Psychological_Trauma-3

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Imagine a couple riding in a car when they are hit head-on by a car coming in the wrong direction.  They walk away shaken, but alive.  They both experience trauma in the immediate sense, but only one of them will end up spending months recovering from the experience.  Now imagine two women who experience the same birth experience of induction, interventions, and finally ending in an emergency c-section.  Again, they both experience immediate trauma, but chances are they both won’t experience long-term suffering.

You could do this for any traumatic event in a person’s life, and yes, we all have many traumatic events: Death, separation, pain, medical problems, accidents, injuries… these all involve traumatic moments for us.  Luckily for us, humans are generally resilient and we don’t always “suffer” long-term from these events, but traumatic they are.  The problem is that sometimes we do suffer long-term, and we can’t actually predict who that will happen to or when.  We can make educated guesses and some people will have a higher likelihood of experiencing something like post-traumatic stress disorder (PTSD) after a trauma, or simply be so scarred it noticeably changes them as people, but we don’t knowEven for those who don’t “suffer” long-term, these events can still shape us: They can change the way we view the world (for better or worse or simply just change it) and they can even change the way our DNA expresses itself.  The field of epigenetics is showing us that our environment says a lot more about who we become than has previously been though, and that events can physically alter the expression of our DNA that we thought was inalterable[1].

This brings me to crying-it-out (CIO).  Or rather, the idea that CIO should still be promoted based on what we know on trauma.

Is CIO traumatic for a child?  Yes.  Anyone that tells you otherwise is ignorant (deliberate or not) or lying. I say this fully aware that if you utilized it, you may want to deny this fact to your dying day, but an infant being left alone to cry/scream without being responded to is enduring trauma.  I am not talking about gently transitioning a child to a crib or their own room, or even gently trying to get little ones to self-settle (not self-soothe, different things entirely) using transitional objects or putting them down slightly awake if these things work for your child.  I am talking about CIO or controlled crying (CC) that leads to an infant crying for parents for extended periods (as the timing increases with CC, parents can end up in CIO territory).

Infants and young children don’t have the cognitive capacities to understand you want them to sleep (and sleep alone) are being shut away and ignored.  The love and care they are (hopefully) used to getting during the day (and previously at night) are suddenly gone.  The noises that creak, the possible pains they feel, the anxiety over separation from a caregiver, these are all very real and there for these children only they now have no one to help them regulate and thus they simply cannot cope.  Yes, we regulate (or help regulate in the case of older children) our children emotionally and physiologically for at least two years[2].  The process by which children learn emotion regulation starts from simply being close to us and having us regulate them via the synchrony that exists between securely attached dyads[2][3][4].  All the fears, the pains, the loneliness result in a child that is screaming for someone to come, but no one does.  This is trauma.  Even if you’re doing it because you think it’s best for them (the “short-term pain for long-term gain” philosophy).

If you still don’t believe me, we also know that crying-it-out results in cortisol increases that are sustained for at least a short-term period after the crying at night has ended[5], giving us a physiological measure of this distress.  I say “at least a short-term” because the longer term hasn’t been studied.  Of course we expect the levels to drop as the child habituates to being alone at night, but how long that takes for a given child is unknown, but may say a lot about the chances of long-term negative effects taking hold.  (If you believe the hype that there are lots of studies showing no long-term effects of CIO, please read this.)

Now, given that we know the act of CIO is traumatic for a child, even if it may be short-lived trauma, should we promote it?  Well, many people speak of the resiliency of children and assume that because they are resilient, they can overcome these early traumas and because the “gain” of CIO is better sleep for parents, it becomes “worth it”.  Although the resiliency argument is generally true, I struggle with this as a way of thinking when it comes to CIO for a couple reasons.  First and foremost, even if our children do bounce back, these experiences still shape the way they experience the world.  As epigenetics has shown us now, acts that aren’t even traumatic – like a mother rat just grooming her pup less – have long-term effects that may transmit to later generations if not “overcome”.  This would seem to be why those in the field of epigenetics realize the huge importance of how we treat our children in the early years while the brain is developing at an astonishing rate[6].

If you think of the people in the car crash, even the one who suffers no long-term trauma will most likely see driving a little differently.  Often people in car crashes will perceive the risk of driving as higher or may feel just slightly more anxious when thinking about driving.  These are not life-altering thoughts or events, and may go unnoticed for a lifetime, but the shift has occurred.  It may be an epigenetic change and it may just be a cognitive schema change, but change it is.  I simply can’t find reason for us to believe this type of change doesn’t happen to all children who experience CIO.  At the basic level, how do they not suddenly think that there are times for which the people you love are not there?  They may be well aware they are there during the day, but when the lights go out, you’re on your own.  Some people will feel this won’t be bad, that it’s a good lesson.  Okay… but why?  Why should a child have to start life out in their early years with this type of thought process or even physical alteration of their DNA?

We must also consider when this goes even further; for example, I was told a story by a loving, caring mother who had sleep trained her toddler and remained utterly responsive only to come in one morning to find her child had vomited at night but never came to get help.  Many might assume the parents were non-responsive at other times too, but no, this is just the way some children interpret our actions towards them.  For this child, being left to cry was a message that they are not to seek help at night.  Will all children feel this way?  No.  But some will.

I will share a personal story here.  My mother was very responsive, but one day when I was six, my friend across the street asked me to dinner and I went over.  Well, she hadn’t told her nanny (who was cooking) so I was promptly sent home.  In my head, this meant my parents wouldn’t have dinner for me so I sat out front, staring into the main window, watching them eat, waiting for them to finish so I could go in and tell them I’d eaten, even though I hadn’t.  At one point though, my mother saw my head popping up and my dad came out to get me.  When I came in I explained that I thought they wouldn’t have food for me.  They were both horrified and immediately told me they would always have food, even if they had to make something else.  Why did I feel this way?  I don’t know.  At some point I’m sure something was said about food and not making extra food for people and this was how I interpreted it.  Did they ever withhold food?  Never.  The fact remains that we just don’t know how children will interpret our actions and our words and as such we should be very, very careful what messages we might be sending to children who don’t understand the world as we do.

