Do I Need to Sleep Train My Baby to Prevent Mental Health Problems?
Recent research by Dr. Isabel Morales-Munoz and colleagues looked at a link between poor infant sleep and the development of certain mental health disorders in adolescence. It has online parent boards a-buzz with assumptions that this means sleep training is good for our babies to protect them against mental illness.
Let’s take a closer look at the research and see:
What does the research actually show?
What doesn’t it show?
What does that mean for parents of “poor sleepers” who are worried? and, the key question I want to answer today, perhaps most importantly for parents,
DOES THIS MEAN YOU SHOULD SLEEP TRAIN YOUR BABY?
First, let me start by saying that parenting is tough! It’s fraught with guilt about whether we are doing the right thing, whether we are causing problems, and whether our children are going to grow up to be wise, wonderful, and caring adults who can cope well with life’s challenges.
Of course, this last one —raising our kids to be wise, wonderful, caring adults who can cope well with life’s challenges is the Big Picture Goal. That’s what we all want for our children.
When research like this comes out it is important to keep it in perspective. It is one tiny part of developing a good understanding of early infancy and later mental health.
If you held one piece of a 1000 piece puzzle and didn’t have the box, you wouldn’t be able to draw any conclusions about the size of the puzzle, the picture, or even how many pieces there are. It is when we combine lots of research studies over time that we can pull together a clearer picture. So, in looking at one study, we really are just looking at one piece. And that’s ok. Let’s start there.
WHAT DID THEY FIND OUT?
SLEEP PROBLEMS IN EARLY CHILDHOOD: ARE THEY LINKED TO LATER MENTAL HEALTH ISSUES?
The authors, who had their research published online in the Journal of the American Medical Association on July 1, 2020, looked at data from 7155 children in the United Kingdom who were followed for 13 years. They looked at
how frequently babies were waking during the night (at 18 months),
irregular sleep routines (at 6months, 30 months, and 5.8 years), and
late bedtimes at 3.5 years.
They’d previously looked at persistent nightmares in children (using the same set of data) and found it to be associated with psychosis and borderline personality disorder. And previous research out of Australia showed that babies with persistent sleep problems in the first year were at greater risk for anxiety and emotional issues in later childhood.
What they found was that waking up frequently during the night (at 18 months) and irregular sleep routines at 6 and 30 months were associated with psychotic experiences in children at age 12-13 years. They also found that children who slept for shorter periods at night were more likely to develop borderline personality disorder at age 11 and 12. Irregular routines were associated with increased risk of depression at 10 years, and later bedtimes at 3.5 years were associated with bipolar disorder symptoms.
Pretty worrisome stuff for parents who are already feeling pretty stretched and who are carrying the weight of the world on their shoulders, right?
I want to emphasize that what they found out was that there was increased risk, not inevitable outcome. Just because your baby is a poor sleeper, wakes often, or goes to bed later, does not mean they will have mental health issues. Or, put more accurately, just because parents report poor sleep does not mean their child will have mental health issues.
Further, this study is not in any way saying that these factors cause these outcomes. They may, in the end, be an indicator, but not a cause.
When you add in all the research we have about the benefits of responsive, connected parenting, it becomes clear that even if sleep is poor, we can hedge reasonable bets that the way we parent will have a big impact on mitigating risks of mental illness. Responsive parenting has already been shown to reduce the impact of a stressful pregnancy on infant mental health outcomes.
Responsive, compassionate parenting is a way to reduce mental illness, and is not something that should be withdrawn to prevent mental illness.
So, if you are thinking that sleep training will fix the link between poor sleep and mental illness, I encourage you to work from the assumption that crying without a parent, and withdrawing support from a distressed infant may turn out to strengthen the pathway here. We don’t know enough to be super clear on this, but we do have enough to make some reasonable assumptions and to err on being responsive, rather than withdrawing parental support.
THE LINK BETWEEN POOR INFANT SLEEP AND MENTAL HEALTH: CORRELATION DOES NOT EQUAL CAUSATION.
