Sleep training

from Wikipedia, the free encyclopedia
Sleeping baby

Sleep training (also: sleep training , sleep training ) is used in the upbringing of older babies and toddlers . Most children learn on their own to find sleep when they are tired and sleep through the night until they are sufficiently refreshed. Sleep training is used with children who are unable to do this and aims to empower them to fall asleep on their own and without further assistance.

In the Western world , around 20-30% of all infants, toddlers and preschoolers have trouble falling asleep and finding their way back to sleep during normal nighttime wakefulness. It is assumed that sleep disorders of this type are primarily due to three causes: 1. Parents failing to respond to signs of tiredness in their child; 2. Poor sleep hygiene (e.g. inadequate sleep during the day, lack of slowing down phases or irregular bedtime); 3. the child's getting used to parental sleep assistance. For children and parents, problems falling asleep and staying asleep can cause great suffering. Bringing the child to bed is regularly accompanied by shouts of anger. The phases of nocturnal crying and elaborate parental interventions mean that the child and parents do not get enough sleep. If the parents are even less able to perceive the child's (tiredness) signals due to stress and insomnia, the process becomes self-reinforcing.

Sleep training is intended to help reduce the child's acquired dependency on the parental sleep aid and improve sleep hygiene.

Childlike sleep patterns

Around the 32nd week of pregnancy, the unborn child's REM sleep begins to show cyclical patterns that change into fully developed sleep cycles around the 36th week - i.e. four weeks before birth; In addition to REM phases, these also include long periods of peaceful sleep. Even before birth, the child reacts to the mother's movements and begins to adapt its wake-sleep rhythm to hers.

However, newborns still sleep 12-16 hours a day. Supports u. a. In terms of hormonal development, the 24-hour rhythm matures further in the first 2-3 months after birth. During the first few weeks of life, infants initially sleep an average of 3–4 hours during the day, later they take naps 1 to 2 times a day. Healthy children at full term are usually physiologically able to get along at night without feeding by the age of 6 months. The frequency of nocturnal awakening hardly decreases in at least two thirds of fully breastfed infants in the first six months, and all infants wake up briefly on average 2 to 6 times per night. A third to half of all children under one year of age - in English technical jargon they are called self-soothers - are then able to calm themselves down and go back to sleep on their own; the parents usually do not even notice such waking up. Children who are used to being laid down when they are tired but still awake are “more calming”. They can usually be laid down to sleep without much effort.

The mechanisms that control the child's sleep rhythm - unlike those of adult sleep - have not yet been fully researched.

Prevention of sleep problems

One way of preventing sleep problems from developing is to stick to fixed sleep times, an adequate (i.e. not too high) level of parental interaction with the child when going to bed, as well as when the child wakes up at night and lies down when the child is tired but not yet asleep .

Some authors also recommend daytime naps and adequate sleep to prevent fatigue

Psychologist Lisa Adams (Arkansas Children's Hospital) and pediatrician Vaughn Rickert ( University of Arkansas ) found in a clinical study that children who are put to sleep as part of a good, calming, and emotionally warm bed-going routine, cry less before going to sleep than children who are less carefully put to bed. If the child associates tiredness with pleasant experiences, this promotes his autonomy to fall asleep. Bed rituals can e.g. For example, the parents give the child a bath about 20 minutes before they are scheduled to go to sleep, read or sing to them or listen to music with the child. The child then transfers the comfort of falling asleep independently to half-awake at night.

Children of parents who had attended relevant parenting courses before birth slept significantly better in clinical studies than children of untrained parents. Children who use transitional objects such as cuddly blankets , cuddly toys or pacifiers and who are thus able to calm themselves down in the absence of their mother are less prone to sleep problems.

Behavioral sleep problems of childhood

Research has only been concerned with sleep problems in children since the mid-1980s. Childish sleep problems, the causes of which lie in the educational environment , are often referred to in the English technical jargon as infant and toddler sleep disturbance (ITSD, "sleep disorder in infants and toddlers"). In the classification system of the American Academy of Sleep Medicine , ICSD , the phenomenon is called behavioral insomnia of childhood (BIC, "behavioral insomnia of childhood"). Full dyssomnias according to the internationally recognized classification system of the American Academy of Sleep Medicine are rarely diagnosed in children; In order to still be able to classify the disorders presented here, the developmental psychologist Erika Gaylor ( SRI International ) has developed a nosology for child protodyssomnias , i.e. for pre-forms of dyssomnias. A distinction is made between two types: problems falling asleep (in the first 24 months of life: more than 30 minutes) and problems sleeping through the night (in the first 24 months of life: more than twice a night). Often both come together.

