Extinction (Going “Cold Turkey”)
When parents, however well intentioned, stop reinforcing a child's night waking, the habit can be eliminated quickly. In fact, psychologists have shown that the more continuous or regular you are in reinforcing the night waking during the first few months, the more likely it will rapidly be reduced simply by stopping the reinforcing behavior. The advantages of ending the habit of going to your baby at night are that the instructions are simple and easily remembered, and the whole process usually takes only a few days. But the seeming disadvantage is that a few nights of very prolonged crying are unbearable for many parents. This procedure strikes many people as too harsh, too abrupt, or cruel. Those are personal value judgments, but bear in mind that this procedure is effective. It works.
The sleep strategy that I have emphasized is called “extinction,” and the alternatives are “graduated extinction” and “check and console” (discussed on pages 214-215). An additional sleep strategy that might be tried at this age is “scheduled awakenings.” Parents note the approximate times when their child wakes up at night and then they awaken him before those times. The child is changed, if needed, and soothed back to sleep. Research has shown that extinction works much faster than scheduled awakenings but scheduled awakenings does work.
Here is an account of one mother who decided to stop going to her child cold turkey in order to eliminate her child's night wakings.
“ONE OF THE HARDEST
THINGS I'VE EVER HAD TO DO”
At six months of age, Stephen was strong, happy, and healthy in every respect but one—he didn't sleep well. He did all his daytime napping in the car, the stroller, or our arms. If we put him in his crib, he awoke immediately and cried until we picked him up. His nighttime pattern was different but equally exhausting. He went to sleep in his crib promptly at 8:00 P.M., but usually awoke within the first hour for a brief comforting, and two or three times between 11:00 P.M. and 5:00 A.M. for a feeding.
This routine was taking its toll. I was almost as tired as when Stephen was a newborn and I had no emotional reserve for handling everyday problems. I was sharp with the rest of the family and got angry if my husband was even ten minutes late getting home from work. We needed to make a change.
The doctor gave us explicit instructions for instituting morning and afternoon naps and unbroken nighttime sleeping. At the end of the appointment, I was full of resolve. We had the weekend ahead of us, when my husband would be around for support, so we decided to start that night.
We put the baby to bed at 8:00 P.M., and he awoke for the first time around 9:30. We didn't go in to him, and he cried for twenty minutes before going back to sleep. He awoke again around 2:00 and 4:00 A.M. and cried about twenty minutes each time. When he cried at 6:00 A.M., I rushed into his room, anxious to hold him and be sure he was the same healthy, happy baby I had put down the night before.
Over the next few days it was amazing to see how quickly he fell into the schedule we had set up for him. He cried ten to fifteen minutes several times, but never again for an hour. Now he naps regularly and sleeps all night, occasionally crying for one or two minutes during the night as he puts himself back to sleep.
Letting my baby cry was one of the hardest things I've ever had to do. Now that the experience is behind us, however, I have no doubt at all that it was right. It gave me more confidence in my abilities to handle tough issues as a parent.
PRACTICAL POINT
Small, soothing efforts such as kissing the forehead, rearranging the blankets, comforting, and patting appear trivial to parents, but they interfere enormously with learning to fall asleep unassisted.
A father told me that “it was painful for him and his wife to admit that what they had been doing was wrong and not good for their child.” What were they doing? At several months of age, they were going in about every two hours, every time the child cried a little. He said that it would have been much easier to blame or get angry with someone like me who said that too much attention at night was not good for their baby, and accuse me of giving bad advice, than it was to recognize that they were the ones responsible for her continued night wakings and irritability during the day. Another mother said that the reason some mothers and fathers have such strong emotional rejection of my advice is quite simple: parental guilt. Since they spend so little time with their child because they are both working, they feel bad and try to spend more time after work in the evening playing with their child. They cannot consider that the bedtime is too late for the child's health, so they conclude that my advice regarding early bedtimes must be incorrect.
HELPFUL HINT
Use thick layers of zinc oxide paste in the diaper region so that no rash will develop when you do not go to your baby at night to change diapers. Ordinary mineral oil will make removal of the paste easier in the morning.
Here are some typical questions and answers for this age group.
Q: I've heard that if I nurse my baby to sleep, I'll create a night-waking problem.
A: The issue is not whether nursing to sleep is good or not, but rather whether nursing too frequently or nighttime nursing is part of a night-waking problem. Please include nursing, if you wish, in nap time or bedtime rituals, but after you finish nursing, whether the child's asleep or awake, put her down, kiss her cheek, say good night, walk away, turn the lights off, and close the door.
Q: I heard that because she learns to associate my breast with falling asleep, she will be unable to return to sleep later in the night if my breast is not present.