I also want to point out that an correlation (poor sleep is correlated with mental health issues) is not a cause (poor sleep causes mental health issues). The link between these two does not mean one causes the other. Sometimes it is just associated. Nothing more.
I have suggested an analogy that I include in my facebook video about this study: it would be like finding a link between blonde hair and the likelihood of getting a sprained ankle on the soccer field. If an association were found (blonde hair is linked to increased risk of sprained ankles) it does not mean blonde hair causes sprained ankles. It would make no sense to dye blonde hair brown (nor would it make sense to sleep train our babies to not call out for us in order to prevent mental health problems). It would, however, make sense to explore if there is something that causes blonde hair AND causes higher risk of sprained ankles. And perhaps we’d be drawn to look at genetics as being a contributing factor.
WHAT DID THEY NOT FIND OUT?
(HOW MUCH SHOULD WE WORRY ABOUT BABY SLEEP AND MENTAL HEALTH OUTCOMES?)
All of these studies, I’ll point out, were based on parent report of sleep, which we know from research is a terrible way to measure actual sleep. I know we all would like to think we can be objective about how much our babies sleep, but we are simply not good at it. So let me say really clearly:
PARENT REPORT OF POOR INFANT SLEEP IS A REALLY BAD MEASURE OF ACTUAL SLEEP.
There are other things they didn’t look at:
They did not adequately control for maternal mental health issues (meaning, that we know that mental health has a huge genetic component that they didn’t account for fully here, and that this might account for the outcomes).
They did not explore trauma, abuse, or other factors that are also associated with increased risk of mental health issues (factors which are on a whole other level of vulnerability and should be addressed preventably and proactively, and which increase the risk of all sorts of things in adulthood).
Actual sleep. It’s worth saying a third time, because we often forget it. Parent report of infant sleep does not line up well with actual infant sleep. Actigraphs are the gold standard, and it can be hard to do studies with actigraphs because they are invasive and time consuming compared to parent report. However, if we had more studies collecting actigraph data we’d have a much clearer picture.
Sleep training was not examined at all in this study and therefore we cannot and should not draw any conclusions about sleep training from this study as a way of avoiding later mental health issues.
The study didn’t explain how they measured “irregular routines”, one of the factors associated with depression at age 10. This is unfortunate because, generally, parents view establishing “routines” as their job, when in reality, babies carry a large part of the “job” of developing routines and rhythms as part of their neuromaturation. We can accentuate these routines, manipulate them to a degree, and we can be aware of and support these naturally emerging rhythms (with morning light, consistent enjoyable bedtime routines, and predictable family routines like mealtimes), but it is rarely necessary to “implement” rigid parent-led routines unless it is critical to our family function (work and school schedules, for example).
Development. The researchers did not explore the impact of developmental factors in poor sleep such as natural disruptions in sleep at particular stages in development. It was not the focus of the study, but does play a huge role in parent perception of sleep problems. Earlier studies have speculated that when parents understand normal sleep development, their perception of the problem shifts. Perhaps if parents are aware of normal sleep development (and the periods of time that get a bit rocky), the correlation between poor sleep and mental health outcomes would not be as strong. We won’t know till we study it, of course, but if we start with understanding sleep expectations better, we can worry less when we know sleep can be tricky at particular ages.
BABY SLEEP TRAINING IS NOT RECOMMENDED AS A WAY TO PREVENT MENTAL HEALTH PROBLEMS IN ADOLESCENCE.
But let’s carry on, because what we really want to know here is what can we do to help our kids grow up healthy and happy, and does it involve sleep training. Let’s explore that a little more.
Exploring this involves reminding ourselves that this study did not look at sleep training. To suggest that this study shows sleep training is beneficial, is misrepresenting the research entirely. Sleep training addresses the disruption our children make in our sleep, while studies show (with actigraphy!) that sleep quality and duration are not actually improved with sleep training. This highlights the role that parent perception of sleep (and report of sleep) has on the problem of “poor sleep”.
