A Healthy Child Needs a Healthy Brain, A Healthy Brain Needs Healthy Sleep

HELP OR HARM

“Primum non nocere” is the Latin translation from the original Greek Hippocratic Oath that medical students take upon graduation, which I did in 1970, to become a doctor:

“First, do no harm”. 

Question: Do I harm my child if I allow my child to have unhealthy sleep?

Answer: Yes. According to the United States of America Department of the Army based on empirical data using traditional scientific methods: Unhealthy sleep is unhealthy for the brain (Blog Posts 1 through 5).

But the Army emphasizes that it is not a stark choice between either ‘help’ or harm’, but rather a matter of degree:

“Ultimately, the promotion of sleep health in the operational environment [Home, School, Playground, etc.] entails optimizing each Soldier’s [Child’s] sleep duration, timing, and continuity to the greatest extent possible, given existing mission constraints [Specific family circumstances]. The relationship between sleep duration and cognitive readiness (and thus military effectiveness) is best thought of as a continuum, with more sleep always producing improved performance. Therefore, to maximize brain health and functioning in an operational environment [Home, School, Playground, etc.], Soldiers [Children] aim to maximize sleep as much as possible with the constraints of the operation [Specific family circumstances]. 

As sleep duration increases, so does the likelihood of mission success [School tests, Athletic competitions, Public performances, etc.]. Effective leaders[Parents] consider sleep an item of logistical resupply like water, food, fuel, and ammunition. Sleep management optimizes Soldier’s [Children’s] performance in austere conditions.  

The goal in all operational scenarios [Home, School, Playground, etc.] should always be to maximize sleep duration because more sleep always results in greater alertness, resilience, and mental activity-greater readiness. When mission requirements [Specific family circumstances] do not allow for adequate sleep, the goal becomes twofold: to optimize alertness and performance during waking periods to the extent possible and to maximize the ability of Soldiers [Children] to take advantage of any opportunities for sleep that do occur.”

So, given the differences among families and children (Blog Posts 14, 17, and 20), parents experience different “existing mission constraints” or “constraints of the operation” and they try to “optimize” and “maximize” healthy sleep in their children “to the greatest extent possible”. Remember, even very small amounts of extra sleep can make a big difference (Blog Post 6)! So practically speaking, occasionally missing a nap or staying up too late may not be a big deal but a chronically too late bedtime might be a real problem. Just moving the bedtime only a few minutes earlier might be the only possible improvement, but, over time, the improvement might be huge (Blog Posts 6 and 7).

Question: Do I harm my child if I allow my child to cry at night in order to sleep better?

One opinion is that it is always harmful to ever let a child cry at night to help him learn to sleep better. Believers in this opinion might refer to various severe childhood traumatic events unrelated to sleep issues or studies of animals undergoing severe stress. 

However, there are factual studies published in peer-reviewed journals, based on the same type of empirical data using traditional scientific methods as did the United States of America Department of the Army, that ask the specific question whether allowing a child to cry at night to help him sleep better helps or harms the child.

All the studies agree: Children are not harmed (Blog Post 71). 

Some studies even show that if you allow your child to cry at night in order to sleep better, it helps children and mothers! For example:

