Healthy Sleep Habits, Happy Child
71
Help or Harm Revisited. Does Extinction or Graduated Extinction Harm Mother-Infant Attachment? An Academic Debate (in Plain English)
March 21, 2022

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Healthy Sleep Habits, Happy Child

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Introduction

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

If you have not already done so, please read Blog Posts 1 through 5 that describe how sleep is important and beneficial. I will post specific information for parents and children based on my book, “Healthy Sleep Habits, Happy Child.” Please do not be put off by my book’s length. This is a reference book. Read only the topic of interest to you.

Blog 71Help or Harm Revisited. Does Extinction or Graduated Extinction Harm Mother-Infant Attachment? An Academic Debate (in Plain English)

A 2020 paper, by Professors Bilien and Wolke, concluded that “Contemporary practice of some parents in the United Kingdom to occasionally or often ‘leaving infant to cry it out’ during the first 6 months was not associated with adverse behavioural development and attachment at 18 months.” See Blog Posts 24 and 67.

• A 2021 criticism of this paper by Professors Davis and Kramer included:

“A lack of maternal response to crying may be associated with elevated cortisol…”. This is a false statement (Blog Posts 24 and 36).

“A sample that is too small may not be able to detect a ‘cry it out’ effect on attachment type.” That is, not enough children were studied by Bilgin and Wolke to make their conclusion.

• A 2021 response to the criticism of Davis and Kramer by Professors Bilgin and Wolke included:

“Only four studies, including ours, have been conducted to investigate the association between ‘leaving infant to cry out’ and attachment.” The original study of 26 mothers and infants (1972) revealed an association between leaving an infant to cry out and insecure infant mother attachment (1978). Subsequently, three replication studies have been conducted (2000 and 2 in 2020). “All of these three replication studies (365 mother-infant pairs) found no significant association between leaving infant to cry-it-out and infant-mother attachment”.

In contrast, it was the original study (1972) of only 26 children that did not include enough children to make any conclusions. However, Belgen and Wolke’s study of 178 mother-infant pairs was just sufficient to detect a difference between attachment classifications and yet no differences in security of attachment were found. “Thus, the evidence of no association between leaving infant to cry-it-out and attachment is based on overall 365 mother-infant pairs in three studies using contemporary parenting practices, while the only study finding an association included 26 mother-infant pairs. Thus, the substantial body of evidence shows no association with secure infant attachment.”

Also, the 26 subjects in the original study “were white, middle-class, infant-mother pairs in intact families who were contacted through pediatricians in private practices; all were stay at home mothers.  That is, its composition was highly selective, privileged without diversity, and there was no blinding and thus bias cannot be excluded. In contrast, both our and other studies used diverse and large samples and attachment ratings were made by an independent group of researchers blind to the exposure [did use cry-it-out or did not use cry-it-out] and research questions”. Determining attachment classification without knowledge of whether cry-it-out was used (blinding) is more objective than the situation where a single researcher assigns attachment classification and also knows whether or not cry-it-out was used. All researchers are all prone to biases; ‘blinding’ helps prevent biased findings.

“In conclusion, considering the evidence from three socially diverse samples compared to the original study, there is overwhelming evidence that letting a baby to cry it out a few times or even often has no adverse effects for infant-mother attachment formation during infancy. Rather, as has been shown over and over again, it is maternal sensitivity that predicts attachment security. In our study, we found that there were no differences in observed maternal sensitivity at 3 months between mothers who let their baby cry out a few times or not. Thus, leaving an infant to cry out a few times or often does not equate to insensitive parenting.”

Blog Posts 14, 17, and 57 discuss the subject of maternal sensitivity in the context of Emotional Availability.

Blog Posts 2427, and 36 also discuss the subject of help or harm when a child is allowed to cry at night in order to learn how to sleep better at night.

My name is Marc Weissbluth and I’ve been a pediatrician since 1973. This baby sleep blog will help you create a healthy sleep schedule for your child. My baby sleep advice and sleep training will teach you how to get a baby to sleep through the night. To stay updated with my latest baby and child sleep blog posts, be sure to subscribe today.

Comments

  1. My baby girl is 5 months and a half (will be 6 months on Jan. 1st). She is only able to fall asleep while I breast feed her, if I put her in her crib for naps or at night while she’s awake or drowsy she cries for a long time and won’t fall asleep on her own. What can I do? Should I let her cry it out?
    Her naps are never longer than 20 to 40 minutes, how can I get her to nap for longer?

    She also still wakes up between 3 and 4am every night and wants to be breastfed, and if I don’t feed her she cries a lot and I don’t have the heart to leave her there. How can I get her to sleep all night?

