Risks of controlled crying

Taken from babesinarms.com

Posted by Bridget in - Bonding with baby -

Position Paper 1: Controlled Crying

Issued November 2002; Revised March 2004
The Australian Association for Infant Mental Health Inc. (AAIMHI)

AAIMHI aims (in part) to: improve professional and public recognition that infancy is a critical period in psycho-social development, and  work for the improvement of the mental health and development of all infants and families.

Definition

Controlled crying (also known as controlled comforting and sleep training) is a technique that is widely used as a way of managing infants and young children who do not settle alone or who wake at night. Controlled crying involves leaving the infant to cry for increasingly longer periods of time before providing comfort. The intention of controlled crying is to let babies put themselves to sleep and to stop them from crying or calling out during the night.  AAIMHI is concerned that the widely practiced technique of controlled crying is not consistent with what infants need for their optimal emotional and psychological health, and may have unintended negative consequences.

Background to AAIMHI’s Concerns

This statement is premised on an understanding of crying to mean crying that indicates distress, either psychological or physical, rather than the “fussing” that many babies do in settling or adjusting to different circumstances. Babies have to adapt to a totally new world and even small changes can be stressful for them. Leaving babies to cry without comfort, even for short periods of time, can be very distressing for them.  Crying is a signal of distress or discomfort from an infant or young child. Although controlled crying can stop children from crying, it may teach children not to seek or expect support when distressed.  Infants from about six months of age suffer from differing degrees of anxiety when separated from their parents. This anxiety continues until they can learn that their parents will return when they leave, and that they are safe. This learning may take up to three years.

Almost all children grow out of the need to wake at night and be reassured by three or four years of age, many much earlier than this. Infants are more likely to develop secure attachments when their distress is responded to promptly, consistently and appropriately. Secure attachments in infancy are the foundation for good adult mental health.  Infants whose parents respond and attend to their crying promptly, learn to settle more quickly in the long run as they become secure in the knowledge that their needs for emotional comfort will be met. The demands of Western lifestyles and some “expert” advice has led to an expectation that all infants and young children should sleep through the night from the early months or even weeks. In fact infants have the potential to arouse more often in the night than older children or adults because their sleep cycles are much shorter. These short sleep cycles allow infants to experience more rapid eye movement (REM) sleep, which is considered to be important for their brain development.

Many parents become distressed and exhausted when their infants and young children cry at night, in part because of the physical strain of getting up and going to their babies to re-settle them, and sometimes in part because of the unrealistic expectation that babies “should” sleep through the night. Many infants and parents sleep best when they sleep together. There is no developmental reason why infants should sleep separately from their parents, and in most parts of the world infants do sleep with their parents or other family members, either in the same bed, or in a cot next to the parents’ bed. There are certain conditions under which bed sharing should not occur, for example when a parent is affected by drugs or alcohol, or where the bedding is overly soft. Parents should check current information about safe sleeping; seewww.askdrsears.com or  www.sidsaustralia.org.au for more information.

Many parents find controlled crying helpful and this is one of the reasons for its popularity. For other parents it does not work, or causes so much distress for the parent and the infant that it is discontinued. There have been no studies such as sleep laboratory studies, to our knowledge, that assess the sociological stress levels of infants who undergo controlled crying, or its emotional or psychological impact on the developing child.

AAIMHI – Controlled Crying Principles

It is normal and healthy for infants and young children not to sleep through the night and to need attention from parents. This should not be labeled a disorder except where it is clearly outside the usual patterns. Parents should be reassured that attending to their infant’s needs/crying will not cause a lasting “habit”. Waking in older infants and young children may be due to separation anxiety, and in these cases sleeping with or next to a parent is a valid option. This often enables all to get a good night’s sleep. Any methods used to assist parents to get a good night’s sleep should not compromise the infant’s developmental and emotional needs.

If controlled crying is to be used it would be most appropriate after the child has an understanding of the meaning of the parent’s words, to know that the parent will be coming back and to be able to feel safe without the parent’s presence. Developmentally this takes about three years. This varies between children so observing children and responding to their cues is the best way to assess when a child feels safe sleeping alone. Full professional assessment of the child’s health, and child/ family relationships should be undertaken before initiating a controlled crying program. This should include assessing whether in fact the infant’s crying is outside normal levels. All efforts should be made to link parents with community supports to minimize isolation and frustration felt by many parents when caring for a young child.

