Monday, 5 December 2011

Crying It Out - The Damage We Can Measure, The Damage We Can't

'Crying it out'...'controlled crying'...'sleep training'....when I had my first baby nearly four years ago, I was told that I needed to do it by everyone from my hair-dresser to my Baby Massage teacher, who handed out badly baked cakes and half baked parenting advice and told me my baby would never sleep through the night. The practice of leaving a baby to cry alone in a cot in order to encourage them to learn to be less dependent on their parents at night is so common and widespread in our culture that it is considered an absolutely normal if not essential part of a baby's first year. The number one best selling author of childcare books in the UK, Gina Ford, recommends it in several of her books, and even the NHS endorses it: on their website and in the book 'Birth to Five', handed out to all new mothers in England, they state:

By the time your child is six months old, it’s reasonable to expect them to sleep through most nights. If there’s no obvious cause, and your child continues to wake up, cry or demand company...teach your child to get back to sleep by themselves. First check that everything is alright. If it is, settle your child down without talking to them too much. If they want a drink, give them water but don’t give them anything to eat. For this approach to work, you need to leave them in their cot or bed. Don't take them downstairs or into your bed. Let them cry for around 5-10 minutes before you check on them. Over the next few nights, gradually increase the amount of time you leave them before checking. It might take a week or two but if you keep the routine going, your child should start falling asleep on their own.

This approach is understandably controversial; CIO is probably the most hotly debated topic in parenting forums and facebook groups. Those who are opposed to it denounce it as 'dangerous', sometimes even stating that it 'causes brain damage' and is tantamount to child abuse. On the other side of the fence, those who have used such methods on their own children claim that it is entirely harmless, and that a happy and well rested mother equals a happy baby. So who is right? 

In such instances it's helpful to look for actual concrete evidence, but, I'm sorry to say, there isn't any. That is, if you're looking for a study that says, 'We took twenty babies, left half of them to cry alone for prolonged periods, while we cuddled the other half, and the ones we left crying grew up to be miserable, whilst the ten we hugged are all happy well adjusted adults.', well, you're just not going to find it, for obvious reasons. Not only can we not treat babies this way in the name of scientific research, but it would also be impossible to separate out the night time sleep training from the myriad of other factors that contribute to the development of a person, successful or otherwise.

What we do know is that stress produces the hormone cortisol, and that this can and does have an effect on the brain, particularly a tiny and rapidly growing one. One study has shown that too much cortisol can affect  the development of the orbitofrontal part of the prefrontal cortex, the part of the brain thought to be most concerned with our social and emotional interactions. Another study suggests that the hippocampus may also be affected, with its numbers of cortisol receptors being reduced by early stress, leading to a reduction in the growth of the hippocampus itself and thus a reduced ability to cope with stress in adulthood. And from studying Romanian orphans, who were left in their cots and entirely deprived of love and affection, we can see just how much of the brain's development is dependent on responsive human interaction - many areas of their brains being visibly less active and 'a virtual black hole where their orbitofrontal cortex should be' (Gerhardt, 2004). 

All of this evidence, (and there is much more available), is telling us something: stressful experiences have a negative effect on our babies, and love, responsiveness, cuddles and touch have a positive effect. But how much stress does just a week or two of 'controlled crying' actually cause? Can we be sure that this is going to cause real lasting damage? Or will it just be a negligible 'blip', and worth it in the long run for the sake of a good night's sleep? Maybe we just need to switch off our baby monitors and get it over with? Right?

For me, crying it out is about more than cortisol, as valid and concrete as that evidence might be. For when we switch off our baby monitors, we switch off another connection - the two way radio we share with our babies from their very first moments of life, the delicate dance of the mother child dyad, the vital and vibrant message of unconditional love and care. When we shut the bedroom door and walk away, we are required to turn off our emotions and our instincts in a manner that, unlike cortisol, cannot be measured, but may damage our attachment, our essential link to our small child, in subtle and far reaching ways.

