The Ferber method: An evidence-based guide to "cry it out" sleep training

© 2008 - 2014 Gwen Dewar, Ph.D., all rights reserved

The Ferber method—also known as “graduated extinction”—is perhaps the most well-known sleep training program for children.

It is also one of the most controversial, primarily because the method involves a degree of “crying it out.” In a series of training sessions, parents leave their children alone for strictly-timed intervals, ignoring their children’s protests and cries. When the method works, kids gradually accept that no one will come to their aid, and, as a result, their behavior becomes less disruptive (Reid at al 1999).

If you’re considering sleep training for your child, this article will help you decide if graduated extinction is the right method for you. Here I review

• When sleep training is NOT appropriate

• How graduated extinction works

• Arguments for and against graduated extinction

• “Gentle” alternatives to graduated extinction and their success rates

As I note below, the scientific evidence suggests that these "gentler" alternatives are as effective as the Ferber approach.

Before you begin: When is the Ferber method inappropriate?

Although the Ferber sleep training is controversial, there are some things the experts agree about.

1. The Ferber method is NOT appropriate for young babies

Young babies need to feed at night, and their sleep-wake patterns are still immature. For these reasons, even researchers who advocate Ferber sleep training warn that sleep training is inappropriate for babies under 6 months old (France and Blampied 1999; Owens et al 1999).

Instead, parents can try out a number of safe, age-appropriate tactics for improving their babies’ sleep. For more information, see these articles on infant sleep problems and infant sleep aids.

For older infants, there is less agreement. However, most studies frequently cited in support of Ferber sleep training do not focus on babies under 12 months of age (France, Blampied and Wilkinson 1991; France 1992; Eckerberg 2004). Moreover, the few studies that have investigated possible side effects have relied on subjective parental reports. Third-party observational assessments and physiological measurements (like changes in stress hormone levels) have not been included in the research design (Mindell et al 2006).

One exception is a study published in 2012 that tracked children from the age of 7 months and reported no increased risk of bad outcomes (Price et al 2012). However, as I note in this blog post, the study lumped together two different groups of sleep-training parents -- parents using the Ferber method, and parents using an alternative technique called "extinction with parental presence," wherein babies are not left alone. The study also appears to have lacked important controls. As a result, the research is not very useful for assessing effects of the Ferber method.

So a point raised by the American Academy of Sleep Medicine in 2006 remains relevant today: There hasn’t been enough research to determine what lasting effects "cry it out" sleep training may have on a child’s mood, behavior, and development (Mindell et al 2006).

Moreover, parents should consider that the Ferber method, or “graduated extinction,” is only one of several options. Two other methods—“extinction with parental presence” and “positive routines”—do not involve leaving babies alone to cry. These less controversial methods have been scientifically tested and judged to be as effective as graduated extinction (see below).

Given these points—and evidence that the Ferber sleep training may be harmful to some babies (see below)—it seems wise to avoid the Ferber method when children are very young. For more information about alternatives to the Ferber method, see this article on “no cry” methods of infant sleep training.

2. The Ferber method is NOT appropriate for kids who have a conditioned fear of being left alone in their beds or who have a conditioned vomiting response

Common sense suggests that traumatized kids should not be subjected to graduated extinction, and advocates of Ferber sleep training agree. If past experiences have taught your child to fear being left alone in his crib or bed—and/or to respond to separation by vomiting—you should consult with a behavioral psychologist about the most appropriate approach to sleep training (France and Blampied 1999).

3. The Ferber method is NOT appropriate as a treatment for most child sleep problems

When parents consider sleep training, it’s usually because their kids are experiencing bedtime problems and/or disruptive night wakings. The Ferber method seems like a possible solution. But is it?

The Ferber method is designed for one, narrow purpose: To get kids to fall asleep without parental soothing. Judged on this basis, the Ferber method is effective (see “Arguments in favor of the Ferber method,” below).

