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Cry It Out Westersoe/iStock.com

Cry It Out, also known as “controlled crying,” is an “extinction method” of ending – “extinguishing” -- the cuing for attention, help, nourishment, hydration, support, and loving, physical comfort that is programmed into the biology of young mammals.

May 17, 2016

Screaming to sleep, Part One & Two: The moral imperative to end 'cry it out'

“A Little Throw Up Never Hurt Anyone”

While in Philadelphia for business, Gabriel pulls up to his cousin Janet’s home to visit.

“You made it!” Janet notes with joy. She embraces him with one arm. Her 5-month-old son Tyler is in the other.

Two hours pass. Gabriel, Janet, and her husband, Keith, share stories and dinner. At various points throughout the conversation, Gabriel plays peek-a-boo with a drooling 5-month-old. 

“OK, it’s 7:30,” Janet abruptly notes. “Tyler’s bedtime.” She lifts her son up from his multicolored bouncy seat, wherein he has spent much of the evening. She walks him down the hall to his football themed nursery. 

Gabriel and Keith each pick up a fresh beer and retire to the family room. Keith clicks on the television. Within five minutes, Janet joins them. 

“Well, that was easy,” she says with a smile. Janet sits on the couch next to Keith, reaches for the remote, and turns up the television.

Suddenly, Tyler is screaming. Screaming. Tyler’s screams could pierce through the din of any commercial. They could break glass. Gabriel sits up with a start, his heart racing. 

“No need to panic,” Keith mutters while kicking his feet up on an ottoman. “Welcome to the land of ‘sleep training.’ The doctor told us that it could take awhile, but Tyler’s got to learn. He always falls to sleep eventually.”

Gabriel looks at Keith in disbelief. “What does he have to learn exactly?” Tyler’s screams punctuate each word.

“He’s got to learn that we don’t come to him every time he cries. Janet totally indulged him those first few months.” Keith continues, “But we are in charge. We are the parents. He’s got to learn his place.” 

“It’s called self-soothing,” Janet adds. “Look, it’s not as if I like it. I particularly hate it when he throws up. But our pediatrician assures us that it’s a normal and necessary part of parenting.”

“He throws up?” Gabriel asks with concern.

“We’ve invested in some high-tech ear plugs,” Keith laughs. “Plus, a little throw-up never hurt anyone.” 

“OK, but you never clean up after him …” Janet not so playfully jabs her husband in the side with her elbow.

As Gabriel listens to the new parents justify their inaction to nature’s most basic impulse, nothing about the situation seems remotely normal. “You mean, you purposefully let him cry knowing he’ll throw up from the stress?” Gabriel looks at his cousin. She turns away. Her cheeks flush.

“Just watch the show, would you?” Keith speaks sharply and turns the television up again.

Fifteen minutes pass.

Tyler continues to wail, but now his sounds are full of despair. He has given up on any chance that his parents will respond. His cries sound hopeless, exhausted, and pitiful.

Gabriel can’t focus. “I got to go,” he says standing suddenly. “I’m tired. I’ve got an early meeting tomorrow.” 

“See you later,” Keith states matter-of-factly without taking his eyes off the screen.

Tyler’s little body, covered in sweat and tears, soon exhausts itself from relentlessly crying out in panic, anger, and despair. Due to the mechanism of self-preservation, his body shuts down his conscious self and falls into a forced sleep. 

Janet walks her cousin to the door. “Is everything alright?” she inquires quietly.

“Look, Tyler is not my son and I’ve never put a baby down to sleep, but I can’t listen to him cry for another minute. I’m sorry.” Gabriel turns to her. “I’ll call you tomorrow.”

As Gabriel drives away, Tyler’s little body, covered in sweat and tears, soon exhausts itself from relentlessly crying out in panic, anger and despair. Due to the mechanism of self-preservation, his body shuts down his conscious self and falls into a forced sleep.  

What is Cry-It-Out (CIO)?

“If your baby is sick, then this is about as tough as controlled crying gets and you will have to be strong-minded not to scoop him into your arms to comfort him. But do try to resist as you’ll only prolong the process and his misery. Try to be efficient and calm as you change the sheet … Don’t speak to your baby, and be as quick as you can so that you don’t get his hopes up allowing him to think that he’s going to be cuddled and fed.” 