And what of our babies experience? Like much of their first two or three years, they will almost certainly have no real memory of being left to cry. For some people, this alone makes the practice acceptable. But I can tell you from my own work with adults who have experienced severe trauma as babies, that, whilst they cannot actually recall the painful events themselves, they nevertheless remain affected by them for the rest of their lives. Often the fact that the trauma occured at this 'pre-verbal' time can make it even harder for them to process and overcome their difficult feelings, by which they remain constantly haunted but which they are unable to name or articulate.

A baby left crying will not, as a relative once assured me, 'soon learn that it's not going to get them anywhere'. In fact, a baby or small child has great difficulty 'learning' anything of this nature, as their understanding of concepts like cause and effect / time / reward and punishment are extremely limited (as anyone who has ever tried the 'If you don't put your socks on we are not going to the park' approach to parenting will testify!) What they do learn if they are left crying is that nobody is responding to them, in that present moment, and that it feels awful. They will learn that they are 'helpless', and some babies, although not all, will eventually give up crying for this reason. Often it is said that CIO teaches a baby to 'self soothe', but how can you learn to 'self soothe' if you don't yet have a full concept of 'self'? A small baby doesn't yet understand themselves as a separate person - this happens gradually, and it's not until around 18 months that a child can even look in a mirror and understand that they are seeing their own reflection.

Rather than learning to self soothe, a baby left crying may instead be learning how to 'split off' or dissociate. This is one way of coping with trauma or distressing events that threaten to overwhelm us - to go somewhere else. If we can't escape in our body, we can in our mind. As a parent, we can help a baby or child to learn how to cope with distress by the way that we ourselves respond. If we take our child in our arms, hold them, say soft words, and offer calmness and love, they will begin to learn how to make this a part of themselves, and how to respond in this way to difficult situations without our presence or help. But if our child is in distress, and no one is there to hold them? They may learn that the only way to deal with such intolerable feelings is to escape. Later in life, this desire to drift away from the pain instead of facing it may manifest itself in the form of addictions, eating disorders, and other serious mental health problems.

Of course, not all babies left to cry will end up with major difficulties in later life. Like everything else, there are degrees of damage, some obvious and clear, some subtle and barely noticeable. We all deal differently with distress, and perhaps it's worth pausing for a moment to consider what you personally do when your emotions are rising and churning. Do you reach for a drink, a cigarette, a sleeping pill? Do you eat more or less than you need? Do you write, do you run, do you paint pictures, do you drive your car too fast? Do you think you cope well with distress, or is this a difficult area for you? And now that you've thought about this, here's another one - how do you deal with the distress of others? When your baby is crying, what happens to you? How do you respond, in your body, in your breath, in your mind, in your heart? What do you find easier to contemplate - leaving your baby to cry alone, or holding your crying baby? If we find if hard to cope with distress, CIO might seem a better alternative than nights spent giving comfort, and so the cycle continues.

Distress is complicated, and we are all of us damaged in some way. As parents, we are in the game of damage limitation. In our material world, a baby who sleeps through the night is highly prized, they are a 'good baby', they are likely to have less negative impact on our youthful looks and our earning capacity than a baby who wakes up often and renders us tired and inarticulate. But if the good baby comes at the price of CIO, is it worth it? I think not. This might feel like bad news if you are sleep deprived and desperate. But I can tell you from personal experience, that your child will eventually sleep more deeply, more independently and for longer stretches, no matter what you decide to do. Suddenly, rather like childbirth, the pain is over, and you are in a new phase, with its own new challenges. And both you and your child will be intensely glad that you didn't risk causing damage, not just to the orbitofrontal cortex or the hippocampus, but to your relationship of love, trust, kindness and comfort, through which your child is learning so much about how to find this comfort in themselves.



34 comments:

  1. Wonderful article. Truly wonderful. Thank you.

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  2. I think that most people just don't understand how damaging CIO is. Neglecting a childs basic needs is NEVER the right solution to a problem. Something interesting to consider is that in the majority of cultures CIO would never be okay; it would be likened to child neglect. It is only in Western culture that some of us seem to think it is acceptable treatment. Thank you so much for writing this.

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  3. Very well written, thank-you.