But the Ferber method is NOT designed to treat most of the sleep problems that CAUSE bedtime battles and night wakings. For instance, the Ferber method doesn’t address

• nighttime fears and separation anxiety

• daytime stress

• nightmares

• snoring and other forms of sleep-disordered breathing

• nocturnal headaches and other painful medical conditions

• circadian rhythm sleep disorders

• sleep walking and/or night-terrors

• sleep schedule problems caused by bedtimes that are too early

If one of these conditions is responsible for your child’s bedtime problems or night wakings, it’s important to find appropriate treatment. Otherwise, you risk worsening your child’s psychological problems or ignoring potentially dangerous medical conditions.

On the positive side, you might find that treating these conditions renders sleep training unnecessary. For instance, if your child resists bedtime because he isn’t sleepy, treating a circadian rhythm disorder or adjusting his bedtime may solve the problem altogether.

For help identifying—and treating—your child’s sleep troubles, see these articles on bedtime problems, night wakings, and nighttime fears.

4. The Ferber method does NOT teach kids how to fall asleep

As Richard Ferber himself acknowledges, the Ferber method doesn’t teach kids how to fall asleep on their own (Ferber 2006). Kids are simply denied access to their parents, and left to work it out for themselves.

If you really want to help your child fall asleep, try this alternative to the Ferber method—a sleep training program known as “positive routines with faded bedtime.” Unlike Ferber sleep training, the “positive routines” program will teach your child how to relax and prepare for bed (Adams and Rickert 1989).

You can also help your child fall asleep by following these sleep-promoting practices:

• Dim the lights in the evening

• Avoid exercise and stimulating activities before bedtime

• Avoid stimulants (like caffeine) and hard-to-digest foods before bedtime

• Help your child cope with nighttime fears

How the Ferber method works

The Ferber method is actually a variant of a sleep training program called “extinction.”

Extinction sleep training is based on the assumption that children have sleep problems because they have learned to depend on parental soothing to put them to sleep. Whenever kids are denied this parental soothing, they may stall, plead, cry, or throw tantrums to delay bedtime. Because they can’t fall asleep by themselves, kids will also be disruptive if they awaken during the night.

Parents who “give in” to their children’s demands for attention are reinforcing the problem behaviors. So the solution is for parents to put their children to bed (while they are still awake) and then leave them alone. If kids cry, parents are instructed to ignore it. Parents aren’t supposed to check on the child again unless it seems absolutely necessary (Owens et al 1999).

The Ferber method departs from extinction training in one key respect: It permits parents to check on their children—but only briefly and according to a strict schedule. On the first night of training, parents put their child to bed and then stay away for 3 minutes. After a brief check (during which the parents take care not to pick up or hold the child) the parents leave again—this time for 5 minutes. Subsequently, parents wait 10 minutes between visits until the child finally falls asleep.

For each night that follows, parents gradually increase the time between checks. For instance, on the second night, parents might wait 5 minutes before the first visit, 10 minutes before the second, and 12 minutes before all subsequent visits. On subsequent nights, these intervals might stretch to 20 minutes or more.

Some parents who try Ferber sleep training see improvements within a few days. In studies testing graduated extinction, parents may complete training within 4 weeks (e.g., Reid et al 1999).

But some parents—disturbed by the notion of ignoring their children, and concerned about the potentially harmful effects of training—drop out before they see any improvements in their children’s’ behavior. Kids subjected to the Ferber method may become much more distressed during training than they were before. These so-called “extinction bursts”--which include more frequent and intense crying, protests, and tantrums—persuade some parents to give up.

In addition, training may fail if parents are inconsistent and periodically “give in” to their children’s pleas. Ferber advises parents to stick to the routine, even if the child becomes so upset that he vomits. In this event, parents should clean up the mess quickly and then leave the room and continue training (Ferber 2006).

Arguments in favor of the Ferber method

According to scientific studies, extinction sleep training-—including Ferber sleep training-—is associated with the following positive outcomes (Mindell et al 2006):

• Kids who complete training are less likely to throw bedtime tantrums

• Kids who complete training are more likely to settle down at night within ten minutes

• Kids who complete training are less likely to awaken their parents during the night

• Parents who complete training report improvements in their own stress levels, mood, and interactions with their children

In addition to these positive results, parents have reported improvements in their children’s’ daytime behavior—perhaps because sleep training “graduates” were getting more sleep at night (Mindell et al 2006).

