How NOT to write about the science in sleep training literature.

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As someone who has devoted her life to empirical research, it is really, really hard to read journalistic accounts of “studies” which totally miss the mark.  In my younger years as a hungry PhD student, I taught methods labs to aspiring political scientists and double-majors in journalism at a university with a top J-School.  My job was to teach them to read actual science and to teach them how to write about that science.  Through the course of the semester, we would all embark on a maddening adventure.  I would coach them through research questions, literature reviews, research designs, and eventually teach them to conduct their research and analyze their results using statistical software.

Still, there was one topic that mattered more than anything else.  Secretly it was the one I hope they took away the most from my course.  I would teach them how to write about science.  I told them if I taught them nothing else this semester, I would hope they would grow to understand what words to use and not use and what things to look for in an abstract. I am in no way a phenomenal writer.  This comes from years of writing dry manuscripts, work reports, and large agency publications.  My husband, the one with the English degree who proofed my dissertation, thinks I am hopeless due to my use of adverbs.  However, I do believe (and have been told) that I teach students how to read science well.  When you are training baby journalists who will go on to work at top publications, this is about the best you can do.  I took that job seriously and still take the job of teaching people these skills seriously when I get the chance.

There are many areas in the age of blogging where people get it wrong.  They write a piece to attract readership or ad dollars.  I also write a blog.  I get it.  However, the areas in mommy and parenting blog land that seem to attract the most attention seem to be topics like breastfeeding and cry-it-out (CIO).  I was taken to task on my personal facebook page this week after a friend linked to an article about the evils of CIO.  She’s an attachment parent (as are basically all of my friends in real life) and doesn’t believe in it.  The comments on the article were certainly disparaging.  Reading them, I realized they think I am an evil parent because I sleep trained my kid.  I can assure you I’m not.  Still, while that drives me to write a post, that’s not my axe to grind.  Instead, upon researching this all, I’ve determined the shoddy coverage of sleep training studies is appalling and we need to “know better, do better”.

 

There are five important ways sleep training articles miss the mark in covering science properly.

STRIKE ONE: Articles are written in a lopsided manner that discounts at least half of the literature on the subject. Love sleep training or hate it, there is a lot of literature on the subject.  The best way to look unprepared is only cite articles that support your point.  This approach isn’t just a poor way to send an article out for review.  It’s also a very unethical way to write about anything in a “news” section of a paper.  If your audience is a news-devouring public, you need to take heed.  A great example of this is in Denene Millner’s piece for Huffpost which is so kindly entitled “Cry It Out: The Method That Kills Baby Brain Cells”. The only piece of “evidence” cited in this article is a think piece by Dr. Darcia Narvaez, a very vocal critic of sleep training at the University of Notre Dame, which hosts a number of cosleeping resources.

It is plain as day that and Narvaez and her colleagues lean much more towards attachment parenting, which is fine.  However, her piece in Psychology Today hardly “proves” that brain cells are killed during sleep training.  Narvaez cites many studies based on mice about cortisol.  Her conclusion about the relationship between cortisol levels and brain development isn’t one.  She asks

“Who knows what neurons are not being connected and wiped out during times of extreme stress… What deficits may show up years later…?”

That’s it.  No “X causes Y” because Dr. Narvaez and I both know the external validity of rat studies on human subjects can be limited and that we don’t determine causality in human and social research.  We’ve both had methods training to discourage such talk.  So, Ms. Millner’s clickbait title is lopsided an inaccurate – even based on her source material’s actual account.

Well done articles are like this one from Slate written by Melinda Wenner Moyer.  Moyer presents evidence both for and against and makes a reasonable conclusion,

“Crying-it-out is not for every parent, I know. But desperate parents—or parents who just want to be done with the 2 a.m. wake up— should feel fine trying the method. It’s not just that there’s no evidence of harm in crying-it-out—there is some solid evidence of no harm. When sleep training works, and research suggests it often does, it can provide long-term benefits for the entire family—giving babies the sleep they need to develop into healthy toddlers and giving parents the rest they need to be sensitive, confident, and happy caregivers.”

What is good about this?  She says “we have good evidence this is not harmful and it can be helpful to your family” and doesn’t say “babies should be sleep trained” or “it is right for everyone” or “science shows sleep training is the best option” because none of that is true or supported by science.

I tried so hard to find an article that was completely above and beyond for sleep training with no exceptions but every good article that cited evidence was just there to show sleep training was not evil/harmful and that people should choose the method that worked for their families.  I was desperate to find something that just shot down all of the literature against CIO and overreached but I couldn’t find that in about 3 days of googling.  Readers, if you find such an article, I beg of you to forward it to me via the comments, my contact info, or twitter!

 

STRIKE TWO: Articles on the subject aren’t sure what CIO is or provide inaccurate accounts of what sleep training is to mislead readers.