-- Dr. Caroline Fertleman and Simone Cave, “Your Baby Week by Week: The ultimate guide to caring for you new baby” 

We, as a culture, do very little to support new parents. Gross misconceptions about what constitutes normal sleep patterns in infancy and early childhood abound, even in professional circles.

We, as a culture, do very little to support new parents. Gross misconceptions about what constitutes normal sleep patterns in infancy and early childhood abound, even in professional circles. We have no federal maternity (let alone paternity) leave and our entire adult population is overworked and sleep deprived. Is it any wonder that the “sleep training” of babies/toddlers has become such a popular phenomenon? Akin to debates about circumcision, corporal punishment, and vaccination, the question of whether or not it is right to let a child Cry-It-Out (CIO) deeply divides American parents.

CIO, also known as “controlled crying,” is an “extinction method” of ending – “extinguishing” -- the cuing for attention, help, nourishment, hydration, support, and loving, physical comfort that is programmed into the biology of young mammals. While popularized by Dr. Richard Ferber in his 1985 book, “Solve Your Child’s Sleep Problem,” advocates of CIO date back to pre-Ferber days. In his 1946 classic entitled “Baby and Child Care,” Dr. Benjamin Spock advised parents to "say good night affectionately but firmly, walk out of the room, and don't go back."

This “don’t-go-back” approach perfectly describes CIO in its “unmodified” or “total extinction” form. Some pediatricians who subscribe to this method of CIO advise parents to shut the door to their baby or toddler’s room and not open it again for a full 12-hour period. The only caveat to this involves assuming nighttime parenting duties if the child is physically ill. Yet, throwing up due to the stress of nocturnal abandonment doesn’t constitute a sign of physical illness and parents are advised by proponents of “total extinction” CIO to clean up the vomit promptly without touching the child or displaying emotion. 

In its “modified extinction” form, CIO advocates argue that parents should leave a baby or toddler alone to cry to sleep. But this stressful experience is best practiced when punctuated with intermittent, and increasingly less frequent, check-ins from the caregiver. The intention of such visits is to persuade the little one verbally, or with minimal physical touch, that their nighttime expression of distress, thirst, and/or panic will not lead to the comfort being sought. 

In both methods of CIO described above, babies and/or toddlers are repeatedly left alone to fall into cycles of sleep. Over time, they learn not to signal to their caregivers as the bonds of attachment fray. Proponents of CIO mistakenly refer to the resulting detached state as one in which the child has learned to “self-soothe.” This is patently false.

Recent research conducted at the University of North Texas clearly reveals that the cortisol levels of babies left alone to CIO remain at unnaturally high levels even days after they learn to stop crying/cuing for help. However, the cortisol levels of mothers -- which register as abnormally high when their babies cry -- return to normal levels in the silence. At this point, mothers and babies are no longer biologically in sync. The mothers assume all is well; they interpret their babies’ silence as proof that their little ones have learned to self-soothe. Yet, physiologically babies can’t self-soothe. Rather, CIO teaches them to panic silently and detach from those whom nature intends for them to trust. 

Sarah Ockwell-Smith, a psychotherapist, doula, and UK-based author of the soon-to-be-published book, “The Gentle Sleep Book: A Guide for Calm Babies, Toddlers and Pre-Schoolers” argues that the erroneous pursuit of a baby that self-soothes profoundly misleads parents. She writes: “You are categorically not leaving your baby to ‘soothe,’ you are leaving him to cry, even if it is only for periods of two minutes at a time … Is it possible to train a baby or a toddler to not call out for their parents when they are in need? Yes, it is, but this is categorically not indicative of an infant who is happy, calm and soothed.”

“Three Schools of Thought”

A human infant is born with a brain that is only 25 percent developed. Babies’ brains grow rapidly in the first two years of life -- up to 70 percent of their adult size. Hundreds of trillions of neural connections are established and billions of nerve cells develop. It’s a majestic biological orchestration requiring a great deal of REM sleep. Babies spend most of their nighttime hours in REM sleep (much more than adults) and this contributes to their frequent night waking and notorious patterns of light sleep. While frustrating for parents, these patterns are actually healthy for babies. During REM sleep, key proteins central to the construction of nerve cells are manufactured and blood flow in the brain doubles. Consider that premature babies spend 90 percent of their sleep time in REM. 

