Tag Archives: Cortisol

An Interview with Professor Wendy Middlemiss – Controlled Crying, Cortisol and more….

In case you’re not aware of Professor Wendy Middlemiss, you should be. Her work is vital in opening society’s eyes to the potential damage that could be done to our infants by the inhumane way we treat them when we ‘sleep train’ them.

If you’re not aware of Professor Middlemiss’ research this is a pretty good summary in lay man’s terms: Babies left to cry feel stressed’ in the Telegraph. and here’s a link to the study abstract for those of you who like a little more science.

Here we ask Wendy about the inspiration behind her research and her vision for change.

 

Tell us a bit about yourself? 

Although born and raised in New York, I currently life in Denton, Texas. I moved here with my family about 5 years ago to take a position at the University of North Texas in the Department of Educational Psychology. The position provided the opportunity to focus my teaching and research on both educational psychology and development and family studies…something few positions offer. I have one son, who will be turning 16 years old this year. He has come to enjoy Texas and his high school experience.

wendy

What led you to your career?

  After college and working in New York in publishing, I found a brochure on the subway about a degree program in Educational Psychology. I had loved my psychology class as an undergraduate and thought—perhaps this would be great. The brochure made it clear that there were lots of things you could do with a degree in educational psychology. That interested me very much—and I think I have pushed the bar a bit in regard to what you do as an educational psychologist.

During my time at Syracuse University, I became very interested in learning more about how we raise our children, whether some of our research truly examined the intricacies of family life and looked with a clear lens into the different types of families and family choices. It was my sense that often research defined all families using one description—with then those families fitting that description looking very good and others, not truly being framed with their beauties and challenges clearly seen.

My work, since that time, has focused on how to better understand families and provide families with information that will help them raise competent children in a family context that fits their own family goals.

 

You are well known for your research into baby sleep training and cortisol levels, what led to you researching this? and do you have any plans to expand on this with more research?

It is always very easy to answer a question of …how long have you been doing this research [about infant sleep]… since the work started with the birth of my son. As a new parent, I had all the requisite nighttime care equipment—crib, bumpers, crib mobiles… everything… even a net for the top of the crib to keep out our cat. When I came home with my son, I didn’t feel comfortable putting him in this big space where I could hardly see him. So, I wanted to know… what is the recommendations about nighttime care, about where babies sleep, about what I need to do and need not to do as a parent.

Given my background, I started reading the research. What I found was, to me, very disconcerting and not as strong a body of research as made me comfortable about any choices. With this, I started to do a literature review… examining the research across the decade or so before my son’s birth. Then, I started asking my own questions. First I asked about the role of mothers’ comfort with sleep routines and babies’ outcomes—finding that it was mother’s comfort with a routine and not necessarily her choices of nighttime care, that were important to children’s later social outcomes.

Then, I started along the path of looking at questions of stress related to nighttime care routines that required having infants cry themselves to sleep. My path in research has always been to help clarify a particular part of nighttime care and provide helpful, clear information that parents can then adapt to their own care routines.

Thinking about the results of your research, why do you think there was an asynchrony between the mothers and babies cortisol levels after three days of sleep training?

Mothers and babies are so well attuned to each other and the communication is so subtle, but so strong. There is research examining microseconds of interaction that show how babies imitate mothers and mothers in return imitate babies… whether in sound, facial expression, or some other way. The research begins to help us see the importance of that synchronous interaction.

As infants grow, mothers and babies become more and more attuned when all is working well. Infants communicate so many different ways. However, with distress, their greatest communicating tool is crying—this is infants’ behavioral response to stress. When infants cry, mothers become attentive to their behavioral indication of distress, the crying raises mothers’ stress level—and together mother and infant resolve the distressing event and the mother helps the infants’ physiological distress response [related to the cortisol] dissipate.

