What Can We Learn About Risk Assessment From the Controversy Over Co-sleeping?

      Ontario Coroner Dr. Jim Cairns stated, "For every child who dies in a crib, we have three or four who die from co-sleeping." But is bed-sharing really the culprit?

      The Coroner's Pediatric Death Review Committee reviews child deaths to glean information about potential risk factors that could help prevent similar deaths. As such, it performs a vital fact-finding and watchdog role for Ontario citizens. The coroner's committees and inquests also make recommendations that can influence health care, child protection, etc.

      The major limitation of the Committee's approach is that they used case reviews rather than representative samples and follow-up studies. Seeing a high prevalence of co-sleeping among the cases, the committee prematurely concluded that co-sleeping was a risk factor for child death in Ontario. They also made a common assumption: that risk factors are also causes.

      Some factors that might have led to a relatively high prevalence of bed-sharing in child death cases are:

• The popularity of bed-sharing. Studies show that 40 percent to 75 percent of parents in the United States share a bed with their baby. The American Academy of Pediatrics says that bed-sharing is increasing, so more children sleep in parents' beds than in the past, including healthy babies.

• Definition of infant deaths. The definition of Sudden Infant Death Syndrome (SIDS) used by the Committee since 2002 no longer includes cases where the baby was sharing a bed, so these cases automatically become "unexplained" deaths.

• Definition of bed-sharing. The Committee's 11 cases of unexplained deaths during bed-sharing included infants sleeping with an adult or another child on a bed, couch, or floor. Controlled research has found that children who share a bed with people other than just their parents are at especially high risk of SIDS.

• Bed-sharing coincides with other risk factors. Studies show that bed-sharing is more common among teen mothers, mothers who smoke, and other risk factors for poor infant health. More than half of the 11 cases of unexplained deaths involved parents who had been drinking alcohol.

      One advantage of unrepresentative case reviews is that they can identify possible risk factors for further study. In controlled research on co-sleeping, the significant factors are: sleeping in a prone position, on a soft surface, with a pillow, sharing a bed other than with parent(s) alone, and not using a pacifier. The finding that infants sleeping on their tummy are at risk for SIDS, and thousands of infant deaths have been prevented by public health education campaigns such as "Back to Sleep."

       Another example was the Coroner's recommendations for risk assessment research that arose from inquiries into high profile domestic murder-suicides. They resulted in a research collaboration between our Research Department and the OPP's Behavioural Sciences Section. The Coroner's Domestic Violence Death Review Committee suggested that suicidality was a risk factor for domestic murder. In contrast, our follow-up research with a representative sample showed that suicidality was not a risk factor for future domestic assaults or their severity. (See the article, "What can we do about domestic murderers?).

      The lessons learned from the co-sleeping controversy can be applied here at MHCP. For example, informal program evaluation with a limited sample of clients who give feedback on the program can help highlight potential benefits and problems, and generate ideas for formal followup evaluation with more objective measurement and greater representation from the clientele. Another example is risk assessment. At MHCP, the co-occurrence of mental disorder and violent behaviour can give the impression that mental disorder causes violence; however, research shows that it is a protective factor, and this information is included in actuarial violence risk assessment. Overriding the actuarial data based on experience with case reviews would result in poor decisions and an unintended increase in violence. At the same time, important risk factors should not be overlooked just because it is hard to see how (if at all) they cause violence.

       The case review approach can identify important factors but more representative, controlled research must be done to confirm whether those factors cause the effects or are true risk factors.