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  4. Great synopsis Mama Mule! Can I add, that the baby not only feels 'helpless' but 'hopeless', and effectively has given up trying to reach out to its parent when it stops crying. How this would affect the levels of trust the baby feels is anybody's guess.
    The other long term effect that his sort of unmanaged distress can have on a baby is a reduced ability to empathise as an adult. Do those babies grow up to be the adults who find it easier to do CIO on their own babies?

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  5. After one more sleepless night this is just what I needed. Thank you for reminding me of why I do what I do.

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  6. Thank you all for these comments!
    I stayed up very late to finish this and then had a bad night with a one year old who 'needed' me a lot, so feel very tired and brain dead today, but when I read this feedback I feel glad I bothered!
    xxx

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  7. Great article, such a controversial subject, but essential that these damaging beliefs are challenged. Good on you for taking the time to write this article, I appreciate it and will add it to my list of resources to share with parents.

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  8. Thank you very much Genevieve, I am getting some wonderful feedback on this piece so I'm very glad I wrote it. I do rather wish that it wasn't needed though! I hope one day it will only be of historical interest ;-)
    xxx

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  9. I may have got it wrong but if your saying distressed crying can cause brain damage of different levels, how am i supposed to feel. Like your proving my fears of being a bad mum. My son is lactose intolerant and wasnt diagnosed for 10 months so each day he would scream uncontrollably for 4-6 hrs and no one, even doctors could help us. So what may i ask have i done to my son for not realising earlier. Take a moment to think about how i now feel. I hope no one else whos baby had colic or other un diagnosed problems from birth reads this cos im sure they will be thinking the same as me. Cheers

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  10. Great article! But as the mum to a very colicky 2 mo old, these discussions just make me feel worse. We have done everything we can think of to keep our little girl from crying but sometimes the safest and best thing is to put her down in her crib and walk away. I hate doing this and reading about the effects of unattended crying just adds to my hurt. I wear her in a carrier all day and by bedtime I am too exhausted to walk/bounce her to sleep. So more often than not she cries herself to sleep in her cosleeper while I try to rock/sooth her and cry myself. Please consider that for some families putting a crying baby down is a last resort and done for the baby's wellbeing and safety. I am not selfishly trying to get her to sleep so I can get my beauty rest, I put her down and sometimes walk away so I don't accidentally hurt her in my frustration and exhaustion.

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  11. To the first Anon, no, I am not saying that 'distressed crying can cause brain damage.' I'm saying, 'it's more complicated than that', and the main thing I am saying is that offering comfort is the most important thing we can do as parents. Both my own babies had 'fussy evenings' and cried a great deal from about 6 weeks onwards, which I found terribly hard. But myself or my partner would hold them and try to offer comfort as best we could. It is holding and comforting that is of such great importance.
    To the second anon I do hope you are getting some support. Perhaps you are finding the distress of another person hard to cope with, as I described in my article. To both of you I reiterate that holding a crying baby is NOT the same as a baby crying alone.
    A good article to read is: http://www.awareparenting.com/comfort.htm
    Warm wishes to you both xxx

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  12. Hello!

    I am finishing my degree in Biology and I don't have any kids of my own so I feel hesitant to respond to this post. I don't know what it is like to be a mother and to hear my child cry. I can't even come close to understanding what moms have to do when a baby is crying relentlessly.

    What I do know is that I was an extremely colicky baby and that must have been hard on my mum. Apparently my tongue was too long and it made it hard for me to breathe but the doctors weren't sure why I was this way.

    I feel so bad for the sleepless nights I caused my mum. She tells me how hard it was to leave me to cry and she would sing to me at the door when she couldn't hold me anymore and she would sometimes just have to leave me to cry because there was nothing more to be done and she somehow knew that it would be okay, even though it didn't feel that way.

    What I would like to say to you personally is: "Thank-you."

    Thank you for helping me understand a little more. Thank you for writing an article that is open-ended and stirs up discussion. Thank you for citing your sources and providing the opportunity to learn for both mothers and mothers-to-be. Thank you for showing me that I can be a mum and still be a Scientist. Because if you can write as you do while raising two children and endure the sleepless nights then maybe I could do that too.