When babies stopped crying during the sleep intervention, the mothers’ physical cue to their distress was eliminated. The mothers’ response to the apparent absence of infants’ distress, was a reduction in her physiological levels of stress. Almost an, ahhh, my baby is okay now…. I can be okay. You can almost imagine the possible relief a mother might feel when sleep had become such a distressing event.

Perhaps the most important part of that research was the finding that infants had been able to dissociate their behavioral response to stress, i.e., crying, from their physiological experience of stress. It wasn’t clear that infants had the ability to do that. However, that was what happened. Infants stopped crying, but their physiological distress remained. Without communicating this distress to mothers, mothers didn’t “see” the indicator of their distress. It seems that in this way, without this behavior cue in this setting, mothers and infants had a different response to the experience.

 

What advice would you give to an exhausted parent with a baby who wakes frequently throughout the night who is desperate for more sleep?

Find a way to find relief through greater support at night, changing the sleeping context so that there is more opportunity to sleep when the baby is sleeping, find someone who can help with night wakings. It is a hard question in some ways without knowing what options each parent has and what each parent finds comfortable to do. Babies will eventually sleep much better than they are when parents are in this situation…however, for many infants that will be months away.

Exhaustion is a real and taxing state of being. It is important not to dismiss the parents’ needs out of hand to alleviate the situation; equally important, is not to dismiss the infants’ needs out of hand. So, my advice would be to see what you can change to make things easier, without expecting that the infants’ sleeping habits may readily change. Sleeping is important for both parent and baby.

However, there are so many things in that care environment that are essential… safety, warmth, breastfeeding, responsiveness. I would advise that parents identify what is essential for care and then adapt what they can to make things manageable. I wish there were a simple answer… perhaps what is also helpful is for parents to know that there isn’t necessarily an easier answer, that sleep of all sorts is quite normal, and that this will pass. This sort of information and support has been found to be very helpful for parents.

If you could give a new parent just one piece of advice, what would it be?  

Love your child…for who they are and who they will be…

Provide them the love and comfort that will give them the security to grown to be the best of who they can be. Your child is a beautiful, lovely new being… who needs your love, comfort, and care. Let them be who they are and guide them to who they can be… accepting of their needs and their characteristics, but responsive in providing them with the tools they will need to be strong and successful… Then, I would assure them that the first tool is being responsive and respectful.

 

What support do you think new parents need? How could society change to offer this?

We need to provide parents with information about how important is their role in supporting and nurturing their child. We need to be honest in acknowledging that what infants and children need is not just restrictions but responsiveness and care. We need to provide families with the resources [information, financial, time] that provide them the opportunity to be parents.

 

What do you think about the current craze of ‘baby sleep experts’?

Any time information is provided in such a context that it tells someone exactly how they need to do something or precisely what needs to be done and when, then likely that information is only helpful to those who would like to engage in that parenting. Our babies, no matter their age, are our babies. We protect them by trying to give them what is the best. If we put together information without telling parents why something is helpful, then we do a great disservice more often than we provide helpful support. “Experts” who are willing to be “novices” in each family’s network, runs the risk of being unhelpful in the suggestions they offer.

Clever kid

Are there any experts in the parenting industry or other scientists in the field whose work you do admire?

I admire the work of those who keep trying to bring to the fore—information. Helpful, well-couched information that focuses on why something is needed and why it helps. Work of people, whether researchers, family practitioners, parent educators… whomever is there telling parents they are important to their children. Some of the people whose work I admire are strong, well-known researchers, such as Dr. McKenna or Shonkoff. Some are people who have taken up a battle but may not be well known, such as Dr. McManus, in Milwaukee.

Others I admire are those who have taken on the challenge of providing information and work tirelessly toward that end, such as Lauren Porter, and Liz Lightfoot and Celeste Pon all in New Zealand. People who, in the case of Lauren, have established Centre’s to continue to bring the message of how important is parents’ responsiveness to children, and Liz and Celeste, who work so tirelessly with parents. I greatly admire the work and energy of Stephanie Cowan who is director of Change for Our Children. She is a wonderful combination of innovation and caution, a woman who does.