Around one in four babies cries persistently when they are put to bed for a nap or for a night's sleep, need the help of their parents (rocking, feeding, holding on) to fall asleep, and they also wake their parents up screaming during the night. In the English technical jargon, such children are referred to as signalers ("signal givers"). Infants who are accustomed from the first few weeks of life to being nursed to sleep or cradled to sleep in the evening usually also require this when they wake up during the night. First-born children are affected slightly more often than their younger siblings. Many mothers of children with sleep problems have histories of problematic attachments.

Scope of sleep training

Sleep training is not suitable for children who have immature sleep-wake patterns, nor for children who are breastfed at night. Since object permanence - i.e. the knowledge that parents are still there when you cannot see them - does not develop in children until the second half of their life, many researchers recommend not starting sleep training until the end of the 6th month of life. In younger infants, sleep disorders can appear as a regulatory disorder as a whole (see also: Excessive crying in infancy ); the problem should then be discussed with the pediatrician.

If there are traumatic fear of abandonment, sleep training is not suitable even after the age of 6 months; this particularly affects children from families with severe psychological or addiction problems. If sleep problems arise in such cases, a behavioral psychologist should be consulted.

Sleep problems in children can also have physical causes, for example pain, such as those associated with colic , gastroesophageal reflux (" heartburn "), hand, foot and mouth disease or with infectious diseases of the upper respiratory tract ( colds ). Sleep training is tailored to children whose sleep problems obviously have no physical cause but are acquired . In this case, the parents have made the child accustomed to until he falls asleep e.g. B. rocked, nursed, carried or driven around in the car, and only to be laid down asleep.

requirements

A tired baby

The prerequisite for all of the methods outlined below is that the parents recognize early and unequivocally when the child is tired. This is not always the case, especially with inexperienced parents. Also, not all babies behave the same; Yawn z. For example, some children can be an early sign of drowsiness, while others only begin to yawn when they are already very overtired. Children who are not sufficiently tired are just as difficult to calm down as those who are already excessively tired.

Typical signs of fatigue are: inattention, staring, turning away, avoiding social interaction, sensitivity to noise, frightfulness, clumsy or slowed motor skills, jerky movements of the legs or arms, arching the back and neck, twisting the body, rolling the head, stretching or spreading the fingers , Disinterest in toys or food, tugging ears or hair, rubbing face and eyes, worrying face, frowning, grimacing, drooping eyelids, sucking fingers and objects, grunting, yawning. In some children, tiredness is initially noticeable through increased liveliness.

Signs of fatigue are: the aforementioned signs in connection with crying, indifference and irritability; Fighting against sleep; the child is restless when held in his arms, but refuses to be laid down.

Method overview

A meta-study presented in 2006 by a team of researchers at Saint Joseph's University in Philadelphia showed that most of the methods of sleep training commonly used today are very effective and bring great benefits to children and parents - as long as the parents feel comfortable with them and use the method consistently .

All of the methods described here aim to induce the child to cry and cry before falling asleep by not being encouraged by parental attention. This creates the conditions for the child that it needs to learn to calm down on its own and to fall asleep and stay asleep without parental help.

Unmodified weaning according to Weissbluth ("Cry It Out")

The pediatrician Marc Weissbluth , founder of the Sleep Disorder Center at the Lurie Children's Hospital in Chicago , is considered the most well-known proponent of a method that is called Unmodified Extinction in the English technical jargon . The method is popularly known in English-speaking countries as "Cry It Out" (for example, "let screaming out").

The method is to put the child awake in bed as soon as he is tired and leave him alone for the night; Shouting is ignored unless the child, e.g. B. vomiting, apparently really in need. In a clinical study, the method led to a reduced cortisol (stress hormone) level in the mothers after 3 days, but the cortisol level in the infants increased, even if they appeared to be calmer.

Gradual weaning according to Ferber

The neurologist and pediatrician Richard Ferber ( Harvard University and Boston Children's Hospital ) recommends a graded variant of sleep training, which is known in the English technical jargon as Graduated Extinction ("gradual weaning"). Other terms are Check and Console ("control and comfort") and Controlled Crying ("controlled crying"). In German-speaking countries one speaks of "Ferbern" (as a verb) or of the Ferber method ; Here the team of authors Annette Kast-Zahn and Hartmut Morgenroth ( Every child can learn to sleep , 1995) advocated the Ferber method.