    So, thank you. I hope you get some sleep tonight. I won't be because I will be studying, but maybe one-day I too will have a crying baby and I promise you that I will remember this post.

    Night.

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  13. What a wonderful comment Missy. I promise you I will remember YOUR words next time I am up late trying to write something meaningful!
    Thank you xxx

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  14. What a great post!
    Thankful for putting into words things I have found confusing about CIO for a long time.

    I just never understood how 'experts' could advocate for CIO when it went against so many of the basics of child development. This has put into simple terms why CIO doesn't work the way some people think it does... little babies just don't have the cognitive development to understand the intent.

    And this is not about how much your baby cries. I had prem twins with severe reflux who cried A LOT and sometimes nothing I did made any difference and sometimes I had to walk away to save my sanity and keep them safe. But I walked away after being responsive, after rocking and soothing and singing and standing on my head... I walked away after showing them I cared, that they were not alone and I came back and did it all again.

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  15. If you train a baby to sleep once they have object permanence and know you are returning (NOT at 6 months, please!), and if you give them love and affection and are sensitively responsive in terms of attachment theory, that is quite different than neglected Romanian orphans who did not have a consistent attachment figure. Also, isn't it possible sometimes a baby cries because they are overtired and responding will overstimulate them.

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    1. SO Anon...at what age do you believe a baby develops object permanence. could you give reference for this please? and yes, it is different to Romanian orphans, that is precisely what i have said in the article. and no, i don't agree that responding to a crying baby will overstimulate them...if you feel this is the case, holding them and rocking gently in a darkened room would be my preference over leaving them completely alone in their distress.
      Thanks for your comment.

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  16. "The practice of leaving a baby to cry alone in a cot in order to encourage them to learn to be less dependent on their parents at night is so common and widespread in our culture that it is considered an absolutely normal if not essential part of a baby's first year."

    Psychotherapist Karen Walant uses the term 'normative abuse' - "Society (at least in the Western World) has encouraged a number of parenting practices that I call "normative abuse." "Normative," because these are approaches that are sanctioned by society, therefore enacted without any moral discomfort. By normative, I mean practices which appear normal for our culture."
    http://www.naturalchild.org/guest/karen_walant.html

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    1. That's a great link, thanks Donna. x

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  17. Very interesting. I think that a sleep deprived mother is also very damaging to her mental health and that of her family, and there are degrees of night waking that need to be managed in a loving way which may mean baby cries but not necessarily 'abandoned' to self sooth. Its all about moderation and anything to extreme is damaging. Westernised cultures don't often have the luxury of extended family to help support a mum and night waking can be incredibly debilitating and a pre cursor to post natal depression. Babies definitely learn sleep cues and sleep association from an early age. Personality, physiology and environment are all important factors in a baby's night waking.

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    1. In our family we have managed the sleep deprivation by co-sleeping, I realise this is not for everyone, but it has truly worked for us. I have to be honest though, that even if there was a reason why we were not able to co-sleep, there is no way I could ever resort to CIO. I would rather be on my knees with tiredness than leave my own baby to cry, even for a few minutes. The way I see it, I am the adult, and need to learn to cope and be strong even when tired, rather than let them 'take the hit'. And I'm never sure of your argument that a sleep deprived mother is damaging to mental health, nor am I sure that your statement that it is a precursor to PND is evidence based. PND is complicated and not simply caused by environmental factors such as tiredness, I'm afraid this view is too simplistic.
      Anyway, thank you for your comment. You are dead right that we lack support in the West. x

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  18. I had severe PPD with my reflux-ing colicky preterm twins. But hearing them cry made me feel worse, so I never let it happen. Even in my compounded sleep deprived state I knew that I needed to be there for them because I was the mother. Learning to nurse them both while laying down (facilitated by large, "flexible" boobs :-) was the best thing EVER.

    My two year olds are happy healthy and good sleepers. I realize this is purely anecdotal, but responding worked to create the mother-children dynamic I sought.

    Thank you for an informative well-felt article.