 

But, I also admire the passion, if not the perspective, of those with whom I strongly disagree theoretically, about whom whose work I probably work tirelessly to put in a different light for parents. These researchers and policy makers have the same passion and often the same goal… the health and wellbeing of our infants, children, and parents. I hope that we find those common, essential elements that will bring our work together to provide information, clear information, to parents. Information that will protect our children.

Breaking News: New Study does NOT show ‘Sleep Training Babies Causes no Lasting Damage’

The study opens with this paragraph:

“Behavioral techniques effectively reduce infant sleep problems and associated maternal depression in the short- to medium-term (4–16 months’ postintervention). Despite their effectiveness, theoretical concerns persist about long-term harm on children’s emotional development, stress regulation, mental health, and the child-parent relationship. “

Behavioral sleep techniques did not cause long-lasting harms or benefits to child, child-parent, or maternal outcomes. Parents and health professionals can feel comfortable about using these techniques to reduce the population burden of infant sleep problems and maternal depression.”

crying-newborn1

Potential Methodology Issues Not addressed in the Study:

  • Sleep problems were ‘parent reported’, at 7mths a questionnaire was given with the question “Over the last 2 weeks has your child’s sleep generally been a problem for you?” 47% of respondents answered ‘yes’ and thus became eligible for trial inclusion. The ‘problem’ was not elaborated upon and I would have liked to have seen more questioning to ascertain exactly what the problems were, what had been tried until that point, what information the parents had received and what support had they received up until that point in those first important 7months as this time period could have a big effect.
  • The sample (out of those reported sleep problems) was selected by the researchers, I can find no mention of how they were selected and what other criteria was looked into in terms of the infant’s/family history/psychological wellbeing until that point.
  • Parents must have been open to the idea of sleep training to agree enrollment in the study, would this therefore mean that their opinions/beliefs were reflected in other parenting practices?
  • Training was carried out on babies 8-10months of age so cannot be applied to any infants younger than this. It also does not tell us the effects of training on older children/toddlers.
  • Parents were able to choose the type of sleep training used – either gradual extinction (what you and I know as controlled crying) or gradual withdrawal (parent starting out sitting with child and moving further away but involving no crying) – though no distinction was made between the type of sleep training used and later impact in the results.
  • Control/Intervention group allocation was blinded only to researchers not parents (understandably it would be tricky to be blinded to parents – but I wonder how knowledge that they were in the intervention group affected parental perception).
  • The control group visited the same nurses and were free to ask for sleep advice, but the nurses in these control groups were not trained to offer specific sleep training advice, however what advice did they give? Pretty much any parent I know could give controlled crying instructions without special training, do we know that they didn’t give similar advice to the intervention group? I cannot find this information out and to me from this point in the study loses all credibility for me – Do we know what the control group did sleep wise? We know they reported that they had had a problem with their child’s sleep in order to enter the study, so it’s pretty likely that they would want to do *something* – were they followed up and questioned and asked exactly what they did do? Again I can find no mention – How do we know that a large majority of the control group DIDN’T sleep train?
  • Outcomes were measure by cortisol samples, taken at 6yrs of age (why on earth would they take them at 6year of age?! I find this very confusing and not at all relevant? From what I can see the first follow up – and potential cortisol testing was at 10 months, yet the concerns over stress to infants from sleep training is during and in the immediate aftermath of the training, a sample taken 2 months up to 5 years later seems bizarre? Where is the cortisol sample DURING and IMMEDIATELY after the training? This is the one that matters IMO).
  • Child emotional questionnaires and ‘quality of life’ questionnaires were parent reported (and occasionally child reported) – meaning that parents filled in the questionnaires giving their own opinions. We know questionnaire reporting is notoriously unreliable with two main factors – 1) wanting to tell the investigator what they want to hear and 2) sticking to ‘middle of the road’ answers, i will add in 3) here – what parent will want to report that they feel their child has an emotional/behavioural difficulty? Especially not when they have been enrolled into a trial looking into the effects their early parenting may have had upon these. I find it very hard to determine whether the measures of psychological wellbeing were all parent reported as the results are very vague, but if I were to make an assumption I would guess that the majority were parent reported. Child reporting surely would include bias – what child would say negative things about their parents in front of said parents?
  • In terms of parenting style (and thus I presume eluding to bonding too?) the researchers appear to feel that “authoritative parenting” (high warmth, high control) is optimal parenting whereas what they call permissive parenting (high warmth, low control) is sub-optimal. I would argue that having “high control” over children is NOT optimal parenting, or indeed respectful parenting and am not convinced at all that highly controlling parents are those exhibiting the most healthy parenting style. I would like to see how they define “high and low control” and look to see how many initial “permissive parents” morphed into “authoritative parents” from the intervention group as a result of the training undertaken, this information though is not provided.
  • Nearly a third of the sample were lost to follow up (31%) – that’s a BIG number and a major limitation – what if they didn’t agree/respond to follow up because they found the intervention traumatic/it didn’t work for them/it went against their instinct?

