As a psychiatry resident, I experienced managing sleep deprivation before having a baby. During my first overnight call, the senior colleague training me suggested we rest during the quiet hours of the afternoon to “build up our sleep tanks,” encouraging us residents to nap whenever possible during long shifts. She then retired to her on-call room but I didn’t sleep and chose instead to spend my free time on other pursuits. By early evening, a steady influx of patients into the emergency room left us unable to take breaks to rest or eat until our relief arrived at the 9 o’clock morning sign-out. By the middle of the night, I was exhausted. A headache formed behind my eyes from the combination of eye strain from the computer screen and fatigue. Given my experience with 24-hour calls before having a baby, the recommendation that new moms “sleep when the baby sleeps” made perfect sense. Of course, it’s tempting to finally catch up on household chores or zone out on Netflix while your baby is napping, but if you’re sleep-deprived, you need to get extra rest whenever you have the opportunity.
As a newborn, our son woke every two to three hours during the night for feeding or comfort. I thought it would improve with time, but it rather dramatically worsened when he was about five months old and learned to roll over. Excited and fascinated by his new skill, he would roll over in his crib, get stuck on his stomach, panic and cry out for help practically every hour. It was worse than any overnight call because it continued night after night. While I was nodding off in a morning meeting, one of my colleagues asked if my husband and I had considered sleep training.
Diving into research, I realized that entire books were dedicated to the different methods of training babies to sleep, with numerous books on each method. The idea that any sleep-deprived parent could read all these books seemed preposterous. After perusing a few internet sites with summaries of the different options, we decided to try it out. The first night, we used the gentle chair method, which turned out to be disastrous. Seeing me sitting in the chair near his crib, our son was at the very least confused and more likely enraged that I wasn’t picking him up or feeding him. This only resulted in him crying more ardently rather than being reassured by my presence. We changed tactics the next night and applied the “cry-it-out method” (CIO). Some may know this as the Ferber Method or “Ferberizing,” named after its inventor, Richard Ferber, a physician and former director of the Center for Pediatric Sleep Disorders at Boston Children’s Hospital.
The method worked as though our son had read the CIO instructions himself. The first night, he cried for about an hour while we went in at the recommended intervals (2 minutes, 5 minutes, 7 minutes, etc.). Instead of picking him up, we patted his back, whispered reassurances, and exited the room. The second night, the crying episode lasted about 45 minutes. By the third night, he was sleeping peacefully after just twenty minutes. He mostly slept through the night thereafter, unless he was sick or disturbed. During the day, he napped more peacefully and appeared calmer overall since he had acquired the skills to self sooth. Consequently, my husband and I were better rested and more able to give our best selves to our time with him. Honestly, listening to him cry those first few nights was difficult, but the sleep training worked and dramatically improved our family’s overall situation.
During the process, I encountered passionate criticisms of sleep training in my conversations with others and in online reading. Celebrity pediatrician and proponent of attachment parenting philosophy, Dr. William Sears claimed that sleep training flooded the brains of babies with cortisol and adrenaline resulting in various long term emotional and psychological issues. Another supporter of attachment parenting, Darcia Narvaez, PhD, has published several times in Psychology Today citing claims that sleep training could disrupt a baby’s body and immune system, compromise their ability to self-regulate, or undermine their trust in caregivers. Stumbling across this online I noted she referenced a few studies that appeared scientific, so I decided to investigate. As with most aspects of scientific inquiry, you can produce evidence to support any claim, but it’s the quality and context of the evidence that determine its relevance to your situation. As caring parents, one of our initial questions when considering sleep training was whether our son would be physically or emotionally harmed by the process.
As I explored the evidence against sleep training cited in one of Narvaez’s articles, I examined the studies she referenced about children developing attachment problems when abused, neglected, or ignored by unresponsive parents and caregivers. Those facts are well established; we can see determinantal effects on child victims of trauma or neglect. But when I considered the whole of my son’s life—the love and affection from his family and daily caregivers, the cuddling, playing, and careful attention given to him—I saw that our three nights of sleep training (total crying time: two hours and five minutes) hardly reflected the harsh conditions faced by abused and neglected children. Instead, a thorough search through the medical and psychological literature failed to produce a single source establishing that a child in a loving environment who endured a few hours of crying during sleep training would be physically or psychologically damaged. However, there was a paucity of data on the safety of sleep training at the time so I couldn’t locate a significant body of evidence assuring me that his sleep training would be relatively risk free.
