Seeing the Baby the Parent Sees:First Step to Understanding

Linda Gilkerson, Ph. DErikson Institute

Infant mental health is….

Capacity to form close, secure relationshipsexperience, regulate, & express emotions and

recover from dysregulationexplore the environment and learn in the

context of family, community, and culturalexpectations

Zero to Three, 2001

Basic needs in early development

• To have one’s competent performance validated and approved:– I can do it and you’re glad!

• To be protected & supported in times of stress that are beyondthe child’s ability to manage alone:– You’ll protect me and help me when it is too much for me.

• To be acknowledged by one’s kin as a fellow human being:– I belong.

» Kohut, 1981

Gilkerson ISBE/Erikson ECMH Consultation Project

Treatment

Secondary PreventionFussy Baby Network

Primary PreventionCrying Happens: What’s Your Plan

Purple CryingAnticipatory Guidance

“It’s like getting onthe fast track topersonal growth andyou can’t get off.”

Becoming a parent

Parents’ two worries

• Is my babyalright?

• Am I a goodenough parent?

T. Berry Brazelton, MD

Fussy Baby Network® Approach

Help from a dual perspective

(1) Help parents in the nowmoment with urgent concern

(2) Build their parenting capacityfor the future

• Parent’s confidence• Relationship• Child’s development

Infant crying

• What do you feel?• Where do you feel it?• What do you want to do?

All babies cry

Crying helps

• Increases lung capacity• Increases motor activity• Generates heat• Helps regulate temperature• Ensures survival

– “Acoustical umbilicalcord”

• Triggers social interaction– Lester, 2006

Crying as biological alarm

• Alerts parent• Does not tell source of

distress• Parents respond to level

of emotion in cry andcontext of cry

• Parents don’t respond toall cries

(Barr, Hopkins, & Green, 2000;Gustafson, Wood, & Green,2000)

Normal crying curve• Peaks at 4-6 weeks• First documented in

Brazelton’s practice• Replicated across cultures• For premature babies• Large variations in infants:

curve is average

(Barr, Konner, Bakeman, & Adamson, 1991;Brazelton, 1962; St. James-Roberts, Bowyer,Varghese, & Sawdon, 1994)

12 weeks

6 weeks

Colic• High amount of crying• Sudden onset

– Paroxysmal– Unpredictable

• Cry quality– Higher pitch, reaches peak quickly– Like a pain cry

• Physical signs– Clenched fists– Grimace/flushing– Gas/distention

• Inconsolable bouts(Lester, Boukydis, Garcia-Coll, & Hole, 1990)

“Late afternoon fist-shaking rage”

Maternal-Infant

DistressRegulatoryproblems,

neurologicalhyper-

sensitivity

Immaturity ofthe digestive

systemExcessive gas

Crying ofnormal

development

Temper-ament

Colic

Bacterialover

Growth -imbalance

Underlyingmedical

condition orinfection

Milkproteinallergy

Reflux

ExcessiveCrying inInfancy

Evaluation and treatment by maternal-infant mental health specialistMaternal psychotherapy

Reflux medicationSmaller, frequent mealsUpright positioningThickening feeds

Maternal dairyelimination if breastfed.Formula change to soy-based or elementalformula

Evaluation andtreatment by medicalprofessionals

Probiotic foods orsupplementsTargeted antibiotics

Simethicone(Mylicon)ChamomileGripe waterDill oil, Fennel oilDicyclomine(Bentyl)

Swaddling, Side positioning,Shushing, Swinging, SuckingEnvironmental dampeningInfant massage / touchChiropractic manipulation

Who is a fussy baby?

• Parent’s perception of the cry, rather than theamount of crying, predicts family stress andmaternal depression/anxiety.– For mother’s (Gilkerson, Porges, Gray et al, in preparation)

– For father’s (Katch, in preparation)• Fussy Baby Network Definition

– A fussy baby is any baby a parent feels is hard forthem to soothe, help sleep, or to feed

– Parent-identified eligibility

For most babies, cry problems resolve.

• A review of 12longitudinal studiesfound that “most infantswith colic have a goodprognoses for normalphysical, cognitive, andbehavioraldevelopment.”

(Lehtonen, 2001)

Why worry about fussy babies?

1.Risk for family stress and maternal depression2.Risk for child abuse3.Risk for parent-child relationship problems4.Risk for child behavior/development problems

Parental Overload

• Extreme fatigue, tension, exhaustion• Depression, helplessness, feelings of failure• Vulnerability, powerless anger, feelings of

rejection• Neglect of own needs; social isolation• Distress/conflict in couple’s relationship• Inhibition of intuitive parenting

• Ziegler, deChuquisengo, & Papoušek, 2008

“No one said it would be this hard.”

• Disrupted dailyroutines

• “Just doing the simplest things…it’sjust not possible”

• Disrupted personallives

• ‘You read about stress in themarriage. This is the stress in themarriage”

• Disrupted social lives• “Now that we have this baby, we

can’t even leave the house”

Criticism and isolation• Family/strangers criticize their parenting

“If only you would...”