cosleep

Perhaps the most interesting part of this research is this:

“There was no evidence that a population based targeted intervention that effectively reduced parent-reported sleep problems and maternal depression during infancy had long-lasting harmful or beneficial effects on child, childparent, or maternal outcomes by 6 years of age. Thus, this trial indicates that behavioral techniques are safe to use in the long-term to at least 5 years.”

Read that again, I’m pretty certain I dispute their claim that it has no long lasting harmful effects given the parental reporting, strange timing of cortisol testing, lack of information on what techniques the control group used, promotion of authoritative/controlling parenting as the optimum type, lack of information of life before 7 months of age (or in fact not much about life afterwards aside from financial questioning – what about childcare for a start) and lack of in-depth information about bonding (why no Ainsworth ‘Strange Situation’ type testing?). No the most interesting part to me is even with all of the above limitations in mind this research tells us there are NO LASTING BENEFITS to sleep training……Now which paper picked up on that then?! No, thought not.

So what DOES the research tell us?

  • There is still NO evidence that shows controlled crying under 8 months of age has no ill effects
  • The results did NOT differentiate between the different types of sleep training used (e.g: No Cry V Crying related options) in the results, therefore we do not know about the individual methods and their outcomes, only ‘sleep training’ as a broad label of many different types of training.
  • That sleep training does NOT have lasting positive effects on a child’s sleep behaviour
  • That nearly 50% of parents still have problems with their baby’s sleep by 7months of age (hey, perhaps that’s because it is NORMAL infant sleep and our expectations are incorrect)
  • That 31% of parents for some reason did not agree to follow up with the researchers
  • That parents tell researchers that they did not feel that sleep training affected their child negatively (tell me something new).
  • That controlled crying DOES work in the short term (I don’t think this has ever been disputed?).
  • That concerns over the effect of controlled crying on babies are still very valid, particularly in light of the recent Middlemiss study (that measured cortisol levels DURING training, not 5yrs later!) – A good summary of the concerns of sleep training can be read HERE.
  • That a whole lot more health professionals and  ‘baby experts’ are going to use this as arsenal to tell parents that there are no concerns with sleep training involving baby crying, that it’s a good thing to do, even if it feels wrong to them, as parents, to do it.

Sigh………..

Sarah (Founder of BabyCalm)

You can read more of Sarah’s articles HERE.

 

Reference:

Price. A, Wake. M, Ukoumunne. O and Hiscock. H. ‘Five-Year Follow-up of Harms and Benefits of Behavioral Infant Sleep Intervention: Randomized Trial’ Pediatrics;  September 10, 2012;