If you are going to write about a scientific concept or phenomena, you should be sure to properly define it first..  Operationalization is a word my husband would wish I’d stop talking about but it means measuring what you set out to measure.  When discussing how something causes harm, you need to define what you think causes harm – your independent variable – before you can say it causes harm.  Cry it out is described in some of these articles in the most disturbing, wrong ways.

Amy Wright Glenn writes for the Philly Voice.  In her articles in the “Screaming to Sleep” series, she describes the most awful scene.  A set of parents put down their 5 month old to sleep at a rigid bedtime before he is ready.  He screams so much he often vomits, they tell their childfree friend.  Their childfree friend is, understandably really upset.  Heck, I was upset reading this and I’m sure my pediatrician would be, too.

The reality is that sleep training is a lot of different things to different people.  It has many different uses, methods, and justifications.   The baby sleep podcast Precious Little Sleep recently addressed how much they hate the term “cry it out” because it doesn’t accurately describe what sleep training is.  Sleep training is just an umbrella term that often covers so-called “no cry” or “gentle” solutions as well as the “nuclear” exhaustion method.  PLS uses, instead,  the acronym “SLIP” or “Sleep Learning Independence Plan”.  Basically, sleep training is anything you do for your baby to help them wean off of sleep associations (cosleeping, bedsharing, using the boob as a pacifier, last feeds, pacifier, bouncing, swing, whatever).  It doesn’t mean your kid will scream and scream.  It doesn’t mean you ignore your child in the night every time they wake.  You still respond to their needs in other ways.  PLS has a great resource on their website for how to start night sleep training (and also you can find one for naps).  Their podcast is fantastic and brutally honest.  It’s a must-have for any parent of young kids and I listen regularly.

So, even a person is opposed to exhaustion sleep training (leaving a baby to cry before they put themselves to sleep) in any manner, SLIP/sleep training should be applied to a number of other applications that we all do and don’t label “cry it out”.  However, you will find that most people who write about sleep training to demonize it refer to it simply as CIO and only discuss exhaustion (also applied in awful ways).  The sleep training handbook my pediatrician gave out gave me links to the Baby Sleep Site and PLS.  Both advocate removing associations gradually and one at a time.  Anything you read on either site or listen to will tell you not to sleep train when your kid is sick, to do it at the right age (5 months may have been far too young to start for the baby in the article above) and to do what feels right.

In my case, I had a 5 month old going through her 6 month regression.  Her issue was not night waking (she hadn’t done that since 6 weeks) but she wanted to stay up practicing flipping over, crawling, and reaching.  Once we got her to sleep, she’d sleep all night.  Without sleep, she was miserable.  We tried everything before we had to do exhaustion.  There were some 10 minute screaming sessions but since Ferberizing didn’t work for her (it just made her very mad), after 2 or 3 days, she went down basically as soon as we put her to sleep.  We waited to do this on a day she did not have serious teething troubles and was no longer reacting to a cat allergy we believe she has.  Since then, she usually goes down about 3-4 minutes after she is put in her crib and sleeps 10-12 hours a stretch.  Sleep training was the only way to soothe our overtired kid but it didn’t look anything like the account Glenn details.  I think often moms talk past one another when they discuss these terms.  And, as new parents, if we haven’t encountered a subject personally, we may not be that familiar with the specifics.  I thought all bedsharing sounded dangerous until I began to read McKenna’s safe sleep guidelines and talked to friends who were doing that sort of sleeping.  It’s very important that when we write about parenting topics that are very polarizing, we defined our concepts with strength.

 

STRIKE THREE: Sleep training is equated with neglect or cruelty and studies regarding serious cases of neglect are used to bolster claims that CIO is cruel parenting and damages childhood attachment to parents.

There is a great explanation of why sleep training is not cruelty on Skeptical Mothering.  The research that Narvaez cites as showing CIO leads to bad parental attachment has very little external validity in this application.  Often cited in accounts which suppose there most be some link between CIO and bad attachment are the Romanian Orphan studies which showed that a lack of involvement leads to severe decreases in intellectual capabilities and attachment.  Another study cited specifically by Narvaez is that of Blunt Bugental et al. (2002) which looks at children already at risk for mistreatment from families living in extreme poverty to determine what can negatively impact attachment in babies.

It is impossible to compare the outcomes of children in Romanian orphanages and those growing up in extreme poverty to children that have many more resources and more attentive parents.  Saying that leaving your child for 10 minutes to cry and leaving your child for 12 hours to cry is comparable seems completely irresponsible.  Articles that treat these cases the same need to look up what “validity” means.  It isn’t the relationship above.

 

STRIKE FOUR: All of these studies have limitations – those both in support and against sleep training – but many articles on CIO don’t discuss these issues.

Many articles against CIO talk about mice studies.  While mice often proxy for humans and both humans and mice are mammals, there are many differences between us.  There are limitations for mice and rat studies in terms of validity across most areas of medical science.  Mice have many different behavioral patterns, have shorter life-cycles, are far less intelligent than humans, and have different needs.

