by Julie Kinney
Laura and Brian McKenna tried for nearly a year to get their 3-year-old daughter, Casey, to go to sleep at a reasonable hour. They sang to her, rocked her and took her into their bed, but nothing worked. They finally settled on a nightly "routine" that will resonate with desperate parents of sleepless children everywhere: At 8:30 p.m., when Casey's younger brother, Sean, drifted off to sleep, one of the McKennas read Casey a story and sang her favorite songs: "Twinkle Twinkle Little Star," "Jingle Bells" and "The Itsy Bitsy Spider." Then they said goodnight and left the room.
Sounds like it would work, right? Not with Casey. She would call and come out of her room over and over again, each time needing to be put back to bed. Sometime around 10:30 p.m., she fell asleep—in her own room or on the floor just outside her door. She then slept well until about 5 a.m., when she came in and woke her parents, falling back asleep in their bed or on the floor. The McKennas then had to struggle to wake her at 7:30 a.m.
Frustrated and out of ideas, the McKennas turned to Children's Hospital Boston's renowned sleep specialist, Richard Ferber, MD, for help. At an appointment in June, Ferber suggested something that might sound counter-intuitive: Begin by putting Casey to bed at 10:30 p.m. The main problem, he explained, was that Casey simply wasn't sleepy at the bedtime the McKennas were setting. She was getting up fairly late in the morning, especially on weekends, and taking very long weekend naps that were shifting her sleep from night into day.
But to readjust Casey's body clock and get her to bed earlier, they would have to start by putting her to bed at a time she could actually fall asleep. In addition, a 6:30 a.m. wake-up time was to be enforced every day—including weekends—and naps were to be limited to 90 minutes.
"After she's fallen asleep willingly for several nights, you can begin moving the bedtime earlier by 15 minutes or so," Ferber said.
The McKennas agreed a reasonable goal would be to move Casey's bedtime to 9 p.m. If she continued to call for them, they should calmly reassure her, waiting increasing intervals before going to her bedside. If the 5 a.m. visits persisted, the McKennas might try temporarily gating Casey's bedroom door. "If you try this and aren't comfortable with it, give me a call," Ferber told them.
Founder of Children's Center for Pediatric Sleep Disorders, the first pediatric sleep center in the world when it opened in 1978, Ferber's name has become synonymous with children's sleep. To some people, it's also synonymous with crying, a misunderstanding Ferber would like to counter. In an updated and expanded version of his best-selling book, Solve Your Child's Sleep Problems, he hopes to clarify his approach and show that there are many causes and approaches to consider before helping a given child get a good night's sleep—and that most of these involve little or no crying.
The success of the book's original version helped spawn the term "Ferber Method." It's been applied to the way Ferber helps parents get their children to sleep, and has often been inappropriately simplified as a single "cry-it-out" tactic. Ferber himself rejects the connection between his work and crying, as well as the word "method" to describe what he does. Yet the phrase has stuck and even become part of popular culture. In the comedy Meet the Fockers, for example, Robert DeNiro's character talks of "Ferberizing" his grandchild, and tells Ben Stiller's character that, "unless it's an emergency, under no circumstances should you pick him up when he cries. He's learning to self-soothe."
That kind of pop culture ubiquity, of course, has had its price. "Ferber's work has been distilled and passed on from parent to parent," says Linda Murray, editor-in-chief at the on-line parenting site BabyCenter. "He's suffered from being so famous that few people return to the original source."
Ferber believes that a child should fall asleep in the same conditions that will be present when he wakes naturally during the night, whether it is in his own room, in a room with a sibling, or sharing a bed with a parent. If he awakes and finds the conditions changed—perhaps he's been moved from his mother's arms into his crib—he may cry until they're reinstated. If this happens, Ferber advises parents to reassure the child by returning to the bedside, as in Casey's case, but to slowly increase the time between each visit.
Although this approach is meant to help with a specific kind of sleep problem, many parents have latched onto it as a cure-all. But when it's used for the wrong reasons, Ferber says, it can make things worse. That, he believes, is what's given it a bad rap in some circles as a "crying torture" that undermines a child's feelings of security. But parents who use the technique appropriately hail it as sanity-saving advice.
Mark Frauenfelder and his wife, for example, suffered many sleepless nights with their first daughter, waking every couple of hours to rock her to sleep. They ultimately brought her into bed with them—a practice called co-sleeping—so they could all get some shut-eye. Their daughter, now in third grade, sleeps in her own bed, but the Frauenfelders still lay with her to help her fall asleep.
When their second daughter arrived and followed the same pattern of nighttime sleeplessness, the Frauenfelders followed a friend's advice and bought Ferber's book. Within three nights, their 6-month-old slept solidly for 11 to 12 hours. Frauenfelder, a Los Angeles-based editor and Web blogger, told his 3,000 daily readers that Solve Your Child's Sleep Problems was the most influential book he's ever read.