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    1. Thanks Mama Mo, I do agree with you about flexible boobs! What a lifesaver! x

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  19. There are many ways to comfort a crying child, holding being only one of them. Babies can be comforted in their cots wo immediately taking them out and/or nursing them. Swaddling, rubbing/patting/rocking, pacifiers, singing/humming/white noise & soft comforting words are all a part of that. So is routine. Babies and children thrive on routine/ knowing what to expect. So as much as was said about babies feeling hopeless & helpless if not held when crying, & thus giving up on crying out because they were "trained" (have learned by routine) that no one cares enough to come to them, babies can also be positively trained to fall asleep in the cot (yes, gently) wo having to be constantly held, nor neglected. This begins during the day with healthy eat/wake/sleep routines that work in establishing their inner biological clock and patterns. This means not feeding them only because they are crying, nor does it mean not feeding them yet because the clock says it is not time - either way lacks judgement. Flexible schedules are essential for a healthy night time sleep for baby and mom. Sleep is very important to the brain of mom & baby in the production of hormones and brain chemicals (like seritonin, which the lack there of causes much depression and is suspect in SIDS) that are only produced during night sleep and cannot be made up for during day naps for momma, therefore it is very important that mom, too, gets plenty of sleep. To say that mom does not need a good night sleep because she is an adult and can control herself is to leave off your research with baby and ignore the basic and much studied needs of the adult brain. This leaves the article unbalanced, thus, unfair (& unrealistic) to Momma. In hard cases, like colic (or whatever the mom of the family considers "hard"), perhaps mom can find help through a trained Newborn Care Specialist (if not from close family/friends) to help at night so that mom can get the rest she needs as well, without guilt for not holding her child 24/7.

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    1. Well I think on most points we will have to agree to disagree Anon. I'm afraid I am too tired to respond to you in any more detail than that! x

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  20. Isn't part of the reason CIO is considered 'bad' because you are allowing the distress of another person? Because elsewhere in a response to an anon you hint that she might find the distress of another person difficult to cope with like that's a bad thing. The distress of a baby IS difficult to cope with. So is lack of sleep. I simply can NOT sleep through a baby suckling. If I could I'd probably be cosleeping. I can relax, but I can't SLEEP. My back aches from sleeping in a position that allows nursing. I know because the more times my child wakes up to nurse the worse my back feels. There are plenty of studies that link poor sleep to diseases like diabetes and more. So I think it is wholly unfair to put mom's sleep against baby's sleep.

    The way I see CIO (which is one aspect of one whole book on sleep training--not the whole 'method' of most sleep training) is that it is a necessary way to break sleep associations. It is not to help the child learn much beyond that. I've been having to wake up between 3 and 6 times a night to nurse my child back to sleep. I can NOT do this until he's weaned. Unless I want to be so tired and grouchy during the day that I'm a worse mother. He is used to nursing to return to sleep and that's what he wants or needs. But one person's needs cannot completely usurp the needs of the other or else there is imbalance and a lot of difficulty. My baby needs more uninterrupted sleep than he gets...I need more uninterrupted sleep than he gives me. So pretty soon I'm going to do some more sleep training and it will involve hubby checking in on baby instead of me every other time until he is able to go longer between wakings and learns to fall asleep without nursing.

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    1. Thanks for your comment Anon. I totally understand your struggle with sleep deprivation, it is extremely hard and I have gone through it with 2 children now. What I would say is that it does get better by itself and there are also ways of gently night weaning when this is age appropriate, without just cold turkey CIO, that you could investigate.
      Regarding your first question, we need to be VERY clear about the distinction between leaving a distressed child alone and allowing them to 'cry in arms'. By comforting our babies we teach them about comfort and that their distress is manageable, and this is essential to their future mental health. Giving comfort does NOT mean, trying to stop them crying.
      I wish you the best whatever you choose, and hope you get that much needed sleep soon x

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  21. I absolutely disagree. I learnt very early on to distinguish between a whining cry vs a distraught, emotional cry of need. When my son was a baby he often got cranky and whinged as he drifted off to sleep. I recognised it as such and left him alone, unless I recognised his more upset cry when he needed something. Adults communicate through different tones and I think it's reasonable to posit that babies do this as well.