Given our sleep-deprived, overworked culture that embraces a hyper-independent vision of success, the question of how best to respond to the normal sleeping patterns of babies and toddlers is a loaded one. In her popular “Aha Parenting” blog, New York-based child psychologist Dr. Laura Markham, author of “Peaceful Parent, Happy Kids: How to Stop Yelling and Start Connecting,” explains there are “basically three schools of thought” with regard to the matter.  

The first approach consists of “the family bed.” Here, the primary caregiver (usually a breastfeeding mother) chooses to sleep nearby her baby or toddler -- either in the same bed or in the same room. Mother and child sleep close enough to each other so that nighttime cues and signals can be responded to quickly and comfortably. Not needing to walk down a hallway after checking a bleary-looking monitor at 3 a.m., a co-sleeping mother simply brings a night-waking baby or toddler to her breast wherein they both can fall back to sleep with ease. Advocates of this approach, argue that co-sleeping, when practiced safely, is the most natural and instinctive way all breastfeeding mammals sleep. After all, consider that we are the only social mammal which can be persuaded to purposefully separate our young from their mothers during nighttime hours.

In the second approach, one finds proponents of gentle sleep training techniques such as those advocated by Markham herself as well as by Elizabeth Pantley in her popular book “The No Cry Sleep Solution.” In this school of thought, young children are not left to cry alone. However, they are taught, when developmentally appropriate, to learn to sleep, or fall back to sleep, without the constant reassurance that they naturally crave. This may involve crying. Should parents walk away when crying occurs? “Never, in my view, if you want an emotionally healthy child,” answers Markham. She continues: “Crying is fine, as long as you’re there.” It’s important to note that these gentle techniques are not taught to babies. After all, it is natural and appropriate for babies to breastfeed to sleep. “Nursing to sleep is no more a ‘bad habit’ than peeing in a diaper,” Markham writes. As children grow, they leave behind diapers as well as breastfeeding in an organic and supported way.

Eighty-five percent of the neural pathways relating to how we respond and interpret the world are formed in the earliest years of our development. Sensitive caregiving, particularly in the first three years, correlates with professional and social success/happiness in later life. 

Finally, standing in stark contrast to co-sleeping and gentle sleep training advocates, one finds proponents of CIO. Like Keith and Janet in the opening story, parents practicing CIO choose to let their children cry alone into an exhausted sleep, over and over, until the little ones learn that protesting their situation is futile. Advocates of CIO may argue that Keith and Janet’s story is too extreme. “I’d never let my son cry until he vomits,” they may say. Or, they may openly admit that such a sign of distress is par for the course. Consider this recent post on a parenting FB group:

I just saw a post on another web site from a mom doing controlled crying. The poor bub has vomited from distress and is sweating to the point he needs his clothes changed - out of distress also. The other moms are commenting - be strong, stand your ground and my LO [little one] vomited too, and it gets easier... So heartbreaking. 

How parents and caregivers choose between these three schools of thought matters. While we may not consciously remember how we were treated in our earliest years, the first three years of human life are vital to the development of our implicit memory serving as the foundation for how we feel about relationships, trust, and love. In fact, 85 percent of the neural pathways relating to how we respond and interpret the world are formed in the earliest years of our development. Sensitive caregiving, particularly in the first three years, correlates with professional and social success/happiness in later life. Yes, how babies and toddlers are treated matters -- a great deal. 

It may be popular to assert that the three schools of thought described above are equally viable options for consideration and practice. In the July 2014 issue of Parents magazine, readers were told, “whatever sleep training method feels most comfortable for you is just fine.” Yet, parents bear the responsibility of being certain that the practices they employ do not harm their children. A growing catalog of peer-reviewed studies clearly assert that CIO harms normal brain development and damages a child’s capacity to develop secure attachment bonds -- essential to the cultivation of empathy, pro-social behavior, and future, healthy long-term relationships. CIO is anything but “just fine.”