For parents enduring nights of sleeplessness and emotional turmoil, these outcomes are extremely important. Advocates of the Ferber method point out that parents who are sleep-deprived are at higher risk for depression and marital conflict (Mindell et al 2006). Such parents may develop negative feeling toward their children and the parent-child relationship suffers as a result. If parents can stop or reduce their children’s disruptive nighttime behavior, the whole family will benefit.

But the Ferber method isn’t the only sleep training program that delivers these benefits.

As noted below, alternative sleep training methods --methods that don’t involve leaving children alone to “cry it out”--have equally successful track records (e.g., Skulladotir et al 2003). For this reason, it’s important to consider the potential costs of Ferber sleep training.

Arguments against the Ferber method

Although studies show that extinction sleep training can be very effective in eliminating bedtime protests and stalling tactics, many people—parents, pediatricians, and researchers included—worry about potential side effects.

Leaving children alone to cry seems to violate our deepest instincts, and no wonder. For most of human history, our ancestors biggest sleep problem was almost certainly the avoidance of predators.

Like modern-day hunter-gatherers, our ancestors slept communally and shared “watch” duties (Worthman and Melby 2002). Children snuggled up to their parents and siblings. And if children cried out, it was important to soothe them quickly to reduce the chances of attracting predators to the camp.

In this setting--the setting that characterized millions of years of human and pre-human evolution--leaving a child alone at night would have constituted child abandonment, if not attempted infanticide.

Our evolutionary past has left its stamp in our brains. When babies and children are left alone at night, they are likely to experience one of the most primal and powerful stressors known to young animals--separation anxiety (Panksepp 2000). Separation anxiety is a panic response arising from a primitive part of brain that also processes information about physical pain (Panksepp 2000).

Concerns about separation anxiety and stress have led some pediatricians, researchers, and therapists to worry about the adverse effects of the Ferber method on a child’s health and well-being (e.g., Sears and Sears 1996; Commons and Miller 1998; Sunderland 2006).

How does the Ferber method affect a child’s stress response system? His relationship to his parents? His developing personality?

Advocates of extinction training note that no studies yet have demonstrated that the Ferber method harms children over 6 months old. But the truth is there hasn’t been much research to resolve the question.

Studies of human infants confirm that crying is physiologically stressful—increasing a baby’s blood pressure, heart rate, and cortisol levels (Levesque et al 2000; Luddington-Hoe et al 2002). Do the intensified crying bouts—the so-called “extinction bursts”—associated with the Ferber method put babies at risk? No one yet has tested this hypothesis.

Nor has anyone has examined the long-term impact of the Ferber method. As of January 2014, I can find no controlled, scientific studies that have attempted to measure the long-term effects of graduated extinction on a child’s

• physiological stress response

• attachment relationship with parents

• emotional development

• personality development, or

• expression of physical affection

As noted above, a study published in 2012 addressed some of these outcomes (Price et al 2012). But because families using the Ferber method were lumped together with families using an alternative method that didn't involve leaving babies alone, the results pertain to the effects of sleep training in general, not graduated extinction in particular. Moreover, it's not clear if parents in the control group actually refrained from sleep training, which makes the results particularly difficult to interpret.

So things haven't changed much since the American Academy of Sleep Medicine called for more research (Mindell et al 2006). We still need more information about the impact of treatment on "mood, behavior and development," and we still need to learn how individual differences among children might affect sleep training outcomes (Mindell et al 2006).

Different children have different temperaments and different needs. Some children have special problems with anxiety, or more difficultly coping with negative emotions. These kids may find the Ferber method especially distressing.

The Ferber method compared: How does it measure up against the alternatives?

The Ferber method is not the only option for parents interested in sleep training. Two alternatives include

• "Positive Routines with Faded Bedtime," and

• "Extinction with Parental Presence" (in which parents remain in the same room with children until they fall asleep)

The positive routines method teaches children how to fall asleep by pacing them through a series of relaxing bedtime rituals—-but only when the child is already showing signs of drowsiness. Extinction with parental presence is a variant of graduated extinction that doesn’t involve leaving children alone.