    I'm generally interested to understand other parents' viewpoints but when you pepper your article with irrational alarmist warnings of permanent trauma, it is not a credible read.

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    1. Sorry you didn't like it Boo. I'm not sure which of my comments in particular you perceived as 'irrational alarmist warnings of permanent trauma'.
      We all parent differently and one person's 'whinge' is another's call for comfort.
      Good luck in your choices anyway x

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    2. What she said. Thanks Boo. : )

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  22. You'd be interested to read the following article summarising an empirical research of controlled crying - http://www.smh.com.au/lifestyle/life/for-crying-out-loud-study-backs-baby-sleep-strategies-20120911-25p2a.html

    I'm not sure why you don't understand your article is irrational and alarmist when you use words like "trauma" and infer that CC leads to permanent changes to a develping brain. I'm not even sure why you mentioned Romanian orphans. This is like discussing the emotional effect of having an argument with your spouse then mentioning the impact of violent spousal abuse. You say babies left to cry will have varying degrees of "damage" when this is plainly unsupported by evidence. Countless parents will testify that they used CC and their babies are healthy and happy - or will you insist there are underlying trauma we just can't see?

    If a parent decides to comfort their baby at every cry, that's their choice. But when you write articles like this it puts unfair and unnecessary pressure on parents.

    I don't need luck in CC. It was the right thing to do.

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    1. Yes, of course I insist that 'there is underlying trauma that we just can't see'! I'm a psychotherapist! We specialise in working with people who have 'underlying trauma you can't see', they are called mental health problems - the 'biggies' like personality disorder, addiction, eating disorder, depression, and the 'smallies', like never being happy or comfortable in relationships, never really liking yourself, never being able to trust yourself, or just generally finding life difficult and unmanageable.

      It would be almost impossible to pin down the actual effects of CIO on each individual and separate them out from other factors that may contribute to difficulties later in life. But it is glib and ill informed to say, 'my baby is happy and healthy', therefore no harm has been done (by CIO or any other parenting choice for that matter!) Everything we do as parents has an effect, often that cannot be seen for many years to come and certainly that cannot easily be measured by any researcher.

      If you think that you have done the right thing, then I really do genuinely wish you well, I am sure you have made other good parenting choices and you obviously care and think about your decisions or you would not be reading a post like this.

      The intention of this article is not to put pressure on parents, but simply to encourage thoughtful debate.

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  23. An eye opening read, I have never left my children to cry and they are very happy, empathic and independent. I however am a mess, even as a child I was detached from others, touch scared me and when I was upset I made sure to go be alone to cry even when very young, when scared I wouldn't go to a parent, I locked myself in my room and sat on my bed until it passed. I wish my parents were alive to ask them just what happened to me as a baby to cause such horrific emotional disconnection I still feel as an adult but thankfully have the opposite of this for my own children who I have incredible empathy with

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  24. There is a middle ground here. I beleive (and research backs up; like the cortisol thing) that prolonged unattended crying changes brain development. I personally believe negatively though of course as you say, it can't really be proven. However, as a Mum who suffered PTSD I needed to get my son to sleep as extreme sleep deprivation was making it worse and, like most Mums know, making me crazy. BUT you CAN do it without leaving your child to cry alone. I have never left my now 2.5 year old alone to cry. We tried co-sleeping but it didn't work for us (I'm hoping next baby (22weeks pregnant) will be more receptive. And I know what you're thinking, "all babies love co-sleeping!" I used to think that too and wouldn't have really believed a Mum who said otherwise) and my son slept through from 5.5months old but we never ever left him to cry or didn't respond to him at night (or any other time of course!) There are lots of ways to teach your child to sleep sensitively while being responsive and attending to their needs so all I mean to say is, I totally agree Gina Ford, Tizzie Hall and the others and CIO is awful and damaging BUT if you're very sleep deprived you can still help your baby to sleep without resorting to that (and it doesn't take too long either) :) x

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