Second, and perhaps more importantly, this notion that we are resilient ignores the very real individual differences that exist between children in this regard as well as the differences in individual temperaments.  Not all children will be resilient; because you had a resilient child who seemed to show no ill-effects (although again, see point one about epigenetic or cognitive changes), it does not mean another child will not show this effect.  There are going to be some children, like highly reactive kids, who will almost always have problems with methods like CIO and parents need to be aware of that (see here for a discussion of how these children respond to parenting), but even for those lower-reactive kids, there will be differences.  We just don’t know what they will be for each child.

This is where I think back to the car accident scenario.  Some people will experience trauma and be over it the next day, perhaps with a cognitive shift in thinking.  Some will experience trauma that will turn into acute stress (where the individual has post-traumatic stress (PTS) symptoms but only within a month of the event).  Higher anxiety, physiological reactions, nightmares, and flashbacks are all symptoms of acute stress and though we may not be able to identify them in children, these experiences can happen.  And of course, some will experience profound stress long-term, in the form of PTS.  Sometimes the change can be so great that we see a marked difference in the person, but sometimes it’s very situation-specific.  All these changes make it very difficult to say there’s a set reaction to the initial trauma of a car accident for any given individual.  Similarly, it is nearly impossible to say that there is a set reaction to the trauma of CIO that we can expect for infants and children.  However, just as we wouldn’t consider getting into a car accident an experience of no significance, nor should we assume CIO is an experience our children will just “get over”.

There’s an issue I hope you realize I haven’t discussed yet because it is important: Children do experience trauma outside of things like CIO and we don’t consider it the end of the world for them.  For example, my own daughter was in a bad car accident with me just a few months ago, but do I consider her forever scarred?  No.  So what is the difference?

I see two main differences.  One, when our children experience trauma as in a car accident or death or injury or pain, we offer comfort and support.  We are not the causes of the trauma and in turn we provide them with a safe place to experience the anxiety and fear and any other negative emotional or physiological reaction that may arise.  Our responsiveness and comfort regulates our children’s physiological reactions (you can read up on this here), meaning they need not experience the kind of stress response that can come with trauma.  Furthermore, we help our children process the trauma even if we cannot be there to offer comfort immediately.  We take time to help them through it, answer questions, or just be there a bit more to make sure they feel safe and secure if they can’t verbally tell us how they are feeling.  I’ve never seen parents who use CIO engage in helping behaviours for their infants and children to help them cope with the trauma of CIO; if they did, I don’t think it would look like CIO but rather gentle sleep guidance.

Second, as I hinted at above, CIO is something people are told to do, not something that just happens.  The purposefulness of CIO and the fact that it is promoted is a key difference.  In no other realm would doctors or families suggest people intentionally subject their child to trauma.  Why?  Because we know that the resiliency children often show isn’t something we should (a) test nilly-willy, (b) accept as fact for each individual child, and (c) “use up”.  What I mean by “use up” is that we know repeated exposures to stressors and trauma can have long-term effects via psychological phenomena like learned helplessness[7][8] and that resiliency breaks down.  We don’t know what kinds of trauma our children will face, so why force early trauma if we don’t have to?

Given all this, I return to the main question: Why are we promoting CIO?  Why do we promote deliberately exposing children and infants to trauma – no matter how short-lived – when there are gentle methods that parents can and should be advised to try first?  Does it mean no family will use CIO?  I’d love to say yes, but I know some will, and hopefully the awareness of CIO as trauma can help families who feel they have to use it find ways to try and counter the trauma.  More than that, I hope it makes us realize that promotion of something should be left for those that do not carry the risks of stress, anxiety, and changes to one’s cognitions or even DNA that CIO does.  If nothing else, can we at least get to the stage where CIO is a last resort instead of a first one?

For a list of gentle sleep resources, please read this link and the suggestions at the end of that piece.

For discussion on what to do if you HAVE done CIO or have a child who has endured trauma, see here.

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[1] Holliday R.  Epigenetics: a historical overview.  Epigenetics 2006; 1: 76-80.

[2] Rothbart MK, Ziaie H, & O’Boyle CG. Self-regulation and emotion in infancy. In N. Eisenberg & R.A. Fabes (Eds.) Emotion and its regulation in early development: New directions for child development, No. 55: The Jossey-Bass education series (pp. 7-23), 1992. San Francisco: Jossey-Bass Publishers.

[3] Cassidy J. Emotion regulation: Influences of attachment relationships.  Monographs of the Society for Research in Child Development  (1994); 59: 228-283.

[4] Frodi A, Bridges L, & Shonk S.  Maternal correlates of infant temperament ratings and of infant-mother attachment: A longitudinal study.  Infant Mental Health Journal 1989; 10: 273-289.

[5] Middlemiss W, Granger DA, Goldberg WA, Nathans L.  Asynchrony of mother-infant hypothalamic-pituitary-adrenal axis activity following extinction of infant crying responses induced during the transition to sleep.  Early Human Development 2012; 88: 227-32.

[7] Seligman MEP & Maier SF. Failure to escape traumatic shock. Journal of Experimental Psychology 1967; 74: 1-9.

[8] Watson J & Ramey C. Reactions to response-contingent stimulation in early infancy.  Revision of paper presented at biennial meeting of the Society for Research in Child Development.  Santa Monica, CA, March 1969.