(For a step-by-step account of these methods, see my article on “gentle” sleep training.)

How does the Ferber method stack up against these two alternatives?

According to the American Academy of Sleep Medicine, these three methods "appear to be on a level playing ground" (Mindell et al 2006: 1269).

In the only controlled, randomized scientific study to compare these methods head-to-head, there were no significant differences in treatment outcomes for kids (Adams and Rickert 1989). However, parents who used Positive Routines reported more marital satisfaction than did parents who used the Ferber method (Adams and Rickert 1989).

The bottom line

The Ferber method can be an effective way to reduce nocturnal crying, protests, and requests for parental soothing. But it’s not the only effective method available.

Before you choose a sleep training program, review these points:

• Make sure that the sleep training program is age-appropriate

• Screen and address your child’s specific sleep problems

• Consider your child’s individual temperament and personality

• If your child has a conditioned fear of being alone or shows signs of conditioned vomiting, consult a behavioral therapist

• Before training begins, make sure that all participating adults understand the procedure. Regardless of the method you choose, success depends on being consistent.



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References: The Ferber methods and its alternatives

Adams LA and Rickert VI. 1989. Reducing bedtime tantrums: Comparison between positive bedtime routines and graduated extinction. Pediatrics 84(5): 756-761.

Commons ML and Miller PM 1998. Emotional learning in infants: A cross-cultural examination. Paper presented at the American Association for the Advancement of Science, Philadelphia, PA, February, 1998.

Ferber R. 2006. Solving your child’s sleep problems: New, revised, and expanded edition. New York: Fireside.

France KG. 1992. Behavior characteristics and security in sleep disturbed infants treated with extinction. J Pediat Psychol 17: 467-475.

France KG and Blampied NM. 1999. Infant sleep disturbance: Description of a problem behaviour process. Sleep Medicine Reviews 3(4): 265-280.

Levesque BM, Pollack P, Griffin BE and Nielsen HC. 2000. Pulse oximetry: What’s normal in the newborn nursery? Pediatric pulmonology 30(5): 406-412.

Luddington-Hoe SM, Cong X, and Hashemi F. 2002. Infant crying: nature, physiologic consequences, and select interventions. Neonatal Network 21(2): 29-36.

Mindell JA, Kuhn B, Lewin DS, Meltzer LJ, Sadeh A and the American Academy of Sleep Medicine. 2006. Behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep 29: 1263-1281.

Owens JL, France KG, and Wiggs L. 1999. Behavioural and cognitive-behavioural interventions for sleep disorders in infants and children: A review. Sleep Medicine Reviews 3(4): 281-302.

Panksepp J. 2001. Affective Neuroscience: The Foundations of Human and Animal Emotions. New York: Oxford University Press. Reid MJ, Walter AB, and O’Leary SG. Treatment of young children’s bedtime refusal and nighttime wakings: A comparison of “standard” and graduated ignoring procedures. Journal of Abnormal Child Psychology 27: 5-16.

Price AMH, Wake M, Epi GD, Ukoumunne OC, Hiscock H, Epi GD. 2012. Five-Year Follow-up of Harms and Benefits of Behavioral Infant Sleep Intervention: Randomized Trial. Pediatrics. (doi: 10.1542/peds.2011-3467)

Sadeh A. 1994. Assessment of intervention for infant night waking: Parental reports and activity-based home monitoring. J Consult Clin Psychol 62(1):63-8.

Sears W and Sears M. 1996. The fussy baby book: Parenting your high-need child from birth to age five. New York: Little, Brown and Company.

Skuladottir A, Thome M, and Ramel A. 2005. Improving day and night sleep problems in infants by changing day time sleep rhythm: A single group before and after study. Int J Nurs Stud. 42(8): 843-850.

Sunderland M. 2006. The Science of Parenting. New York: DK Publishing.

C.M. Worthman and M. Melby. 2002. Toward a comparative developmental ecology of human sleep. In: Adolescent Sleep Patterns: Biological, Social, and Psychological Influences, M.A. Carskadon, ed. New York: Cambridge University Press, pp. 69-117.

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