Other strategies, apart from controlled crying, should always be discussed with parents as preferable options. If an infant or child has already experienced separation from a parent due to sickness, parental absence or adoption, or if he or she becomes very distressed, the method should not be used. This is because children who have already experienced traumatic separation are more vulnerable to negative effects from the kind of stress caused by controlled crying.

Where parental stress due to infant crying may lead to risk of abuse it is essential that parents be linked with social supports and therapeutic intervention. Parents should be told that the controlled crying method has not been assessed in terms of stress on the infant or the impact on the infant’s emotional development. Where it is used recommendations should be for exercising caution and playing safe. For example, paying attention to level of distress rather than number of minutes baby has to be left to cry, or not continuing with any technique if it does not feel right.

For further information about this document, contact Pam Linke on Tel: (08) 8303 1566.

Suggestions for alternatives to controlled crying:

Fleiss PM, Hodges FM & Phil D (2000).

Sweet Dreams: APediatrician’s Secrets for Your Child’s Good Night’s Sleep. Los Angeles: Lowell House. Hope M (1996).

For Crying Out Loud! Understanding and Helping Crying Babies. Randwick NSW: Sydney Children’s Hospital. McKay P (2002).

100 Ways to Calm the Crying. Melbourne: Lothian. McKay P (2002).

Parenting by Heart. Melbourne: Lothian. Pantley E (2002).

The No-Cry Sleep Solution. NewYork: Contemporary Books. Sears W & Sears M (2003).

The Baby Book: Everything you need to know about your baby – from birth to age two. New York: Little,

Brown and Company. Tracey N et al. (2002).

Sleep for Baby and Family. Sydney: PIFA.Tel: 02 82301646.A wide range of articles for parents can be found on: www.naturalchild.com orwww.askdrsears.com Dr Sears has some other

Bibliography:

The list below is not specifically for studies on the impact of controlled crying on infants because there are no records of such studies. The list has sources of general background information related to sleep and to understanding children and stress.

Bell SM & Ainsworth MD (1972). Infant crying and maternal responsiveness.

Child Development 43, 1171-1190.Blurton Jones N (1972).

Comparative aspects of mother-child contact. In: Blurton Jones N (Ed).

Ethological Studies of Child Behaviour. Cambridge: Cambridge University Press. Bowlby J (1973).

Attachment and loss: 2. Separation. Harmondswroth, Middlesex: Penguin. Dolby R (1996).

Overview of Attachment Theory and Consequences for Emotional Development. In: Seminar 15. Attachment: Children’s Emotional Development and the Link with Care and ProtectionIssues. Sydney: Child Protection Council. Hope MJ (1986).

Selected Paper No. 43: Understanding Crying inInfancy. Kensington, NSW: Foundation for Child & Youth Studies. James McKenna’s Mother-Baby Behavioural Sleep Laboratory. www.nd.edu/~jmckenn1/lab Keller H et al. (1996).

Psychobiological aspects of infant crying.Early Development and Parenting 5, 1-13. Lamport Commons M. & Miller PM. Emotional learning in infants: Across-cultural examination. Leach P (1994). Children First: What we must do, and are not doing – for our children today. London: Penguin.

McKenna J & Gartner L (2000).

Sleep Location and Suffocation: How Good Is The Evidence? Pediatrics 105, 917-919. McKenna J (2000).

Cultural Influences on Infant Sleep (abbreviated chapter) Zero To Three 20, 9-18. Mitchell EA & Thompson JMD (1995).

Co-sleeping increases the risk of SIDS, but sleeping in the parental bedroom lowers it. In: Rogum TO (Ed). Sudden infant death syndrome: new trends in the nineties. Oslo: Scandinavian University Press. Odent M (1986).

Primal health: A blueprint for our survival. London:

Century Hutchinson. Perry BD. Memories of Fear: How the Brain Stores and Retrieves

Physiologic States, Feelings, Behaviors and Thoughts from Traumatic Events.http://www.childtrauma.org/CTAMATERIALS/ Memories.ASP>Perry BD & Pollard R (1998).

