group.
Again, the study did not note whether the parents who attended the clinics teaching intervention methods chose to use one, both or neither of the behavioral interventions taught. The researchers also did not appear to collect data on what methods the parents in the non-intervention group chose to use.
The researchers did control as much as possible for differences in the children's gender and temperament and the mother's depression symptoms, socioeconomic status and education level.
The basic finding: no long-term harms were noted in the children of parents who had access to the specific behavioral techniques taught at the intervention clinic, compared to the children who received usual care. No particular benefits were noted either.
Choose the Method That Works for Your Family
So, there were essentially no differences among both groups in terms of children's mental health, sleep patterns, social functioning and stress levels. There also did not appear to be any differences in the relationships between the parents and the children. This means that parents who choose to use one of these methods can take heart and feel better about their decision.
"The fact that it did not show anything as far as abnormality or improvement in six years was important," Dr. Kohler said. He said these findings should dissuade the parents who have shied away from any type of extinction method, which can be used to improve sleep for children.
Meanwhile, parents who choose not to use one of these methods may take comfort in the fact that over the long-haul, their children also appear to be doing just as well. In the short-term and medium-term, parents who did not receive the interventions did report a slightly higher percentage of sleep problems with their children.
Further, the most significant difference between the groups for the parents was in the previous study when the children were age 2. In that study, published in Pediatrics in 2008, that the rate of depression in the mothers was lower in the intervention group compared to the moms in the non-intervention group.
Regardless, this study offers comfort to parents who decide whichever method works best for their family.
"Behavioral sleep techniques have no marked long-lasting effects (positive or negative)," the authors wrote. "Parents and health professionals can confidently use these techniques to reduce the short- to medium-term burden of infant sleep problems and maternal depression."
Meanwhile, the researchers did note that these two sleep training methods taught in the intervention clinics may not necessarily be appropriate for all children.
"In the context of potential harm, it is unknown whether there are subgroups of infants (eg, those who have previously been maltreated, experienced early trauma, or are anxious children) for whom the techniques are unsuitable in the short- or long-term," they wrote.
"If supported by empirical investigation, there could be a case for using more gradual interventions such as adult fading instead of the more intensive graduated extinction (controlled comforting) to manage infant sleep," they wrote.
The most recent (five-year follow-up) study was published September 10 in the journal Pediatrics. The study of the children at age 2 was published in Pediatrics in September of 2008, and the first study was published in the Archives of Disease in Childhood in November of 2007.
The research for the most recent study was funded by the Australian National Health & Medical Research Council Project, the Pratt Foundation. The original Kids Sleep Study was funded by the Foundation for Children and the Victorian Government’s Operational Infrastructure Support Program. The authors declared no conflicts of interest.