This is not to say that rat and mice studies cannot be used in this discussion.  Not at all.  In fact, sometimes animal studies are all we have.  You cannot easily study infants in a lab setting and control for all factors because you can’t breed a group of infants and raise them all the same except for one factor.  There is a reason we now have IRB’s.  Still, we need to be careful of limited validity of conclusions we draw.  And, even when we do try to study infants in an ethical fashion, we find that studying them in lab conditions may be the stressor and not different methods of putting them to bed.

In other cases where humans are used, there are issues of SES status (see above) which seem to create an issue of selection bias.  It is difficult for children to overcome the harm of systemic poverty.  Comparing those children to wealthy children in good public school districts who have not a care in the world is just not fair.  Outcomes will be different. Another large issue is sample size.  Samples are often small.  Thus, all conclusions must be taken with a grain of salt.  These studies don’t generate highly generalizable conclusions and shouldn’t be treated as the word of god – nowhere near!  An example is in a recent study from 2016 which made the rounds.  Forbes says it “could be best for most babies” but the study has an incredibly small sample and should be taken with a grain of salt.

 

 

STRIKE FIVE: The need for parental sleep is never included in these articles.

One of the serious problems with all parenting commentary is that it focuses on the outcome of infants as the sole outcome of note.  Look, babies come first.  No parent on earth would disagree with you.  However, your medical professionals will tell you to treat parenthood like an emergency landing in an airplane – you have to put your O2 mask on first so you can help the child next to you.  This is why women like me who can’t breastfeed on meds but need those meds choose formula or why parents go back to work after determining stay-at-home-parenting is not right for them and makes them sad and lonely.  You have to take care of yourself so you can take care of others.

Sleep deprivation is real, people.  We know that sleep deprivation causes accidents behind the wheel.  The NHTSA estimates about 100,000 car accidents and 1,550 deaths each year can be attributed to drowsy driving.  Similarly, research also shows you may become a far less happy and nurturing parent with a lack of sleep.  No matter if you feel happy or not, your face and expressions may show up as less happy and more sad or angry to your baby.  Thus, if you want to foster attachment, a lack of sleep may really undermine your goals.  Finally, in women suffering from postpartum depression, there is an association between worsening depression and bad sleep patterns.  If your baby is not sleeping, you are a danger to yourself and others and you can’t bond with your baby to the best of your abilities. 

Since sleep makes everything easier and a lack of it can make or break your mood and function, the need for moms (and dads) to sleep should be a big consideration taken into account when you decide to sleep train or not.  And if you are one of the judge people who thinks moms sleep train to “be lazy” or “not be parents” you should take note: everyone’s life situations differ from yours.  I’m glad you wrote an article about how you think it’s evil and your kid never needed it.  However, I can assure you that me ending up in a institutional facility would not have improved my baby’s secure attachment to me.  I know that sleep is a huge trigger.  Everyone is doing better when mom and dad sleep.  If we are to cite research, let’s be as holistic about it as possible.

So, when writers with no science background describe these studies and use words like “prove” or “cause” which are deterministic without also accounting for limitations, they do us all a disservice.  If there was one thing I wrote all over papers, it was the statement  that “WE DON’T PROVE IN SOCIAL SCIENCE.”  As social scientists, we can’t say x causes y.  We can say x is associated with y.  That’s the best outcome we have.  Medical trials can sometimes be deterministic in their conclusions but they still don’t go as far as to say “we cure all cancer in all patients” because even the most effective treatments don’t work on all human subjects.  Math is a perfect science but regression analysis is not when it’s applied to people.  Thus, when we talk about conclusions, it is important to read what the scientists find is problematic in their research.  Hint, hint, this will be in the “discussion” section of most peer-reviewed articles!  As someone who has had my own work taken curiously out of context, I can’t begin to describe how misleading and frustrating this is for researchers who devote their life to a given topic.

In the end, we all need to do a better job of discussing science and be very specific about what we know and don’t know.  We can say with a review of the literature that extreme neglect is inevitably harmful for babies, that widely-used and appropriately-conducted sleep training is not shown to knowingly harm infants who are otherwise well taken care of, and that the literature needs more work to say definitively what methods are best and which may not be effective.  We can also say that sleep training or the decision to not use certain methods should absolutely be a decision made by parents for their families.  It is not just a decision made in regards to a given baby but also in regards to everyone’s sleep goals and needs.  There are so many valid reasons to decide not to use sleep training or certain types of sleep training and so many valid reasons in favor of this approach.  Everyone should stop being shamey about the evil of cry it out.  And, honestly, if you hate it, write a ton of blog posts about it but leave science out of it if you do.  Chances are, if you start using evidence to support your claims and only support your claims, you may be doing it misleadingly.

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