    Thanks so much!

    1. What is a typical 24-hour sleep pattern (times of falling asleep, duration of sleeping, duration of soothing to sleep)/
      What are you plans for duration of breast feeding and does she take a bottle of expressed breast milk?
      What does your husband want to do?

  2. I used to bathe her at 7pm and she would be asleep by 7:30/7:45pm.
    She gets a dream feed of formula milk at 10pm but would wake up between 3 and 4am wanting to be fed or comforted.
    And would be awake between 5:30 and 6:30am
    Then would take two or three 20 to 40 minute naps during the day here and there.
    Since two nights I’ve been bathing her at 6pm and she’s asleep by 6:30ish but still wakes up between 3-4am. And then was up at 6:30am.
    Tonight when I put her down while she was still awake at 6:30pm hoping she would self soothe, she cried for 50 minutes before falling asleep.

    My husband is open to anything.

    I’m planning on breastfeeding for another month more or less.

    Thanks so much for your help!

    1. Based on her brief naps, her bedtime is too late. Please read “Parents’ Reports’ regarding ‘Bedtime’ and the Blog Post on ‘Drowsy Signs’ and give me your thoughts regarding my opinion that the bedtime needs to be moved earlier.

    1. First, read about drowsy signs and move the bedtime earlier.
      Second, read Blog Posts about extinction and graduated extinction.
      Third, read ‘Parents’ Reports about extinction and graduated extinction.
      Then tell me what you would like to do.

  3. Hi Dr. Weissbluth,

    Our 3.5 month old struggles a lot with sleep, and I’m concerned we are not doing our job to teach him healthy sleep habits. At the recommendation of our pediatrician 2.5 weeks ago we began letting him cry himself to sleep at night time when he initially goes down. The crying gradually became shorter, but most nights he still cries for 15-20 minutes before falling asleep. He’s had a few nights with very little or no crying. The biggest improvement has been that he now sleeps for 4-5 hours after falling asleep, but after that he still gets up every 1-2 hours all night long for the most part. I breastfeed him when he wakes up simply because I’m so tired and it’s easier. Sometimes we still have a hard time getting him back to sleep after that. My husband is willing to help any time, but he isn’t always successful.

    Naps produce so much anxiety in me because I often have a hard time getting him down. After changing him and singing to him I will lay him down awake in his bassinet. He will fuss and then scream, so I end up bouncing him in my arms until he is asleep and then I lay him down. I may have to do this several times to get him to sleep, and after his first nap he often ends up napping in his vibrating chair the rest of the day.

    We also just stopped swaddling him prior to doing the extinction method at night. Could this be an issue that he’s adjusting to not being swaddled?

    His schedule is still not extremely consistent, but after our bedtime routine and crying he is usually asleep between 7-7:30 and then awake for the day between 6:30-7:00. He wakes up at least 3-4 times a night usually. He is ready for his first nap about 1 hour after waking up. His other awake times throughout the day are 1-1.5 hours. I try really hard to watch for his drowsy signs, but I must be missing them for most naps. He’s a pretty content baby so I only really notice yawning, fussing, etc. and I know it may be too late at that point.

    We have thought about doing the extinction method for naps, but I don’t think I can handle him crying for naps yet since he still cries at night time. I feel so bad for him when he’s crying. Do you have any recommendations?

    Thank you so much!

  4. I forgot to mention that he often takes one 1-2 hour nap in his vibrating chair per day, but the other naps are 20-40 minutes. I have my 4 year old at home most days as well, so I feel guilty spending so much time getting the baby down for naps.

    1. Please describe in detail the common schedule of sleep times for both of your children and any specific family circumstances that are relevant.
      Please repeat your specific concerns that appear in your comment on my Instagram reel.
      What exactly is your your major concern?
      How supportive is your husband?

  5. I have 2 other boys, ages 4 and 7 who are asleep between 7:00-7:30 every night. Then they are up around 6:30 a.m. for school. My 4 year old has preschool twice a week. I am a teacher, but I took off the rest of the school year. I have to take our 7-year-old to school every morning at 7:30 and pick him up at 2:30 due to my husband’s work schedule.

    My husband will get up any time in the night if I wake him to try and get our baby back to sleep. He’s also willing to be with our baby any time I need to get out or want to go do something with our big boys. We agree together on what to try to make sleep more successful for our baby, and he’s willing to continue any routines I’ve established.