A: Nonsense! Almost all the mothers in my practice nurse their babies to sleep, and at night, when they are hungry, either the mother nurses or the father bottle-feeds the baby. I believe it is perfectly natural to nurse a baby to sleep, and by itself this act does not cause sleep disturbances. Older children can be very discriminating; they can learn to expect dessert after dinner, if that is the family custom, but not after breakfast. I think babies can also become very discriminating; they can learn to expect to be fed when they are hungry but not to be fed when they are not hungry.
Q: Once I let my child cry a long time and she vomited. Won't I be trading one problem for another?
A: Consider other sleep strategies that involve less crying. However, if the vomiting always occurs, I think you will want to always go in to clean her promptly and then leave her again. If the vomiting is irregular and occasional, you should try waiting until after you think she is deeply asleep before checking, and then quickly clean her if needed.
Q: Won't my baby simply outgrow this habit?
A: Believe it or not, eighteen-year-old college freshmen who don't sleep well had difficulties sleeping as infants, according to their mothers, as reported in one study. It seems that if the child doesn't have the early opportunity to practice falling asleep by herself, she'll never learn to fall asleep easily.
Q: Even if she won't outgrow this habit, what's really wrong with my still going to her at night?
A: Consider your feelings. Good studies at Yale University show that all mothers eventually become anxious, develop angry feelings toward their child, and feel guilt about maintaining poor sleep habits. These feelings may persist for years. True, you will also feel guilty letting your baby cry in protest, but this will last only several days. Here's one mother's account.
“I FELT CRUEL,
INSENSITIVE, AND GUILTY”
The moment my daughter, Amanda, arrived home from the hospital, she exploded with a very bad case of colic. I took her to the pediatrician's office several times, only to be told there was “not a thing wrong, relax.” I also received several suggestions about nursing and a pat on the back. All of these suggestions irritated me, and I felt as though I was being perceived as an anxious, first-time mother.
After twelve weeks of crying and screaming, Amanda was evaluated by two child development specialists. I decided we should work with one until my daughter's crying and screaming settled down. We also saw a psychiat
rist, who recommended medication and also suggested that we continue to be followed by the development specialists. In the meantime, our lives had become a nightmare. Amanda cried most of the day and always screamed in the evening. To our horror, this behavior had worked itself into the night hours, too.
By five months, we were referred to Dr. Weissbluth for what we hoped was a sleep disorder. I say “hoped,” because we were at the point of seeing a pediatric neurologist and having an EEG done. I was very frightened for my daughter, and my husband and I were exhausted. I was eager for the consultation. My daughter had definitely been cursed with colic. Could this now be wired exhaustion from a sleep disorder caused by the treatment for colic—rocking, swinging, motion all the time? It was.
Amanda was old enough now to try “crying it out.” It was the most difficult thing I've had to do as a new mother.
The first night Amanda screamed, choked, and sobbed for thirty-two minutes. I remember feeling sick to my stomach.
The first two days weren't too terrible. However, the third and fourth were almost intolerable. Amanda would cry through her entire nap time. Then I would get her up to keep Dr. Weissbluth's time frame going. Her temperament after these episodes is known only to mothers who have been through the same ordeal! When she would scream for over an hour during nap time and in the evening, I felt cruel, insensitive, and guilty.
Three things kept me going: my husband's support; Dr. Weissbluth's concern, encouragement, and compassion; and the fact that I knew it had to be done—Amanda had to learn to sleep.
It took Amanda about a week to catch on to the idea. The bags under her eyes faded, her sporadic screaming attacks stopped, and her personality was that of a predictable baby—a sweetheart when rested and a bear when she's past a nap time or her bedtime.
I would offer these suggestions to other mothers and fathers who have to take this measure in order to teach their babies to sleep:
You, as parents, have to understand and believe intellectually that it is the right thing to do. Otherwise feelings of guilt will overpower you, and you will give in. You must have the support of your spouse, as it will be too much of a strain to bear alone.
You are doing what is best for your baby. It seems cruel and unacceptable as a loving new mother to let your baby cry. But it is a fact of parenting—many, many things will bring tears and protests in the years to come.
Enlist the support of a sympathetic friend as much as you feel the need to. I found close telephone contact a tremendous help. Some parents may not need this close interaction, but many of us do.
In your role as parents, teaching your child to sleep may be the very first difficult task you have to undertake. Those parents who do should feel a special sense of accomplishment, for it is a very difficult task! Those of us who have been through a baby with a sleep disorder know what misery is. But so does the baby, who is crabby and exhausted all the time. Once patterns and the practice of sleep are established, everyone benefits and finally life can be somewhat predictable again.