Lifelong Harm 

I remember the scene vividly.

I’m around 1½ years old. Recently separated from my mother, my grandmother cares for me. I see myself standing in my crib at my grandparents’ home. It’s dark. I am crying and crying. I don’t know what I did that was so wrong. I’m confused, utterly distraught. So, I climb out of my crib and walk through the house. I find my grandmother in the kitchen cleaning. I cling to her leg crying, begging. I want to be picked up. “I am a good girl!” I tell her.

Years later my grandmother confirms the story. She said it broke her heart to ignore my cries. She was pressured to make me cry myself to sleep by her husband, my grandfather, and by her son, my biological father.

She tells me she is sorry. 

-- Victoria Fedden, author of “Amateur Night at the Bubblegum Kittikat” 

“For a baby, being left to cry is like torture,” states Darcia Narvaez, professor of psychology at the University of Notre Dame and executive editor of the Journal of Moral Education. 

Pain responses are activated when babies are physically separated from their caregivers. This leads to the “underdevelopment” of receptors for serotonin, oxytocin and endogenous opioids – chemicals essential for our experience of happiness. In particular, the neural pathways formed by oxytocin released in our infancy remain with us and continue to impact our adult physiology. When these pathways are compromised it makes forming healthy, future attachment relationships challenging at best. 

Given this biological reality, Narvaez is deeply concerned about the negative impact that Cry-It-Out (CIO) methods of approaching infant/toddler sleep have on children. 

She warns: “When a baby's needs are dismissed or ignored, the child develops a sense of mistrust of relationships and the world. And self-confidence is undermined. The child may spend a lifetime trying to fill the resulting inner emptiness.” 

Biology links mothers to children, and when the relationship is in sync, cortisol levels (associated with stress) as well as oxytocin levels (associated with bonding) rise or fall together. CIO breaks this bond.

CIO is also painful for connected caregivers to experience. Consider the story of a new mother standing in the shower with her hands over her ears so she doesn’t have to hear her daughter scream. Many parents who try CIO eventually succumb to the angels of their better nature and seek wisdom in methods that honor the basics of human physiology.

Biology links mothers to children, and when the relationship is in sync, cortisol levels (associated with stress) as well as oxytocin levels (associated with bonding) rise or fall together. CIO breaks this bond. True, parents can numb themselves. Like Janet and Keith, featured in Part One of this article, caregivers can be persuaded to ignore their natural physiological urge to respond to their child’s cues of distress. As seen in Victoria Fedden’s reflection, caregivers also can be pressured into practicing CIO.

Yet, everything in a baby’s physiology links him to his caregiver. Research done by professor James McKenna at the University of Notre Dame analyzes recordings of co-sleeping, breastfeeding mothers and babies. Babies naturally turn to their mothers, not only for the nourishment of breastfeeding, but to regulate breathing, heart rate and physiological well-being. 

“Given a choice, it seems human babies strongly prefer their mother’s body to solitary contact with inert cotton-lined mattresses,” writes McKenna.

To be forcibly separated from the sounds, smells and presence of the only habitat a baby has ever known is frightening enough. To be ignored when cues of distress are repeated until the body physiologically shuts down in order to maintain self-preservation is torturous.

It also has lifelong effects.

Last year, researchers from Princeton University, the University of Bristol, Columbia University and the London School of Economics and Political Science worked together to produce a report titled, “Baby Bonds: Parenting, attachment and a secure base for children.” Sutton Trust, a London-based institute, funded and published the report.

According to their research, 40 percent of 14,000 children born in 2001 lack secure attachment bonds formed by “early parental care.” Children under the age of 3 who do not establish these early vital bonds are “more likely to be aggressive, defiant, and hyperactive as adults.” All concerned about the well-being of our immediate future should take note of this study. 

How can parents ensure that children develop secure attachment? It’s simple. When a toddler cries, reassure and hold her. When a baby cries, pick him up.

Susan Campbell, a professor of psychology at the University of Pittsburgh, comments on the above study: "When helpless infants learn early that their cries will be responded to, they also learn that their needs will be met.” 

