Mistaken Approaches to Night Waking
Excerpt from Sweet Dreams: A pediatrician's secrets for your child's good night sleep, Lowell House, 22-28
By Paul M. Fleiss, M.D., M.P.H., F.A.A.P., 2000

The idea, often heard these days, that babies can and should learn to "self-soothe," without any physical or emotional interaction with parents, is incorrect. The best and most effective way for a child to learn to lull himself quietly back to sleep after experiencing a night waking is for parents to have demonstrated their dependability and availability when the child was a baby. Otherwise, that emotional upset the baby suffered as a result of the traumatic event that aroused him from sleep in the first place may, be compounded by the terror and frustration of feeling abandoned and unwanted. If a baby learns that his mother will come to him whenever he awakens in distress and cries out for her, he is more likely to develop into a self-reliant and self-assured child who will have the ability to assess and manage his own night wakings without involving his parents unnecessarily. It cannot be overly stressed that depriving a baby or a child of emotional support when he needs or wants it runs the risk of creating an emotionally unstable child and eventually an emotionally unstable adult. Only good can come from cuddling your baby whenever he needs it. In the best of worlds, a baby would automatically receive all the cuddling he needs without ever having to ask for it.

I know how hard it is for some parents to accept this wisdom. It is directly contrary to the advice that many American parents have been given for the past few generations. It is often hard for today's parents, who may have been deprived of adequate cuddling and emotional support from their own parents when they were babies, to give that support and physical comfort to their own children. They may feel uncomfortable holding their baby or dealing with the emotional requirements of a child.

Many years ago, I had a neighbor who was a very intelligent, sensitive, and successful woman. She and her husband had just had a beautiful baby daughter, and, naturally, they wanted the very best for their baby The baby's pediatrician was attached to the most prestigious, long-established, and well-respected HMO in her state. When that pediatrician warned the mother against ever picking up her baby when she cried lest she "spoil" her, and when he warned her never to feed the baby except at four-hour intervals, she followed that mistaken advice to the letter. This mother had the best of intentions toward her daughter. She wanted to do the right thing, but the advice she was given was so wrong as to achieve the exact opposite results. The poor baby spent almost all of her time screaming and crying alone in a playpen. This was what the doctor had ordered.

Her daughter survived all right, and she grew up to be very beautiful, but she also grew up to be an emotionally unstable, distant, and insecure young lady whose troubled relationship with her mother was a source of pain for them both. Sadly, this scenario is all too typical in our country. So many of today's adults were raised by intelligent and well-meaning parents who were given very bad advice from professionals who themselves were operating from seriously mistaken medical textbooks and medical teaching. Thankfully, this sort of antichild teaching is being challenged and scientifically debunked.

This, then, brings us to the very important issue of crying. This is a topic of great importance to many parents, and many have heard a lot of conflicting advice on this subject. I will tell you now that my approach to this issue is grounded entirely in a philosophy that recognizes the genuine emotional and physical needs of children in this situation and seeks to support them in a compassionate, loving, and scientific way.

Because of the publicity that this issue has generated, "sleep experts" have emerged to give parents two similar methods of "treatment"-both of which are unacceptable to thinking parents.

The first of these misguided "treatments" is the so-called "timed visit" or "Ferber method,"[3] otherwise known as "extinction," which attempts to use behavioral conditioning to teach children to "self-soothe." I think it is instructive to note that the frightening term extinction refers to the process of ignoring a baby's nighttime cries and refusing to soothe the baby. Oddly, it is the people who advocate ignoring a baby's cries who use this term.[4] The negative connotations of this word tell us that this practice is incompatible with responsible and loving parenting.

When a child wakes up and cries, advocates of extinction tell parents to enter the baby's room to check that the child is not in any "real" danger. They may reassure the baby verbally, but they are forbidden from nursing the baby or giving her any physical comfort. Then the parents are instructed to leave the child's room, even if she is still upset and crying. Against their better judgment, parents are ordered to let the baby or child "cry it out" until she goes back to sleep from exhaustion. If the child is still crying after five minutes, parents may go back and try again, but they are discouraged from touching the child. They then exit the room. If the child is still upset after ten minutes, the parents may return. If the child is still distressed and crying after fifteen minutes, they go back in briefly, but then leave the child alone for twenty minutes, and so forth. Each night after that, the amount of time before going into the child's room is increased by five minutes.

If we are to believe the self-promoting reports offered by the advocates of this method, it is usually supposed to work after a few nights. Success is measured by the reluctance of the child to call out for his parents, even if he still wakes up, needs help, or is traumatized by fear. If extinction fails to achieve the desired goals, the advocates instruct parents to wait a month and then try again.

Even if this method does stifle the cries of the child in distress, we have to ask ourselves if this is really such a good thing. The advocates of extinction have ignored the psychological impact of this sort of treatment. They measure success merely by the degree to which the child has been silenced. No one yet knows what happens in the mind of a baby who is systematically ignored and coldly bullied in this fashion. Certainly; no reasonable person can honestly believe that a baby can understand that she is being "trained" to "self-soothe" or to make a transition from a state of distress to one of relaxation. Adults know from their own experience that they themselves are unlikely to learn new tasks properly when they are crying and in a state of emotional distress.