It will get better!
A few more typical questions and answers:
Q: I don't believe in this kind of unnatural programming.
A: Consider the “unnatural” effects of chronic sleep fragmentation on your child.
Q: I don't think I can do nothing when my baby cries for me at night.
A: Letting your baby cry is not doing nothing. You are actively encouraging the development of independence, providing opportunities for her to learn how to sleep alone, and showing respect for her ability to change her behavior.
If, after reading the preceding sections, you want to try allowing your child to learn to soothe herself to sleep but still feel you wouldn't be able to listen to her cry, consider the following:
WHY CAN'T I LET MY BABY CRY?
Unpleasant childhood memories. These may surface and remind you of feelings of loneliness or being unwanted.
Working mother's guilt. You may feel guilty about being away from your child so much.
We already tried and it didn't work. Maybe the child was too young then; maybe you taught her, by your behavior, that if she cried for more than a certain amount of time, you would go to her; maybe you unknowingly provided partial reinforcement by going to her at some times but not at others.
I enjoy my baby's company too much at night. This may be because you're not a good sleeper yourself.
If I don't nurse my baby at night, she might lose weight. This is not true.
We're under a lot of stress. In My Child Won't Sleep, Jo Douglas and Naomi Richman write:
If you are feeling stressed, your child may respond by not sleeping so well. If the stress is related to difficulties between you as parents, you may think that your young child will not notice, but the chances are that he will. His way of waking at night and coming into your bed can be a way of preventing you from talking to each other and sorting out your problems, and his presence can act as a useful contraceptive.
Although this quote applies to older children, it's possible that maintaining the baby's night waking or having the baby sleep with you when he or she is younger also serves the purpose of avoiding marital problems.
I feel that I am a bad parent if my baby cries. You are not a bad parent if you are helping your baby learn healthy sleep habits.
I am afraid that letting my baby cry will cause her permanent emotional harm. There is no evidence that protest crying while your child is learning how to sleep better will cause any kind of emotional problems later in life.
PRACTICAL POINT
When your overtired child first starts to sleep better during a retraining period, he may appear, in the beginning, to be more tired than before! You are unmasking the underlying fatigue that had previously been present but was hidden by the turned-on, hyperalert state.
Summary
Infants’ sleep patterns begin to resemble that of adults at around four months of age. It may help to think of sleep as having two related components. The first is sleep/wake organization, which means how long the sleep period lasts and when the sleep periods are occurring. The second is sleep quality, which here means whether the sleep is consolidated or fragmented and the duration of the different sleep stages.
Let's Walk Around the Clock
Here is the package of advice to prevent or correct sleep problems for children four to twelve months.
Control the wake-up time
Short interval of wakefulness (ultra-short for postcolic kids) before first nap
Consistent soothe-to-sleep method (A or B) for mid-morning nap, around 9:00 A.M.
Limited nap duration to protect next nap
No snoozing during period of wakefulness if mid-morning nap is not taken
Consistent soothe-to-sleep method (A or B) for early afternoon nap, around 1:00 P.M.
Limited nap duration to protect bedtime
Variable third nap; you be the judge (but no third nap after nine months of age)
Early bedtime (time varies based on how your child appears, the quality of naps, and past performance) with regular soothing routine
No more than two feedings at night up to nine months of age (exception: unrestricted if breast-feeding in family bed)
Action Plan for Exhausted Parents
Months Five to Eight: 16 percent have three naps, 84 percent have two naps
If your child is postcolic or has a difficult temperament put him to sleep, after soothing, within only one hour of wakefulness for the morning nap.
During the one hour of wakefulness, if possible, expose your child to bright natural light.
If he cries, leave him alone for at least ten to twenty minutes. If the child has an easy temperament, prepare to leave him alone for one hour.
Try to establish naps around 9:00 A.M., 1:00 P.M.; and if needed, a late-afternoon nap. Try to avoid naps at other times.
Month Nine: 5 percent have three naps, 91 percent have two naps, 4 percent have one nap
Eliminate
late-afternoon nap to protect early bedtime.
Months Ten to Twelve: 1 percent have 3 naps, 82 percent have two naps, 17 percent have one nap
Morning nap starts to disappear.
When morning nap starts to disappear, move bedtime twenty to thirty minutes earlier.
If afternoon nap starts to disappear because morning nap is too long, move bedtime much earlier to shorten the morning nap. Protect and preserve the afternoon nap.
If there is resistance for the afternoon nap, start the nap earlier.
Consider your resources for soothing (see page 73).
If resources are limited, go slowly and tackle one problem at a time—for example, bedtime battles.
Healthy Sleep Habits, Happy Child Page 32