With this method, too, the child is put to bed in a tired but still awake state and left alone. On the first night, if the child screams for so long, the parents look after 3 minutes for a short time afterwards, talk to the child soothingly and possibly rub his back, but do not pick him up. The second check takes place after 5 minutes; all further checks are carried out every 10 minutes. In the next few nights, the intervals between the control visits to the screaming child are extended according to the specifications in the following table until they reach a maximum of 30 minutes. Checks only take place while the child is crying and do not take more than 15 seconds to complete. The table only shows the basic idea, the numbers differ slightly for some authors.

Night no. 1. Control 2. Control 3. and every
further check
1 after 3 min. after 5 min. after 10 min.
2 5 10 12
3 10 12 15th
4th 12 15th 17th
5 15th 17th 20th
6th 17th 20th 25th
7th 20th 25th 30th

This method has also been examined many times in clinical studies and has been confirmed to be efficient. For some children it was effective in a few days, but for others it took up to 4 weeks. Many parents get so stressed during this time that they stop training.

Weaning with parents present

In this method, known in English as the "Parental Presence" method, one parent sleeps for a week in the same room as the child, in a separate bed that is visible to the child. When the child is tired, it is laid down with a short ritual; the parent lies down in his own bed and pretends to be asleep. After the child falls asleep (after more or less screaming), the parent has the choice of either sleeping too, or getting up and returning when they are tired themselves. If the child wakes up and screams at night, verbally reassures them for a few minutes, then the parent protects them from falling asleep again. After the first week, the parent no longer lies down by themselves, but either leaves the child alone or, as long as the child is crying, comes for a brief check every 5–10 minutes (similar to the Ferber method). If the parent has their permanent bed in the same room, they will not lie down until they are tired. The representatives of the method report that children scream less with this method than with the methods according to Weissbluth or Ferber, and that it leads to the child falling asleep after a week.

Some authors also classify co-sleeping as a method of sleep training. In scientific studies, however, an effect of this practice on the child's ability to fall asleep independently has not yet been proven.

Gradual weaning

Many other methods have been described in the literature how parents can step by step take back the help they have given their child to sleep. The author Kim West recommends z. For example, one parent may initially sit on a chair next to the cot to soothe the tired, screaming child; Over a period of several weeks, the chair is then removed further and further from the bed until it is finally on the other side of the door. Methods in which the parent moves further and further away from the child are also referred to as "camping out" in English.

The author Elizabeth Pantley, who is close to William Sears and Attachment Parenting , recommends first of all to improve the bed-going routine and then to wean the child sensitively and without a fixed procedure in very small steps from the parental sleep aid. The child should only be put down at the last moment before going to sleep, but should be picked up again if it starts to cry again. Pantley's method is known in the United States as the No Cry Sleep Solution , but it takes several weeks to complete and is less reliable than the above methods. In the German-speaking area, Karl Heinz Brisch made similar recommendations.

Additional interventions

For children who wake up at set times at night and then do not go back to sleep unaided, some researchers recommend a method known as Scheduled Awakening . The child is woken up 15-30 minutes before the expected nightly awakening and then calmed down so that it falls asleep again. The child is initially woken up regularly, but after a few days it becomes less and less frequent in the hope that the child will now wake up less easily. The method is not considered very reliable.

criticism

One of the sharpest critics of any sleep training is William Sears , who has been trying to popularize attachment parenting since the early 2000s . Sears advises parents never to let their children scream, and is convinced that long screaming, as is the rule in sleep training , can lead to brain damage in children due to increased cortisol levels .

However, the study cited by Sears on stress-induced developmental disorders in children does not name the cause of crying before falling asleep (in an otherwise happy childhood), but rather scenarios in which children - such as B. in Chinese or Romanian orphanages - were seriously neglected or mistreated. The authors later complained about Sears' misrepresentation of their findings. In another study that described connections between excessive screaming and decreased intelligence, which Sears also refers to, he ignores the fact that it did not investigate the effects of sleep training at all, but a sample of screaming children who had neurological disorders. which may have caused both : intellectual retirement and excessive crying. Sears has also been accused of incorrectly referring to studies that do not support his theses in other cases.

The accusation that sleep training is cruel and does not represent an education but rather a punishment of the child is one of the standard criticisms of almost all opponents of sleep training. In German-speaking countries, Herbert Renz-Polster has spoken out against sleep training. Criticism of sleep training is also expressed on Internet forums ; For example, in 2013 a mother started a petition against the new editions of Kast-Zahn's and Morgenroth's books, but was unable to collect the necessary number of signatures.