A crying baby's needs are so simple, and they are so simply supplied. A baby cries to communicate to you his need for the touch, warmth, comfort, security, and love that only you can provide. Why would anyone deny such a simple, human request? Is a cuddle and a tender word such a hard thing that we cannot give it to a child in need? I personally believe that no normal, emotionally stable parents would put their precious baby through this sort of "conditioning" unless they were grievously misled. Sometimes I fear that some parents may be misguided into thinking that babies are just another type of pet animal, like a dog that can be trained to obey and perform simple tasks on command. It should go without saying that babies are not dogs and should not be treated as such. You cannot "train" a baby to obey your orders. A baby comes into this world "knowing" exactly what his needs are. Meeting these needs in an intelligent, humane, and loving manner is the only way to ensure that your child progresses smoothly through the biologically determined stages of human development.

The other popular method that some "sleep experts" advocate is the "sleeping partner" method. If the baby awakens in the night and cries out for her parents, one of the parents is instructed to go to the child's room and lie down somewhere in the room, but not in the same bed. An improvement in "sleep behavior" is supposed to happen after three or four nights. The baby is supposed to accept the "sentence" of sleep without protest. Somehow the baby is supposed to understand that the parents expect her to sleep through the night. Somehow the baby is supposed to understand that, if she wakes up because she happens to be thirsty, because she just needs to be reminded that her parents are still there and that they love her, or because she is frightened by a nightmare, she is to keep still and refrain from bothering anyone.

I have heard at lectures and read in books by "sleep experts" that these methods work 80 to 90 percent of the time, but my own clinical experience with parents who come to my office in Los Angeles demonstrates to me that these methods are largely ineffective and certainly do not work at a rate as high as the "experts" claim.

Regarding a child as if he were nothing more than an animal to be trained is a grave mistake. We really have little idea what kind of long-term damage we are doing to our babies when we treat them this way: When a baby fails to call out for his parents when he is in distress at night, it cannot be because he has "learned" a useful behavior. It is more likely that he has just given up on his parents. Psychological defense mechanisms erect a wall between the child and his parents. I can think of few things sadder than a child who can no longer love his parents but fears and distrusts them instead. In all of nature, there is no mammalian species in which the mother fails to respond immediately to her infant's cries. Despite their superior intelligence, only humans can be tricked into endangering the health, happiness, and welfare of their own offspring.

It is helpful for parents to remind themselves that babies and young children are emotional rather than rational creatures. A child cannot comprehend why you are ignoring his cries for help. Ignoring your baby's cries, even with the best of intentions, may lead him to feel that he has been abandoned. The result will be an insecure and unhappy child. You cannot "spoil" a child by responding to his cries. Children are "spoiled" by being ignored. If they cannot get your attention through the usual means, they will resort to unpleasant behavior to get it. The more you ignore your children, the more unpleasant their behavior will become, and the more "spoiled" they will appear. The lesson you are teaching is that you value bad behavior more than good behavior. I am sure that all parents will realize the undesirability of any child learning such a lesson.

Expecting a crying baby or a young child who has experienced a night waking to "self-soothe" without any positive and nurturing interaction from you is unreasonable and ineffective. Responding to a child's cries, comforting her, and lovingly trying to help her overcome whatever is bothering her is not only effective, it is the only proper way to soothe and calm a child in order to help her fall back asleep. A crying baby wants the calming presence of a parent precisely because the baby instinctively knows that the presence of a comforting parent is the solution to her problem. Unless the parent makes himself available to the baby, the baby will not be calmed. Babies are responding to biological needs that sleep "experts" either ignore or deny.

It is true that a baby whose crying is ignored may eventually fall back asleep, but the problem that caused the night waking in the first place has remained unsolved. Even if parents have checked to make sure that the baby is not sick or in physical discomfort, unless they pick up the baby, interact with him in a compassionate way; soothe him, or nurse him until he falls back asleep, the underlying or accompanying emotional stress will remain. The emotional stresses of a baby do not simply go away if they are ignored. They multiply and may lead to long-term disorders in the relationship between parent and child. Meeting your baby's emotional needs by answering his cries and interacting with him, therefore, is the approach of choice for parents.

Remember that babies cry for a reason. We may not always know what the reason is, and we may not always be able to solve the problem, but we can always try: If a baby cries at night, it may be because she is hungry, thirsty, sick, cold, hot, uncomfortable, agitated, lonely, or frightened by a nightmare. Whatever the problem is, the fact that the baby cries indicates that the baby is unable to solve the problem alone. She requires the assistance of her parents. Let us also remember that babies cry only as a last resort, after all other means of trying to establish communication with the parents have failed. A child's crying in response to a night waking, therefore, can represent an intensification of the initial stress that caused the waking in the first place. Consequently, the most sensible and compassionate approach is to respond immediately to your child's cries. Babies do not cry because they have nothing better to do or because they are trying to annoy you. They cry because they are in real distress. When your baby cries, she is calling you. She is requesting your assistance the only way she knows how. After all, a child who has awakened at night and begins to cry may be sick, in discomfort, in danger, or in pain. You will not be able to assess the situation until you go to your baby and hold her in your arms.

3. Named for Richard Ferber, the best-known advocate of this controversial approach. Ferber, Richard. Solve Your Child's Sleep Problems. New York: Simon & Schuster, 1986.

4. Ramchandani P., Wiggs L., Webb V., Stores G. A. systematic review of treatments for settling problems and night waking in young children. British Medical Journal; 320(7229):209-213 (January 22, 2000).

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