• Others don’t believe that the baby cries“I don’t know what you are talking about. This baby is fine.”

• Parents must deal with backlash over crying“It’s hard to feel validated.”

• Parents feel guilty and apologetic“I’m not hurting her, I swear.”

• Parents begin to feel undermined and isolated“I’m just going to stop talking about it.”

Parents ask:“Where is the finish line?”

“You think it is never going to end…”

Negative emotions• Wishing infancy away

• “ It’s supposed to be bliss…• I just want it to be over.”

• Progression of emotions• Overwhelmed• Angry• Guilty

“Do you ever get mad at her?…feel like you’re going to hurt her?”

Risk for depression• “Double Whammy”

of Infant Colic andMaternal Depression

• 46 % of mothers seen atBrown University ColicClinic had moderate tohigh depression

(Maxted et al., 2005)

files.blog-city.com/.../86734/p/f/sleepless.jpg

Mothers with high depression

• More likely to see infant as fussy-difficult• Reported significantly more ‘daily hassles’• Reported problems in family functioning• Had significantly lower maternal self-esteem• Reported less social support, and less

satisfaction from social support(Maxted et al., 2005)

)

Conclusions

• The ‘double whammy’ of colic and maternaldepression could place these children, mother-infantdyads at additional risk

• Colic is not just a problem of infant management• Health care professionals need to address maternal

functioning and family functioning issues whentreating infant colic and excessive infant crying

(Maxted et al., 2005)

Positive emotions

• Ending of negative emotions

• Strong bond with child

• Personal growth

• Acceptance“I learned a lot about being patient

… giving of myself unconditionally.”

“Colic changes you.”Lester, 2006, p.39

• Baby– See me

• Family– Hear me

• Helpers– Teach me

Interactional Failurein Soothing Context

• Baby– When being held, “fighting against going to sleep” with motor restlessness,

tactile rejection, and back-arching• Parent

– Ineffective normal soothing strategies during crying bouts– Use dysfunctional interactions when soothing and settling to sleep with

frequent changes in intense or bizarre soothing strategies• Parent/Baby

– Impeded handling in face of motor restlessness and parental insecurity– Vicious circles of reciprocal escalating tension and arousal

• Interruption of fussiness by carrying around and offering diversified stimulation;interruption of stimulation triggers immediate crying, which is answered byintensified stimulation

– Lack of “angel circles” with intuitively attuned relaxed dialogues aftersuccessful soothing or during quiet alert waking states

• Ziegler, deChuquisengo, & Papoušek, 2008

Risk for child abuse

Crying DurationShaking Baby Cases

Age in Weeks

2.75 hrs.

(Barr, Trent, & Cross, 2006)

0

5

1 0

1 5

2 0

2 5

3 0

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Age in Months

Gray et al, 2004

ADMISSIONS TO ER FOR INFANT CRYING

33% had diagnosis of colic/crying

6-11AM12-5AM6-11PM12-5PM0

5

10

15

20

25

30

35

40

# O

F PA

TIEN

TS

Time of ER Visit:

(Gray et al, 2004)

Excessive Crying in InfancyClinical Syndrome

• Triad of Symptoms– Infant Behavioral Problems

• Inconsolable crying with problems in sleep-wake organization– Parental Overload/Psychological Distress– Parent/Infant Interactional Failure in Soothing Context

• Face-to-face well-attuned• Stressed/dysregulated during inconsolable crying and settling to

sleep• Repeated dysregulated patterns can spill outside of soothing

interactions and create a pattern of Parent/Infant RelationshipDistress

– Ziegler, deChuquisengo, & Papoušek, 2008

Infant Behavior• Autonomic

– During paroxysmal bouts, over-inflatedtummy, reddened face

• Motor– Restlessness/fussiness– Hyperextension– Tactile defensiveness; resist close body

contact– Urge to be in vertical position; rejection of

horizontal position—supine or prone– Need to be carried around in upright

position for vestibular and visualstimulation

– Irregular tone, some asymmetries; slightneuromotor delay may be caused bycontinual carrying and lack of prone/supineposition on firm surface

– Occasional functional abnormality ofcervical vertebral column from birthtrauma or intrauterine positioning

• Ziegler, deChuquisengo, & Papoušek, 2008

• State• Unexplained, inconsolable crying with

long periods of inexplicable fussiness andirritability

– Shrill, hyper-phonic, dysphonic crying– Absence of or brief quiet alert states– Cumulative sleep deficit with extremely

short day sleep phases; fall asleep late andnever compensate during the day

– Over-fatigue and hyper-reactivity withcrying peak in evening hours

• Regulatory• Hyper-reactive to internal and external

stimuli; hyper-sensitive to sound– Paradoxical “hunger” for stimulation (wide

open eyes, seeking stimulation) and can’tavert gaze when tired or over-stimulated

– Overanxious with anxious withdrawal; toprotect from over-stimulation may useexcessive inhibition or freezing with sleeplike breathing and staring (asleep with eyesopen)