This lays the necessary foundation for the development of secure attachment, upon which future emotional well-being depends. Yet, 40 percent of an upcoming generation has been harmed by misguided negligence and the abdication of sensitive and responsive parenting.

Advocates of CIO carry much of the blame.

Pressure to Cry-It-Out (CIO)

“Just let him cry. He’s got to learn to fall to sleep on his own.” 

“Don't let your baby manipulate you.”

“My mommy-shift ends at 8 p.m. sharp.” 

Many new parents experience a great deal of pressure to let their babies and/or toddlers CIO. Whether this pressure comes from medical professionals, loved ones or a parenting partner, it can feel relentless and confusing. Consider the following excerpt taken from Part One of this article. 

“He’s got to learn that we don’t come to him every time he cries. Janet totally indulged him those first few months.” Keith continues, “But we are in charge. We are the parents. He’s got to learn his place.” 

“It’s called self-soothing,” Janet adds. “Look, it’s not as if I like it. I particularly hate it when he throws up. But our pediatrician assures us that it’s a normal and necessary part of parenting.”

To their credit, professionals advocating CIO do so because it works. Over time, the practice of CIO certainly does end the crying (cuing behavior) of babies/toddlers. Dr. Jodi A. Mindell, a psychology professor at Saint Joseph’s University in Philadelphia, advises parents to be “consistent” when it comes to using CIO. “They need to pick a plan they can absolutely follow through on,” she states.

When practiced consistently, CIO teaches little ones that no one responds to their cries. They learn to sleep, or suffer, in silence.

While there is much to laud about consistency and routine when it comes to best parenting practices, consistency in and of itself is morally neutral. After all, one can be consistently unkind. What matters most is that parents are consistent in nurturing their children, not ignoring them. The only caveat here relates to the emotional stability of the caregiver. In a moment of profound frustration, it is wise to step aside briefly -- even from a crying baby -- and regain composure so as not to inadvertently harm the child. But this isn’t CIO. When practiced consistently, CIO teaches little ones that no one responds to their cries. They learn to sleep, or suffer, in silence.

We are the only social mammal that can be convinced to purposely separate our young from their mothers during sleep and, furthermore, we are the only mammal that can be convinced that it is a good idea to ignore their desperate pleas for nighttime connection. How is this possible? A brief overview of two studies relating to brain development helps answer this question.

Ten years ago, Michael J. Meaney, scientific director at the Ludmer Centre for Neuroinformatics and Mental Health at the Douglas Mental Health University Institute, studied why some rats were more anxious than others. First, Meaney divided mother rats into two categories: low-nurturing and high-nurturing. Then, he examined the “critical period” of the first 10 days of a baby rat’s life -- which would be roughly equivalent to the first six months of human development. It is during this period of time that genes relating to a rat’s ability to manage anxiety are turned on or off. Rats with low-nurturing mothers remained anxious when facing new situations for their entire lives, unless they received medication. Why? The genes associated with establishing the neural pathways of managing anxiety never turned on. A high-nurturing mother was needed to trigger the gene’s activity.

All mammalian brains work in similar ways. Genes relating to key behaviors turn on and off (permanently) in the early stages of mammalian brain development. By studying rats and other mammals, we can learn a great deal about our own neurobiology. If a human mother is low-nurturing, her children may not develop the needed neural circuitry to manage their own emotional lives with ease. Upon entering parenthood, these children may find it challenging to interpret their own baby’s cues in an appropriate way.

"Responding sensitively to infant crying is a difficult yet important task," notes Esther M. Leerkes, professor of human development and family studies at the University of North Carolina at Greensboro. Last September, researchers led by Leerkes sought to determine why some mothers view the crying of infants in a “mother-oriented” way (wherein the cries were interpreted as manipulative nuisances) versus mothers who view the crying of their babies in an “infant-oriented” manner (wherein cries correctly connoted an infant’s need for care). Their findings, published in the journal Child Development, highlight how a mother’s difficulty in processing her own emotions and/or her experience of depression was central in distinguishing between the two groups.