Further, when we are exploring the risk factors of teen mental health we can turn to the huge body of research around infant mental health as a place to start. We know that secure attachment is critical for infant mental health. We know that self-regulation of big emotions supports mental health. We also know that self-regulation is a maturation process that happens over time in environments that have a calm caregiver who can help an infant co-regulate. And we also know that some babies are naturally more skilled at co-regulation, and that babies develop self-regulation at different ages. So from that perspective it makes no sense to withdraw co-regulation (parent proximity and responsiveness) to try to encoruage independence or self- regulation, and prevent mental health issues down the road.
SO WHAT CAN YOU DO IF YOU ARE WORRIED ABOUT YOUR POOR SLEEPER?
We, as parents, do not have control over many of the things we thought we’d have control over when we pictured being parents. We cannot make children sleep when they are not tired or when they are stressed. We cannot make them walk when they are not ready or when they do not want to. And we cannot prevent all the outcomes that genetics and circumstances impact in the course of our baby’s life.
We can, however, reduce risk through responsive parenting. And so, for those concerned that their “poor sleeper” is destined to have mental health issues , especially when they run in your family, I have the following suggestions:
Talk to your doctor or naturopath or integrative medicine physician if your baby is not sleeping well and you think there is something organic or health-related going on;
Continue to respond with love, calm self-regulation, proximity, skin-on-skin, touch, and nursing, or whatever other attachment-based strategies you use, in order for independent sleep to emerge developmentally, and to reduce the risks of trauma, separation, and other factors;
Seek further support from an attachment-based, mental health-informed sleep consultant. Get help problem solving ways to optimize the environment for sleep (theirs and yours!), receive validation and reassurance, and identify barriers to good sleep that we have control over.
STILL WORRIED THAT YOUR BABY ISN’T YET SLEEPING THROUGH THE NIGHT?
I can relate.
My first born was a bonefide awful sleeper. I am quite certain actigraphic data would back me up (as would those little slips of paper I used to keep track of how often he was waking) —really! I also had a very stressful pregnancy, with the loss of my mother to cancer before we’d even announced the pregnancy.
And so, I stuck as closely as I reasonably could to being as responsive as I could to his needs, while still establishing boundaries for my own wellness (less than perfectly, I’ll add, but I did what I had the capacity to do at the time).
I explored (and discovered!) treatable, organic health-related reasons for the wake-ups. And I continued to be responsive to his needs, ignoring the time lines of “should” when it came to sleeping through the night and sleeping on his own.
Mental health issues are on my radar. Not as something that I feel I can entirely prevent, but as something I can reduce the risk of, and reduce the impact of by trusting my instinct to be a responsive parent, by being attentive to needs and changes, rather than hyper-vigilant, and by reaching out if and when we feel we need support.
I also know that rather than worry about something not fully in my control in the future I can focus on parenting the child in front of me: what are his needs right now? How can we remain securely attached so that he comes to me when facing challenges? Are there ways to support his development, resilience, capacity, and confidence now, rather than attempting to mould him into someone specific down the road?
PARENT THE CHILD IN FRONT OF YOU, NOT THE PERSON THEY WILL BE.
And so, to close, I know the worry is real. And I know that research can seem like it is a glaring red flag of problems that we need to worry about. In reality, research is information that we can use to empower us in making the best decisions we can as parents.
Science matters. But it matters only because of how it helps guide our decisions, not our worries.
WE ARE ALL DOING THE BEST WE CAN. AND THERE IS MORE SUPPORT IF AND WHEN YOU NEED IT.
So I encourage you to acknowledge that you are doing the best you can, that you are a loving and caring parent, and that there is support for you if and when you need it.
If that support includes sleep consultation, I’m happy to talk with you about what that would look like.
Resources:
Boyd, H. (2020). SLEEP SCIENCE: Infant Sleep Problems and Teen Mental Health. Facebook live. Available at: https://www.facebook.com/heatherboyd.ot/videos/2719315441724334/
Marceles-Muroz, I, Broome, M., & Marwaha, S. (2020). Association of Parent-Reported Sleep Problems in Early Childhood With Psychotic and Borderline Personality Disorder Symptoms in Adolescence. Journal of the American Medical Association, doi:10.1001/jamapsychiatry.2020.1875. Full article available at: https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2767298