Homeostasis, stress, trauma, and adaptation: a neurodevelopmental view of childhood trauma. Child and Adolescent Psychiatric Clinics of North America 7, 33-51. Trevathan W & McKenna J (1994). Evolutionary environments of human birth and infancy: Insights to apply to contemporary life.Children’s Environments11, 88-104.

Kangaroo care / Skin-to-Skin contact

I decided to do a piece today about the benefits and effects of skin-to-skin contact or as referred to as Kangaroo Care, between mother and newborn baby. This topic will discuss how skin-to-skin contact impacts early and successful breastfeeding initiation and extends exclusive breastfeeding duration.

Skin-to-skin contact has become more widely accepted and implemented into hospital policies because of it's many benefits. The World Health Organization launched a "Baby Friendly Hospital Initiative" in the '90 and so began the implementation of such practices as the above mentioned. For the history of the BFHI go here

So, let's go straight to the benefits of undisturbed Kangaroo Care for at least an hour after birth

*Babies are more likely to latch and get a proper latch
*The baby is less likely to cry
* The baby is more likely to breastfeed exclusively longer
*If left undisturbed, the healthy term baby takes an average of one (1) hour to orientate to the breast, attach and start to breastfeed.(This is known as the Breast Crawl in which a newborn infant literally crawls to his mothers breast unassisted in search for nourishment)Babies affected by medications used during labor and birth may require longer than one hour
*Baby adapts better, stabilizes temperature, breathing, heart rate and blood sugar levels
*Mother and baby imprinting is fostered with baby using the strongest newborn sense- smell
*Baby's hand and mouth contact with the nipple stimulates maternal oxytocin to enhance uterine contractions, milk let-down and mother-baby interaction and bonding.

Initiating breastfeeding after a vaginal birth

Unless a medically indicated procedure is required, ,immediate skin-to-skin contact with the mother is facilitated and continues undisturbed until the baby has had the first breastfeed, even if mother and baby has to be transferred. The baby is allowed to follow the normal sequence of innate feeding behaviors and initiates breastfeeding when ready.The staff should provide assistance by keeping the mother and baby together and encouraging the mother to recognize and respond to her baby's innate feeding behaviors

Initiating breastfeeding after a cesarean birth
Skin-to-skin contact between mother and baby should preferably be initiated in the theatre suite. Where this is not possible, a mother who has not had a general anesthetic is in skin-to-skin contact with her baby within 10 minutes of the time she arrives in recovery, unless a medically indicated procedure is required. A mother who has had general anesthetic should have skin-to-skin contact within 10 minutes of being able to respond to her baby. And the same protocol is followed as with a vaginal birth.

I would like to add though, that Kangaroo Care's benefits does not end once you get home. Regularly having skin-to-skin contact at home in the weeks and months to come is just as important and beneficial for mother and infant as it was right after the baby's birth

And how do we do it here in Aruba?
Having all of this said, I would like to apply this locally. In Aruba, unfortunately we do not have such a breastfeeding friendly hospital. Where skin-to-skin contact is concerned, my ob/gyn did place my daughter on my chest (not my bare chest though, and my daughter was wrapped up in a blanket because it was freezing in the L&D room. However, my daughter was taken away after about 5-10 minutes to be measured etc. I've spoken to our one and only IBCLC and RLDN (Registered Labor and Delivery Nurse)Marlene Giel, and she's explained to me that although they do encourage and implement kangaroo care to some extent, much improvement is to be made. She also explained to me that the HOH(Aruba's hospital) is in the process of adopting the BFHI (Baby Friendly Hospital Initiative). One day, hopefully soon, we will see more mothers enjoying skin-to-skin contact without unnecessary interruptions, more mothers having the choice to room in with their baby without having to be in a first class room. And more mothers enjoying holding their precious little ones without the snarl of "If you hold her, you'll spoil the baby".