    My primary concerns are:
    1. Should we continue with the extinction method initially at night time if he is still crying most nights after doing this method for 2.5 weeks?
    2. How can I help our baby sleep better at night after his initial 4-5 hour stretch?
    3. Is it bad that he takes only 1 nap a day in his bassinet (most of the rest are in his vibrating chair due to it being so difficult and time consuming to get him to sleep in his bassinet for naps) and how can I help him to go down for naps easier/self soothe, and nap for longer periods?

    Thank you!

    1. Thank you.
      For your 3.5 month-old, the main focus should be on night sleep, which becomes more organized after 6 weeks, because day sleep patterns develop around 4 months of age and become much more organized between 4-6 months of age. However, the expectation is that by improving night sleep now, his day sleep will also improve.
      Please describe a common day and night time sleep schedule plus duration of the sleep period for your baby: Times asleep, onset time for nighttime bedtime routine, and fall asleep time at night. Also describe his behavior and mood during the hour before he falls asleep at night when he is with toys but not screens or interacting with siblings and parents (he is alone and unattended to).

  6. We typically begin his bedtime routine around 6:30. However, the last 2 nights we began it at 6:00 to try and move bedtime earlier. When we began at 6:00 I put his PJs on, nursed him, sang to him and cuddled with him, and then laid him down awake by 6:30. He typically cries for 15-20 minutes before falling asleep. So, the last 2 nights he was asleep by 6:50/7:00. Both nights he then woke up around 11/11:30. I fed him, and he then slept another 2-3 hours. After that however, he wakes up every hour and it’s often hard to get him back to sleep even if I end up nursing him. My husband will try during these times. Sometimes he is able to soothe him back to sleep.

    He is then awake for the day around 6:45/7 and seems ready for a nap by 8:00. It can take me a good half hour to get him to sleep, but often he’ll do his first nap in his bassinet. He will sleep for 30-40 minutes. He’s then awake for another 1-1.5 hours and I feed him at the beginning of this awake time. Some days his 2nd nap is 1-2 hours long, but only if he’s in his bouncer/vibrating chair. He typically takes 4 naps a day (most are 30 minutes long) and awake times range from 1-2 hours.

    His temperament is pretty mild. He sometimes fusses in the evening during the hour before bed, but is usually easily distracted with toys or our interactions with him.

    1. If he actually fell asleep a little earlier during the last two nights, that is proof that his previous fall asleep time was too late.
      “He sometimes fusses in the evening during the hour before bed” suggests that his previous bedtime was too late.
      MY suggestion is to temporarily, for 4-5 nights only, begin a bedtime routine at 5:00PM and leave the room at 5:30PM (expected fall-asleep time). Monitor and record sleep latency, night wakings, wake-up times, naps, and behavior plus mood between 4-5PM. No nap is to start after 3PM but if he is asleep then, let him sleep. He may need intense soothing/distraction in the late afternoon/early evening. let me know how it goes.

  7. Hey, my 9 month old always seemed to have slept better with physical touch, so we let her sleep on us or next to us from the beginning. I exclusivly breast feed her. At night the easiest thing always was to just give her my breast and we both continued sleeping. For the first several months she took naps anywhere. (baby carrier, bed, ect.) as long as she had physical touch. The last 4 weeks she has been waking up every frquently (every 1 to 2 hours) especially during the second half of the night. I read your book and established a rountine for days/naps/bed time. Right now she is waking up inbetween 6.30 and 7am. Takes a 30min nap around 9.20 (in crip), a second 30min nap around 12.20 (in crip) and on some days a 3rd nap also 30min around 15.30/16.00. if she takes a 3rd nap she goes to bed around 19hr, if not around 18hr. then she sleeps for around 3 to 4 hours in her crip. (sometimes wakes up once inbetween to be held and put back to sleep). Then (this is around 10pm) she gets fed and then she sleeps another 2 hours in her crip. After that i am to tired to put her back down into her crip so i take her to bed with me and she wakes up every 1 to 2 hours. just wanting to have a few minutes of breast and then continues to sleep. My husband is willing to help me, but she just cries with him and does not really go back to sleep. (it wakes her more up instead of calming her down when he goes in). I dont really know where to go from her, but i am very tired and would appreciate your advice.

    1. Does your infant have any self-soothing skills?
      Do you think your child is well-rested or short on sleep?
      What are your goals?

  8. I dont think she has much of any self-soothing skills. She seems like a happy baby during the day. Just after her naps she always seems tired for another 20 / 15 min. I would like to have just 1 or 2 night feedings. (thats my main goal) of course it would be nice if we dont have to carry her anymore to sleep for all the naps and night time.

    1. Please read the first few chapters in my book to fully understand why learning self-soothing skills is a prerequisite to healthy sleep and why the absence of self-soothing skills causes cumulative sleepiness and sleep problems.

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