• If rule out (or in)– Medical problems (ear infections, UTI, fractures)– GI Problems

• Reflux• Lactose intolerance• Cow’s milk protein intolerance

– Functional abnormalities of spinal column

Regulatory Imbalance• Imbalance between excitatory (arousing) processes and inhibitory

(calming) processes (Lester, Boukydis,Garcia-Coll, Hole, & Peucker, 1992)

• Imbalance impedes infant’s regulation of stable sleeping and waking statesand smooth transitions between states (Papoušek & Papoušek, 1984)

• Underlying cause is not known– Sucrose hypothesis: central self-soothing mechanism is not developed– GO systems (sympathetic nervous system) develops before SLOW systems

(parasympathetic)– Transient immaturity or temperament

• State or trait?– Prenatally acquired constitutional factors

• Pretty good evidence (human and animal) that prenatal stress in mother relates toneonatal irritability and excessive crying in first 6 months

Parent/child relationship problems• Parent is overwhelmed by baby’s needs

– Parent can’t hear baby’s cries• Parent feels baby’s cries are rejection

– You don’t love me. I’m a bad mother.• Parent feels baby’s cries are aggressive

– You kicked me for 9 months. You’re not gonna push mearound now.

• Parent unable to care for baby in a consistent,nurturing way– Baby may withdraw from or resist parent; builds into

separation problems, temper tantrums, sleep problems,precocious caregiving: child becomes the parent

Risk for developmental/behavioralconcerns

• Severe colic/persistent excessive crying in infancy hasbeen linked to the following child outcomes:– Motor, language, and cognitive delays– Behavioral problems (“temper tantrums”)– Negative reactivity (“fussiness”)– Sleep disorders– Feeding problems– Parent-child relationship problems– Hyperactivity

(DeGangi et al., 2000; Kries, Kalies, & Papousek, 2006; Papousek & von Hofacker, 1998Rautava et al., 1995; Savino et al., 1995; Wake et al., 2006; Wolke, Rizzo, & Woods, 2002

Sensory processing at3 to 8 years of age

• 75% demonstrated some degree of atypical sensoryprocessing

• Hours of fussing—not crying—were associated withless efficient skills in sensory processing, coping, andexternalizing behaviors.

• Crying: seen as adaptive, organized behavior• Fussing: seen as physiological, self-regulatory

deficiency• (Desantis, Coster, Bogsby, & Lester, 2005)

New Rule of 3’s

• Follow• Until• Resolved

Fussy Baby Network® Approach

Intervention Processes

• Mindful-Self Regulation:– Maintain/return to a calm state

• Empathic Inquiry:– Explore parent’s feelings about baby and parenting

• Collaborative Exploration:– Eevelop shared understanding of baby; parents’ goals,

theory of the problem, solutions tried• Capacity Building:

– Etrengthen parents’ confidence and competence• Integration:

– Build a coherent narrative around stressful experience

Why do parents call?

• 91% of parents call because of a concernrelated to crying, sleeping and/or feeding– 50% excessive crying– 34% sleeping difficulties– 7% feeding challenges

Families• Racial/Ethnic Background Primary Caregiver

– 47% Non-Hispanic Caucasian– 30% African-American– 18% Hispanic/Latino– 3% Asian– 2% Multi-racial

• Income– 23% of families earn less than $15,000– 36% of families earn more than $75,000

Age of Referral• Most babies are referred during the “crying months”

– Average age at referral 16.3 weeks (almost 4 months)61% 0-3 months of age19% 4-6 months of age13% 7-9 months of age7% 10 months and older

Referral sourcesFBN referral sources

35%

15% 19%

31%

Health Provider

Advertising

Internet

Other (trainings,friends, socialservice)

Change in Distress RatingsComparison of recalled distress

at intake and case closure

Time

Case ClosureIntake

Estim

ated

Mar

gina

l Mea

ns

5.0

4.5

4.0

3.5

3.0

2.5

2.0

1.5

1.0

Family Type

Non Foster Family

Foster Family

Program Evaluation

• Satisfaction rating: average of 4.7 (1 – 5 scale).

“The suggestions that were given really made a big difference in my life. Iam truly grateful for the intervention.”

“My wife works during the day and they even called her so that she couldbe involved. They listened before they responded. They broke downquestions to make sure they understood what I meant. The doctor listenedto us. When I brought up feeding issues, the doctor listened to us and weended up being right.”

“She asked great questions and had simple, effective advice. She broughtour attention back to when the baby wasn't crying and reminded us how wefelt about our baby then. She helped us cope with the crying.”

Parenting Stress

Parenting stress for mothers of fussy babies, pre- and post-FBN services, compared to non-help-seeking mothers

PS

I sco

re

Maternal Self-Efficacy

Maternal Self-efficacy for mothers of fussy babies, pre- andpost-FBN services, compared to non-help-seeking mothers

Maternal Depression

Depression for mothers of fussy babies, pre- and post-FBNservices, compared to non-help-seeking mothers