Cry it out – The Misconception
When the “Ferber Method” is discussed, I have most commonly heard people say one of two things – (1) Cry it out, and/or (2) Cry till you puke.
I had the pleasure / privilege, of hearing Dr. Richard Ferber give a lecture. It was about 5 years after Medical School, and about 2 years into my Sleep Medicine practice. And I am embarrassed to say that I told some parents that they just need to let their kid cry it out. Also, frequently I do get parents that come in, say there kid does not sleep, and that they even “tried” to let their kid just cry it out.
3 Key Points
Dr. Ferber mentioned three things in his lecture that stood out to me till this day.
- If you need something to get to sleep, you will need that to get back to sleep.
- Kids are smart, they do what works, and they stop doing what doesn’t work.
- You are not teaching your kid to cry, you are teaching them to sleep and self soothe.
The third concept stood out to me most. It wasn’t so much a one-liner, but rather a concept. It is the concept of sleep association. His method revolves around sleep association, not cry it out.
Children do cry, But this is not unique to sleep
One thing that needs to be understood, is that the child will cry. This is not unique to sleep. There are times where you may discipline your child, you put them in time out, and they cry. The lesson is not that if they put there hand in a light socket you will make them cry, but rather the lesson is that it is a rule that you do not touch the light socket. And if they do touch the light socket, a rule has been broken and there are consequences when a rule of any-type is broken. — Same goes for sleep. However it is unfortunate that the name “Ferber Method” remains associated with crying to sleep.
Again, please refer to my discussion of Sleep Association if not done prior, or if a refresher is needed on Behavioral Insomnia of Childhood.
If your child cries the first day of school, Do they never go to school again?
Now you have created a routine that is associated with sleep, and you have developed tangible objects that will be there in the bed when the child awakens. The child cries. No parent wants to hear there child cry, we always want to love and nurture. However, you don’t take your child out of school because they cried the first day of kindergarten, you don’t abandon education. The concept is of Sleep Association, the reinforcement comes with the understanding that there may be tears. It is very important that you explain why something is being done. You would be surprised how much a child really can understand at any age. However even more so, if a concept is never explained that as they grow it will never be understood.
Concept: Kids are smart. They do what works. They stop doing what doesn’t work.
A parent’s mind is as logical as it is emotional. A parent may think they have to get to sleep and they need to rest. So the parent may give in and allow the child back into the parent room. The parent’s thoughts were very logical. However what the child perceives is if they cry loud/long enough, eventually they will be allowed back into the parent room.
Cry till you puke? Or are we thinking ahead?
Dr. Ferber addresses that fact that some children may “puke” when they cry. He states that if you recognize that this occurs, put an extra set of sheets on the bed. When the vomit occurs, go in and take the top sheet off to clean up, soothe the child for vomiting experience, but allow the child to learn to self-soothe for sleep.
Sleep Associated Object.
To these concepts, I would like to add to emphasize an object that is already in the bed as the soother. For my son, when I had to go back to the room I would first walk to Panda. Then Panda, with his deep silly voice, would tuck him back to bed. I would say, “Its OK Manuel, Panda and Puppy are here, no need to cry, time to go to sleep.
Overlapping developmental periods
Another concept that I like to discuss, are there are different stages of psychosocial development. I blend some of these concepts.
Erik Erickson describes a developmental period of Trust vs. Mistrust that occurs between Birth and 18 months of age. During this stage, children learn whether or not they can trust the people around them. When a baby cries, the caregiver attends to its needs. When these needs are consistently met, the child will learn that he can trust the people that are caring for him.
Also coinciding and overlapping Erickson’s Trust vs. Mistrust period of psychosocial development is Jean Piaget’s stage of Object Permanence that occurs around 8 to 12 months of age. Object permanence is the understanding that objects continue to exist even when they cannot be seen, heard, or touched. There is a time where if you cover a toy, an infant stops looking for it and seeks something else. Later during development, if you cover a toy, the infant will pull the cover because it recognizes that the object is under the cover and has not in-fact vanished.
The fact that the child is crying for the parent is good in many senses. This is more then just a positive spin. It signifies and reinforces that during the most crucial stage of development, Trust vs. Mistrust, the parent was indeed successful! — And this lasts a life time.
Parents need to also understand that Object Permanence is not just referring to toys and pacifiers, but to the parents as well. The child has already developed this and a parent may just not realize it. When you leave the child at a daycare or with another family member, the child does not think that the parent just disappeared and is lost forever. The parent later picks the child up and the child is happy to see the parent. — This should emphasize something else, the child indeed is able to transfer associations of soothing to other things beyond the parent. The child may have a favorite toy or story that soothes them in the other place of care. There are other associations that the child has already developed. If the child can do this in the daytime, why can’t they do this at night also. They can, and they will if it is cultivated.
Tough Love!
Another Psychological concept: Tough Love was coined by Bill Milliken, a definition of such is: The compassionate use of stringent disciplinary measures, to attempt to improve someone’s behavior. — My interpretation is that after disciplining your child, you also have to say “I love you”.
I blend several of these concepts together in trying to get a parent to be able to get to sleep in there own room, own bed. Sleep Association, Trust vs. Mistrust, Object Permanence, and Tough Love. I have many parents ask me, that if they don’t come to there child when they cry at night, will they lose the Trust from Trust vs. Mistrust.No. Importantly, Trust vs. Mistrust overlaps almost the first 2 years of life. Object permanence develops at 8-12 months of age, but continues to evolve as well to concepts rather then just objects. And, That is why you say I love you first thing when you put your child to bed as well as first thing in the morning.
Complications/Confounders.
A child may have a medical disorder, for example gastrointestinal, that may cause a child to awaken more then what is normal. My son for example was lactose intolerant, this was not realized until after almost a year of age. Similarly, my second child Jada Love, we tried to breast feed her as well. We noticed early whenever she had breast milk, very high in lactose, her stooling pattern was more frequent, watery, and she fussed more. Both of my kids slept better once the transition was made to Lactose free formula. For all the advantages that breast milk has, it was not able to be tolerated by our kids.
A child may have an impairment in understanding boundaries or social interactions. A child may early have problems with hyperactivity and impulse control. In many patients with Autism or ADHD, frequently the parent tells me that for years they noted there differences either to there kids or to other kids. And it is not coincident they had sleep problems as well. 50% of children with ADHD also have sleep problems. Children with Autism may have lower levels of urine and blood melatonin levels.
Certain children with brain malformations or brain injury may not have the same Circadian (sleep/wake) neuroanatomical pathways needed to establish a normal sleep/wake cycle.
And there may be sleep disorders occurring that could cause fragmentation of sleep architecture that cause more frequent arousal and/or awakenings.
Before Tough Love is implemented, consult with your pediatrician to ensure there is not a medical or developmental disorder that is causing the perceived disturbance. And this is not unique to sleep/wake discipline setting routines, but rather to any daytime discipline problem that may be occurring as well.