Clinical studies on risks and benefits

Possible harm from sleep training

Educational psychologist Wendy Middlemiss and others conducted a study at the University of North Texas in 2012 that observed children with sleep problems and their mothers during five days of inpatient sleep training. The study showed that the children had elevated cortisol levels during the sleep transition phases (when their mothers made them scream). They screamed less on the third day, but continued to have elevated cortisol levels during the sleep transition. The mothers, on the other hand, only had elevated cortisol levels as long as their children screamed a lot.

The clinical study published in 2012 by Anna MH Price's research group with 173 six-year-olds concluded that children who received sleep training as infants did not differ in any way from children who were not trained in terms of emotional development, mental health, closeness to their parents and parenting were. Another study by the same research group, published in 2012, looked at the long-term fate of children who received Ferber's sleep training or the camping-out method at the age of 8 months; These children also showed no psychological abnormalities 5 years later. The studies were criticized because of several methodological weaknesses: About a third of the study participants no longer took part in the follow-up examination after five years, especially families with a disadvantaged social background; the sleep training for the infants was not standardized but could be chosen by the parents themselves; the control group was not checked for possible self-initiated sleep training.

The American Academy of Sleep Medicine recommends the "Cry It Out" method as the standard method for treating child behavioral sleep disorders.

Use

The benefit of early sleep training is to save children who turn out to be "signaling devices" from having problems later. Long-term studies have shown that unresolved sleep problems in infants have a tendency to persist into preschool and school age. They can disrupt the physical, emotional, social and cognitive development of the child, lead to obesity and have repeatedly been linked to ADHD . Sleep problems in children can disrupt the parent-child relationship; In addition to persistent screaming, they are the second most common trigger for infant abuse , which for example leads to shaking trauma. Parents who do not get enough sleep due to their child's sleep problems are more prone to relationship conflicts and, especially the mother, to depression . A long-term study found that the mothers of sleep-trained children were less likely to develop depression than the mothers of the comparison group. Depression in the mother is a major cause of attachment and other mental disorders in children.

literature

Web links

Individual evidence

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  26. ↑ Jodi A. Mindell, Brett Kuhn, Daniel S. Lewin, Lisa J. Meltzer, Avi Sadeh: Behavioral Treatment of Bedtime Problems and Night Wakings in Infants and Young Children. Sleep, Volume 29, Issue 10, 2006, pp. 1263-1276.
  27. ↑ Annette Kast-Zahn, Hartmut Morgenroth: Every child can learn to sleep. Graefe and Unzer, 2013, ISBN 978-3-8338-3618-3 ; "I don't want to know how many parents have yelled at and shook their children at their children." Retrieved February 8, 2015 . Die Welt, April 30, 2006.
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  29. ↑ Michael Gradisar, Kate Jackson, Nicola J. Spurrier, Joyce Gibson, Justine Whitham, Anne Sved Williams, Robyn Dolby, David J. Kennaway: Behavioral Interventions for Infant Sleep Problems: A Randomized Controlled Trial . In: Pediatrics . May 2016 ( abstract ).
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  32. ^ The Ferber method: An evidence-based guide to "cry it out" sleep training. Retrieved February 3, 2015 .
  33. ^ The Parent Present Sleep Training Method. (No longer available online.) Archived from the original on February 3, 2015 ; Retrieved February 5, 2015 . Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. ; Parental presence: step-by-step. (No longer available online.) Archived from the original on February 8, 2015 ; Retrieved February 5, 2015 . Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / www.honestparenthood.com  @1@ 2Template: Webachiv / IABot / www.kidspot.com.au
  34. ^ For Getting Baby to Sleep, Sticking to a Plan Is What Counts. Retrieved February 3, 2015 . New York Times, December 12, 2006.
  35. ^ Sleep Training Methods Demystified. Retrieved February 5, 2015 .
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  37. ↑ Elizabeth Pantley: The No-Cry Sleep Solution: Gentle Ways to Help Your Baby Sleep Through the Night. McGraw-Hill, 2002, ISBN 0-07-138139-2 ; German edition: Elizabeth Pantley: Sleep instead of scream. The loving sleep book , Trias, 2nd edition, 2014, ISBN 978-3-8304-8004-4 ; Elizabeth Pantley's website. Retrieved February 7, 2015 . ; No-cry sleep training. Retrieved February 7, 2015 .
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  41. ^ Joan Kaufman, Dennis Charney: Effects of early stress on brain structure and function: Implications for understanding the relationship between child maltreatment and depression. Development and Psychopathology, September 2001, pp. 451-471.
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