To close this topic, Here I leave you with the most heart warming story I've read about a mother's love, read Carolyn Isbister's story about how skin-to-skin contact saved her severely premature baby's life

A lesson in Attachment Parenting and Gentle Discipline

This blog was inspired by a first time play date of my daughter Dahlia and my friend Noortje and her daughter Zoe



We were invited over for a play date of sorts. So excitedly we went, Dahlia and I. It was Zoe, Dahlia, Noortje and myself on the front porch watching the girls play with a play stove Zoe has. Everything was going well. Noortje's husband cut up some fresh watermelon and avocado for us and the girls ,and all ate and played happily. Then... Dahlia got interested in a bike (she loves "big girl" bikes) So, she went on it..much to Zoe's displeasure. And so it began. Dahlia and Zoe going mad.. Both were at one point screaming, then..after Noortje insisted that it is Dahlia's turn to ride the bike, Zoe lost it. Completely.. What I found so interesting wasn't the temper tantrum Zoe was throwing.. rather, it was the way Noortje was handling it..She sat there, cradling and holding Zoe tight in her arms while rocking her and shushing her softly. She empathized with Zoe and continued rocking her. I was so amazed and pleasantly surprised, because never in my life had I seen or heard of (on Aruba) a mother responding so lovingly to a screaming child. All I was accustomed of seeing was mothers yelling back and striking their children for such behavior, which in turn just perpetuated the tantrum even longer. I've seen the common method of leaving the child there to scream after being verbally punished. All of this is common to our island, but never have I beheld Noortje's method beyond my reading material.

I sat and spoke to Noortje about temper tantrums and she and I both expressed the same views about how to handle it. With love. patience. calmness. We were both so relieved to find acceptance and validation for our parenting methods. I had done some reading on the subject and am trying my best to implement it into our daily lives. Is it working? I'll find out soon enough. Is it worth it? Absolutely

What is this method I keep ranting on and on about? It's attachment parenting and gentle discipline. La Leche League International had a great article in their magazine entitled "Temper Tantrums"
In it Donna Bruschi explained that a child's tantrums is a cry for help. Further research into gentle parenting on websites such as Attachment Parenting.org shows that reacting to a temper tantrum with aggression and anger actually perpetuates and exacerbates the child's plea for help. Why does a child then, fall to the ground, kicking and screaming, and sapatia like we say here in aruba, and not just come to the mom and tell her what's wrong? Simple.. a child or baby, can't. What can they do then? Well, it's simple again, cry, LOUD. How we as parents respond to such behaviors has a big impact on the child's mental, emotional and physical well being and development

So..you must be wondering.. what AM I supposed to do then when my baby/child throws a temper tantrum. I'll put an excerpt from Donna Bruschi's article.

Stay calm, detached, and nearby, offering support as needed (as well as protection from sharp edges, traffic, and other hazards). The parent may have to restrain or physically remove the child to prevent him from hurting himself and others. If the parent finds herself getting upset, it is better to make sure the child is safe, leave the room, and calm down. If this is not possible, she should stop talking and breathe deeply. If this is not possible, she should try again with the next tantrum. She will handle tantrums better with each attempt.

The parent can reassure the child that she really wants to understand what is wrong. Help him to calm down. Only when he is reasonably calm should the parent continue. If the child gets upset again, return to calming techniques.

Ask the child what happened, and listen. Listen for the facts (the situation) and listen for the feeling (the emotion).

If he can't verbalize it, make suggestions and watch his body language for cues that you are on the right track. It may help for the parent to imagine herself in the child's place. Once the parent has identified the trigger, she can help the child to understand it. Common triggers are the inability to do a task or the loss of a favorite toy. Other triggers are fears, punishment, and separation from the parent. Aggravating factors can be exhaustion, hunger, and loud public places

Since reading this, I've tried it with my 19-month-old daughter too. My husband and I stopped responding with physical discipline and focused more on our daughter's emotions and feelings at that very moment. When she starts flinging and flailing her hands at me with the intention of hitting me, I grab her hands lovingly, tell her to look me in the eyes, and I calmly acknowledge her anger, her frustration and disappointment. I get down to her eye level and I verbalize her feelings and tell her that I understand how she feels and that it's normal to feel a certain way but that hitting is not an acceptable way to express those emotions. With what result? Well, our daughter has stopped hitting significantly, also, she does seem to respond more to us when we try to correct her. We hope and feel secure that she will one day (hopefully in the nearby future) learn to control her strong emotions better and that she will grow up to be an empathetic and loving human being.