"If it took months for it to work, then I would buy the 'inhumane' argument," says Frauenfelder. "But three nights, and only one difficult night, is nothing. Our daughter is a very happy baby."
Ferber's expertise evolved from a career-long interest in sleep. As a medical student, he investigated circadian rhythms—sleep and wake cycles—in mice. He pursued clinical studies in sleep and motor rhythms as a fellow in Psychiatry Research at Children's, looking at babies' natural development of crying and sucking rhythms and researching natural sleep patterns. In 1978, Ferber joined two Children's colleagues in opening the sleep clinic.
They quickly discovered that sleeplessness arises mostly from non-medical issues, particularly improper sleep schedules (as in Casey's case), poor limit-setting and over-feeding during the night. Another common cause was what Ferber terms "poor sleep associations"—conditions that a child comes to need to fall asleep, such as rocking, back-rubbing, sucking on a pacifier or lying on mom or dad.
"We looked for ways to help parents and families discontinue these sleep associations and identify things that enable children to fall asleep on their own. This way, when they naturally wake during the night, they are likely to go back to sleep on their own and sleep through the night."
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Keep your child on a consistent and appropriate schedule
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Your child should fall asleep under the same conditions that will be present at times of normal wakings later in the night
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Do not continue unnecessary nighttime feedings
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Be honest with your child: Do not sneak out of the room after they are asleep; if you will be
leaving, let them see you leave
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Set enforceable rules for bedtime and be willing to enforce them; both parents should handle matters the same way
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Armed with this knowledge and bolstered by the thanks of families he had helped, Ferber released Solve Your Child's Sleep Problems in 1985. It's gone on to sell hundreds of thousands of copies, but he felt it was time to update the original source material since his research on the topic has continued.
In doing so, he stresses that there is much more than a single, or simple, method to be found in the nearly-twice-as-long revision. Broken into 18 chapters, the updated Solve Your Child's Sleep Problems addresses sleep issues in children of all ages, from newborns to adolescents. It offers explanations of children's fears, provides an understanding of sleep phases and details typical sleep requirements for children at each stage of development. It also covers treatments for bedwetting, as well as the less-common, medically related sleep problems like apnea and narcolepsy. Throughout, Ferber suggests options to suit different parenting styles and sprinkles anecdotes that remind parents that they are not alone in their struggle.
One topic that gets significant attention in the revision is co-sleeping. The original version devotes barely a paragraph to the topic, but much research in the last two decades—as well as a shift in cultural thinking and Ferber's own patients' experiences—encouraged him to say more this time around.
"In the first edition, I urged parents to allow children to sleep in their own beds because there was a feeling in the 1970s that if children didn't sleep alone, they couldn't become independent," says Ferber. "But that's obviously not true, and long ago we took to letting parents decide for themselves what is best for them and their child."
Recently, the American Academy of Pediatrics issued guidelines strongly discouraging co-sleeping, which has been linked to sudden infant death syndrome in epidemiologic studies. "While avoiding co-sleeping is safe advice for the population at large, we've found that individual families can co-sleep fairly safely if they make the environmental changes necessary to ensure the safety of the baby," Ferber says.
The practice is on the rise. According to the 2003 National Infant Sleep Position Study, 45 percent of infants spent at least some time in an adult's bed during a two-week period.
"Many of my patients and families co-sleep, and we have designed approaches to help them achieve successful co-sleeping arrangements," Ferber adds.
It is this willingness to rethink a stance on a sensitive topic like co-sleeping—rather than an adherence to a strict "method"—that has made Ferber a hero to many sleepless parents.
"I receive so much unsolicited mail saying, 'Thank you,'" he says. "I wrote the book because I wanted to make the information we had learned available to other families. The approach has become such a common cultural reference because it works."
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The McKennas enacted Ferber's plan of putting Casey to bed at around 10:30 p.m., and experienced almost immediate success. Here, in her own words, Laura McKenna describes how she and Brian got Casey to sleep in her own bed.
We waited until she looked tired at around 10 p.m., then put Casey down to sleep. She woke up about 15 minutes later and cried, but Brian was able to get her back to sleep by 10:45 p.m.
She woke up at 2:15 a.m. crying at the gate. I walked her back to bed and told her to get into bed by herself and lie down.
She fell back to sleep, but woke back up around 20 minutes later. It was then a battle until 4:15 a.m., when she finally fell back to sleep.
As Casey cried at the gate, I told her everything was okay and to go back to bed. But in the end, Brian got up and walked her back to her bed a few times before she finally fell back to sleep.
We put her to bed around 10 p.m. She fell asleep in about five minutes and slept through the night!
The same as night two. Each morning I ask her if she knows what she did, and she tells me she stayed in her bed all night and we high five!
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To learn more about supporting neurology research at Children's Hospital Boston, contact Donna Richardson in the Children's Hospital Trust at (617) 355-2061 or donna.richardson@chtrust.org.