Since sleep training our son, a few well evidenced medical articles and studies supporting the benefits of sleep training and demonstrating its safety by scientific methods have emerged. Tried as I might, I couldn’t summarize the evidence better than the following sources. One blog of a pediatric sleep consultant called, A Little Sleep, posts the article, “What does research and science say about sleep training? in which numerous studies are explored. None found any adverse effects from sleep training on child development and behavior or on parent child relationships. Several studies showed benefits including better sleep for parents and children and improvement in maternal mood and reduction in maternal depression. This blog post came to a similar conclusion as I had years prior, stated as “attachment damage comes from research conducted with grossly neglected children…not from children who undergo a few days of sleep training and who come from healthy homes.” Another website, Once Upon a Bedtime, contains an article, “What does science REALLY say about sleep training?” referencing the same or similar studies containing data for the safety of sleep training. This article takes it one step further, including evidence for not only the potential benefits to infant and parental sleep, benefits to the parent child relationships but also potential downfalls of being overly responsive. Dutch researches observed that prompt responses to crying led to more crying later in life and such responsiveness was associated with insecure-avoidant attachments for children. Insecure-avoidant attachment is characterized by discomfort with emotional closeness and difficulty forming emotional attachments with others when children grow into adulthood.
While we were sleep training both our children, I routinely encountered idealized accounts of what parents, usually mothers, are supposed to do instead of sleep training. Critics of sleep training often lament the past or praise other cultures where mothers are inseparable from their children, wearing their babies by day and constantly attending to their needs throughout the night. Should people feel this approach is right for them and their families then I would say by all means, do it. However, I don’t think that women should be expected to leave their jobs outside the home when they have children in order to be considered good mothers or guilted into any particular parenting practice. Many people chose to work outside the home or need to do so to support themselves. If you’re wearing your baby all day, you’re probably not going to an office or other location where you’re employed by someone else but rather staying home on leave, taking care of your house and children with some opportunities for rest while the children are napping. In non-Western cultures, mothers caring for children may live in tribes or hunter-gatherer societies and can participate in community tasks while enjoying the benefits of community supports. In a variety of cultures and historical time periods, parents can accomplish attending to their children daily without the help of daycare or nannies if they live in large households with extended families nearby who can assist them. Contemporary families, however, whether with two partners or a single parent, often don’t have such extended family supports, live in suburbs or cities and commute to work, handling jobs that require maintaining uninterrupted concentration, or performing tasks without an infant strapped to them, or at the very least, showing up reasonably on time and staying awake. While reminiscing about the past or idealizing other cultures may highlight the baby’s needs, it doesn’t account well for parents working outside the home and can also shame working women and families into thinking they should be awake day and night, constantly employed in service of others, leading to feelings of inadequacy and dangerously high levels of exhaustion.
We look to the past or other cultures to find and replicate what works because, as humans, we learn from those before us, and learning is part of striving to do our best. The desire to excel at parenting is natural, given the internal and external pressures to be perfect at it. Donald Woods Winnicott, a British pediatrician and psychoanalyst, introduced the term “good enough mother” in the 1950s, as the social landscape was moving towards women’s liberation. The concept of good enough mothering seemed particularly relevant and comforting to me during our son’s early years, especially when we were sleep training. Winnicott described a process from infancy in which the mother (or caregiver) begins with complete attention to the baby’s needs. She responds immediately, fulfilling her baby’s needs and sacrificing her own, including sleep. In the first few months of life, the baby sees their mother as an extension of themselves, inhabiting what Winnicott referred to as a magical world of illusion. In this world, the caregiver provides everything needed—changing them when they’re wet, feeding them when they cry from hunger, and rocking them to sleep any time of the day or night. This helps establish a feeling of safety for the baby. However, Winnicott recommends that as time goes on, the mother should gradually allow the infant to experience small periods of frustration within their tolerance. While remaining caring and empathic, she should avoid rushing to fulfill her baby’s every need immediately. She is no longer “perfect” but “good enough” in the eyes of her child. This gradual process of allowing the baby to tolerate frustration aligns with the natural cognitive processes as the baby begins to discover a reality external to itself. In the past or in cultures where people have many children, this process likely took place naturally as the child’s mother became pregnant again or next child was born.
Developmentally, by four to six months, babies become more aware of their surroundings, initiating the process of discovering an external reality. This discovery introduces the concept that others have needs, laying the groundwork for essential social skills such as sharing and respecting others. Coincidentally, around six months—an age when Winnicott suggested babies learn to tolerate some frustration—most babies can sleep six or eight hours through the night without feeding, and their brains are forming a regular nighttime sleep cycle. Hence, sleep experts commonly recommend initiating sleep training around this age. Winnicott argued that if a mother fulfills every wish of the baby for too long, the baby’s discovery of an external reality is interrupted. The baby will not learn that others have needs and that the world does not always conform to their wishes. Winnicott argued that a good enough mother is better than a perfect one, as perfectionism in parenting counterproductively sets unrealistic expectations for the child about the real world.
Instead of being the perfect parent, we’re all simply choosing what we believe will be the best for our child and family. Dr. Ferber’s advocacy for sleep training and self-soothing has long placed him at odds with Dr. Sears favored co-sleeping and attachment parenting approaches. However, in 2006 in a Day to Day episode distributed by National Public Radio (NPR), both authors finally conceded that different approaches worked for different parents. Reflecting on Winnicott’s ideas, reviewing the medical evidence, and observing our son helped me resolve my concerns and feel confident that sleep training was the right choice for us.
Ultimately, for myself, I met the good enough mothering standard in terms of sleep.