Summary: Study of guidance and practice in relation to child sleep and sleep training in Denmark, Greenland and the Faroe Islands

Introduction

The concept of ‘sleep training’ infants and young children to fall asleep without assistance and independently to stay asleep with few or no interruptions, has in the last few centuries been seen by many as a necessary and desirable part of a child’s development. Sleep training means that the child’s signaling behavior is either completely ignored, or that the caregivers show a minimized or delayed response to the child’s signals that they need care and help, for example through crying, calling or screaming.  Sleep training is therefore incompatible with the acknowledged importance of sensitive response. The research into the child’s overall development shows the importance of a child developing a secure attachment to his or her caregivers, and sensitive response is very important for this development. Sleep training can therefore risk damaging the attachment.

We have undertaken a study of the advice given to parents of young children in Denmark, Greenland and the Faroe Islands, with the intention of getting a wide picture of sleep training in practice in these countries. We have had a special focus on the guidance that parents receive from professionals, especially health visitors (sundhedsplejersker) and on a wide range of literature on the subject, which is handed out and often also promoted to parents. Although a variety of sleep training methods exist, a common factor is that the child often has to be left alone in the bed, where parents do not respond to the child’s signals. The most far-reaching form of sleep training is one in which the parents have to stay outside the room where the child is, even if the child is upset or crying – this is called ‘cry it out’, abbreviated to CIO. We have a special focus on this type of sleep training in our study

The survey consists of several components: a request for access to documents sent to Denmark’s 98 municipalities and subsequent inquiries to some of those municipalities, a voluntary questionnaire with answers from 3,627 parents from Denmark, Greenland and the Faroe Islands and a review of official guidelines and other written material that is recommended for parents. The survey primarily covers the years 2017-2019, although the questionnaire was also open to parents of children born earlier than 2017.

Results

The questionnaire had 2,711 responses from parents to children born in the study’s primary period, 2017-2019. 42% of these (1135) had been recommended or advised some form of cry it out methods; 312 had received this advice from at least one professional, 145 had received this type of guidance from their health visitor and 1016 received it from personal contacts, such as friends, family, colleagues or parent groups. A further 332 parents who had not received cry it out advice directly from professionals or personal contacts nevertheless read books or other media which recommended cry it out to them, and/or reported advice/recommendation about cry it out from social media. This means that 54% of the parents with children born in 2017-2019 have been exposed to cry it out sleep training in some form.

Many of these cases involved very young children – 25% of those who received guidance in cry it out from their health visitor, and who told us the age of their child at the time the guidance was given, received the guidance when their child was 0-3 months old.
Not all parents who received CIO advice from the health visitor actually followed that advice, but it appears that first-time parents are more likely to do so (46%) than those with older children (22%). For those that followed the advice, only 29% obtained the result that the child became able to fall asleep alone, without crying. This is far from impressive, especially given the potentially harmful effects of these methods. 

When we look at the 100 geographical areas from the study: 98 Danish municipalities as well as Greenland and the Faroe Islands, we found 67 areas where health visitors have advised parents in using cry it out sleep training – and, given the sample size of the questionnaire, this is likely to be a conservative estimate. Results from our request for access to documents and inquiries to the health care in all municipalities in Denmark are in marked contrast with each other: 9 municipalities sent us answers or literature, which showed that their health visitors had given this advice verbally or through written material. Out of these, only two municipalities answered yes to the fact that the management was aware that the health visitors orally instructed that the child could cry alone after it had been put to sleep. 74 municipalities clearly stated that they did not give CIO advice, and a remaining 15 did not provide adequate replies to the questions for a variety of reasons.

Most municipalities do not compose their own guidelines for their health visitors regarding advice on sleep, and they instead refer to the guidelines from the Health Ministry (Sundhedsstyrelsen). However, these guidelines are in many ways unclear and self-contradicting.
For in-depth explanation, please contact us as this has not been translated into English.

When we look at the more general sleep advice (for example, whether parents are encouraged to use or advised to avoid breast- or bottle-feeding around bedtime), there is a clear preference for advice that separates the child from the parent as opposed to advice which includes contact.  For children born in 2017-2019, parents are over 3 times more likely to receive only separation advice than only contact advice.

Discussion

It is clear that cry it out and other less far-reaching forms of sleep training are widespread in the areas included in this study. These outdated and potentially harmful concepts are circulating in the population, but they also come from health professionals and child care professionals as well as from literature that is recommended or handed out by health visitors.

Our study suggests a number of actions that could improve this situation.

First and foremost, clear and unambiguous guidance in children’s sleep is needed for health visitors and other relevant professionals. Ideally, the Health Ministry should compose and publish these, but the individual municipalities can supplement the Health Ministry’s guidelines with their own.

Secondly, more communication is required both in relation to the updated guidelines for professionals, but also more generally in society in relation to the potential harmful effects of sleep training. Here, of course, health visitors and other professionals have a major role to play in informing the public.

Thirdly, there is a need for for health visitors and their managers to have regular, focused conversations about sleep advice. The current situation, where managers do not have knowledge of how their employees supervise, or whether they follow the Health Ministry’s recommendations, is a societal problem and also probably leads to a significant underestimation of the incidence of sleep training when viewed from local or national management level.

Proponents of cry it out sleep training often claim that these methods are quite effective. Our study indicates that a significant majority of attempts to sleep train children for various reasons are not completed. Parents considering whether or not to try sleep training should be made aware of the potential harmful effects of these methods, as well as the low probability of achieving the desired goal of training the child to sleep alone.

The use of sleep training points to a more general societal assumption that children’s development of independence (including being able to fall asleep on their own, sleep through without help and calm themselves) is natural and desirable even at a very young age, and that separation of parents and child are a tool to achieve this goal. However, this assumption has long been rejected through, for example, the research in attachment.

In addition to the debate on sleep training, there is therefore a broader question that needs to be asked regarding the validity of the view of forced and structured separation as a tool for developing independence.