• Journal of Abnormal and Social Psychology (1959): “No unfortunate side- or after-effects of this treatment [extinction] were observed.”
• Journal of Developmental and Behavioral Pediatrics (1991): “Extinction is an effective, reasonably rapid, and durable treatment for infant sleep disturbances. Mothers became less anxious as the study proceeded. The data is consistent with previous reports on improvements in parental self-esteem, depression, marital satisfaction, and sense of control. Some have argued, sometimes forcefully, against the use of extinction procedures with infants, on the grounds that such procedures will damage the infant-caregiver (mother) bond and impair the infant’s sense of security. A measure of infant security was explicitly included in this study to test this hypothesis, and again, the results are clear. Infant security significantly improved over the course of the study. We can reject the hypothesis that exposure to extinction will impair security.”
• Journal of Pediatric Psychology (1992): “There was no evidence of detrimental effects on the treated [extinction] infants whose security, emotional/tension, and likeability scores improved.”
• Journal of the American Academy of Child and Adolescent Psychiatry (1998): “Sleep training improves daytime mother-infant interactions.”
• Journal of Paediatrics and Child Health (1998): “Extinction improved problematic childhood sleep behavior and is associated with significant improvement in maternal mood.”
• Journal of Abnormal Child Psychology (1999): “Extinction and graduated extinction treatments improved bedtime and nighttime sleep problems and only positive side effects were associated with both treatments.”
• Attachment & Human Development (2000): “There was no relation between infant crying and secure and insecure attachment classifications.”
• Pediatrics (2003): “Graduated extinction reduced sleep problems and did not aversely affect later child behavior, maternal depression, or family functioning.”
• Sleep (2006); “Adverse effects were not identified. On the contrary, infants were found to be more secure, predictable, less irritable, and to cry and fuss less. Parents exhibited rapid and dramatic improvements in their overall mental health status, reporting fewer symptoms of depression, enhanced marital satisfaction, and reduced parenting stress.”
• Pediatrics (2008): “The intervention had a beneficial impact in reducing maternal depression symptoms and no evidence of longer-term adverse effects on either mother’s parenting practices or children’s mental health.”
• Early Child Development (2012): “By the third day of the program, all infants settled to sleep independently without a bout of distress, the fussing was less intense.” 
• Pediatrics (2012): “Behavioral sleep techniques have no harmful effect on measures of children’s emotions, behaviors, psychosocial functioning, child-parent closeness, or attachment five years later.”
• Pediatrics (2016): “Graduated extinction provided significant sleep benefits yet convey no adverse stress responses or long-term effects on parent-child attachment or child emotions and behavior. Mothers reported less stress after intervention.”
• Journal of Child Psychology and Psychiatry (2020): “No adverse impacts on leaving infants to cry it out in the first 6 months on infant-mother attachment were found.”
• Journal of Developmental & Behavioral Pediatrics (2020): “Cry out was not associated with observational measures of maternal sensitivity or infant-maternal attachment.”

For more information, see Blog Posts 67 and 71.

CORTISOL

As previously mentioned, one opinion is that it is always harmful to ever let a child cry at night to help him learn to sleep better. Believers in this opinion might refer to various severe childhood traumatic events unrelated to sleep issues or studies of animals undergoing severe stress (see above). They incorrectly believe that during the crying, elevated cortisol levels occur that not only indicate severe stress but actually harm the developing brain.  But the studies they cite are not specifically related to a child who is being allowed to cry at night in order to learn to sleep better. Here are the facts:

• During an Extinction study, among 6-month-old infants, children fussed and cried less, and cortisol levels decreased over the next 3-4 days.
• Among infants age 6 to 16 months, after a 3-month, randomized, objectively monitored study, all children were sleeping better and measurements of cortisol showed:

• Large decreases in the Graduated Extinction group.
• Moderate decreases in the Fading group.

“At the 12-month follow-up, there were no differences regarding secure and insecure attachment styles nor emotional nor behavioral problems compared to controls. We do not interpret these data as the infant ‘giving up’ but instead self-soothing. This is a crucial point when considering the chain of arguments that Graduated Extinction may lead to problematic emotions and behaviors in later child development. This hypothesis requires a significant and chronic cortisol elevation resulting from Graduated Extinction, yet it is further disconfirmed by our long-term emotional and behavioral findings.”

• Levels of cortisol dramatically decrease during a nap. Not taking a needed nap means that the body remains stressed.

So, during or after Extinction or Graduated Extinction and when sleeping better, there are lower cortisol levels. 

In contrast:

• Fragmented sleep in 12 to 36-month-old children was associated with elevated cortisol levels.

“The elevated cortisol levels were associated with more negative emotionality, social withdrawal, and appearing sad, nervous, or fearful.”

So, not sleeping well elevates cortisol levels.

(To be continued.)