So, why is CIO advocated and practiced when it goes against the basic fiber of healthy mammalian behavior? Our neural circuitry is damaged. Whether we study anxious rats or mothers who label their crying infants “manipulative,” the answer is the same. The CIO method of approaching infant/toddler sleep advocates either the total absence of any nurturing or the very low presence of nurturing during nighttime hours. Such behavior guarantees that the pattern of damaged neural pathways continues. 

When considering the pressure parents face to practice CIO, especially when it comes from medical professionals, Tracy Cassels, founder and primary writer for Evolutionary Parenting, has this to say: “I don’t know what happened in their lives that have led them to promote such cold, inconsiderate practices … To suggest parents must neglect their children in order to ‘help’ them. It must have been horrible.”

While it may be true that some professionals who advocate CIO are traumatized individuals, I prefer to think of them as simply misinformed. Due to new discoveries relating to brain science, medical practices have changed dramatically with regard to how we treat concussions. The same response is needed today when it comes to advice given to new parents regarding infant/toddler sleep. It’s unconscionable that, once familiar with the basics of how CIO harms the brains of developing children, medical professionals continue to advocate the practice. 

A Moral Imperative

The good news is babies are not meant to sleep through the night because it’s not safe for them to. The bad news is babies are not meant to sleep through the night because it’s not safe for them to. So here is the ugly truth, being a parent is hard.

 -- Gena Kirby, co-founder of The Progressive Parenting Network

Human infants and toddlers naturally wake for nourishment, hydration, comfort and the reassurance of loving touch at night. In fact, many adults naturally wake at night to drink a glass of water, use the bathroom or seek out the comfort of a beloved one following a bad dream. CIO advocates a nighttime experience that adults would protest if it were forced upon them. Shouldn’t we be more considerate of our children?

When a child is left to CIO, she doesn’t learn the “skill” of sleep, Maté explains. Rather, her brain escapes from the “overwhelming pain of abandonment” and “shuts down.” 

Dr. Gabor Maté used to advise parents to let their children CIO. In 2006, Maté, a Canadian pediatrician and co-author of “Hold On to Your Kids: Why Parents Need to Matter More Than Peers,” wrote a compelling co-ed for The Globe and Mail entitled: “Why I no longer believe babies should cry themselves to sleep.”

In his article, Maté highlights how neuropsychological research compels him to speak out publicly against a practice he once advocated for as a physician and practiced as a father. When a child is left to CIO, she doesn’t learn the “skill” of sleep, Maté explains. Rather, her brain escapes from the “overwhelming pain of abandonment” and “shuts down.” While such a shutdown brings quiet reverie for frustrated and exhausted parents, it comes at a steep price. The implicit memory encoded in the brain structure of the CIO baby is that the world is an uncaring place. “This is why, if I could relive my life, I would do much of my parenting differently,” Maté laments. 

When I consider what it would be like to purposefully leave my toddler-aged son alone to cry his way into an exhausted slumber, I shudder. The reaction is visceral. I don’t need a moral theory to more deeply persuade me that such a course of action goes against the clearly guided instinct I have to care for my child. Nevertheless, I am a scholar of ethics and find affirmation in the fact that ethical systems the world over insist upon our moral obligation to “do no harm.” 

Do no harm

At times, these three words may seem archaic and hopelessly idealistic upon pursuing headline news. When considering the billions spent on war, it’s clear that many institutions are relentlessly involved in the profiteering of harm. Nevertheless, each moment offers us a choice. We can add to the collective pain burdening the human family, or we can do what we can to alleviate it. While we may believe that some people (those labeled as terrorists, murderers, rapists, etc.) deserve to be harmed, the intentional harming of innocents is universally condemned and morally repugnant.

Upon discovering how harmful CIO is, we have an obligation to end this practice of purposefully neglecting our children at nighttime. Dr. Richard Ferber himself admitted he had little knowledge of infant psychology. So, why turn to his method for advice? As the popular parenting slogan goes, “When we know better; we do better.”

Research is clear. The school of thought regarding infant/toddler sleep known as CIO (in all of its forms) harms the most precious and innocent among us. To knowingly harm babies and children is wrong. Period. May we work for a day when CIO is looked upon like the ancient practice of Chinese foot binding is today: archaic, harmful and best relegated to the pages of history.

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