Working with Families with Infants with Cry, Sleep Feeding Problems

1. Working with Familieswith Infants with Cry, Sleep & Feeding Problems Zack Boukydis, Ph.D. Associate Professor Institute of Psychology Illinois Institute of Technology cboukydi@iit.edu

2. Why Do Babies Cry? List:

3. What is the function of babies’ crying? Distress Signal [Communicates with Parents] Regulating Mechanism Any Baby’s Cry Signals Different Levels of Arousal and Is An Attempt to Return to a More Stable State

4. Normal Crying Curve Peaks at 4-6 weeks First documented in Brazelton’s practice Replicated in 15 studies Across cultures True for preemies and full-terms Normal crying curve—peaks at about 6 weeks --some evidence now it might be 4 weeks.. First documented by Berry Brazelton in 1962 through cry diaries kept by families in his Cambridge Mass practice Confirmed in over 15 studies…audio recordings, observations, diaries True across cultures that have been studied—western to continuous caregiving-- True for premies as well as Can complicate interventions… try a different formula at the beginning of cry curve may not feel it is helping, when it actually is try something toward the end, even if not right thing…seem like it is working Normal crying curve—peaks at about 6 weeks --some evidence now it might be 4 weeks.. First documented by Berry Brazelton in 1962 through cry diaries kept by families in his Cambridge Mass practice Confirmed in over 15 studies…audio recordings, observations, diaries True across cultures that have been studied—western to continuous caregiving-- True for premies as well as Can complicate interventions… try a different formula at the beginning of cry curve may not feel it is helping, when it actually is try something toward the end, even if not right thing…seem like it is working

5. How Does Crying Effect Families? List:

6. How does inconsolable crying affect families? Disrupted lives Living on the edge Social isolation Search for a diagnosis Helpless/rejected Maternal depression Marital discord Family stress ·Parents say their lives are disrupted ·feel like they are living on the edge ·Become socially isolated—don’t go out; don’t have others in ·Withdraw…Search for a diagnosis…. ·what is the matter with my baby? With me? ·In the face of unexplained, uncontrollable crying, parents feel helpless and inadequate, and rejected. ·For mothers particularly painful because feel like good mothering being able to quiet your baby and feed your baby. ·Maternal depression and Colic: reseracher a Brown found what they called the Double Whanmmy” for famlies: colic and symptons of matrenal depression in 46% of the group relative midle calss mostly causcais families; appearing elsewhere in literature as well; consult that health care provider must address mother’ s functioning and family issues when treating infant colic ·Impact on couple and family system: ·One study looked at families with no colic, moderate, and severe colic on families, ·Unsure and Unorganized ·families less organized; weaker parental coalitions; unclear boundaries; especially with grandparents; parents in study were younger and first baby; Severe Colic: ·Together in Distress ·More organized family structure; stronger coaliton between parents ·But less optimism, satisfaction, energy, most unresolved conflicts, most blaming, and difficulty coping ·BY 36 months, there was still a trend toward less optimal family functioning in colic families ·Colic is a family problem and efforts need to be efforts at the family level. ·Parents say their lives are disrupted ·feel like they are living on the edge ·Become socially isolated—don’t go out; don’t have others in ·Withdraw…Search for a diagnosis…. ·what is the matter with my baby? With me? ·In the face of unexplained, uncontrollable crying, parents feel helpless and inadequate, and rejected. ·For mothers particularly painful because feel like good mothering being able to quiet your baby and feed your baby. ·Maternal depression and Colic: reseracher a Brown found what they called the Double Whanmmy” for famlies: colic and symptons of matrenal depression in 46% of the group relative midle calss mostly causcais families; appearing elsewhere in literature as well; consult that health care provider must address mother’ s functioning and family issues when treating infant colic ·Impact on couple and family system: ·One study looked at families with no colic, moderate, and severe colic on families, ·Unsure and Unorganized ·families less organized; weaker parental coalitions; unclear boundaries; especially with grandparents; parents in study were younger and first baby; Severe Colic: ·Together in Distress ·More organized family structure; stronger coaliton between parents ·But less optimism, satisfaction, energy, most unresolved conflicts, most blaming, and difficulty coping ·BY 36 months, there was still a trend toward less optimal family functioning in colic families ·Colic is a family problem and efforts need to be efforts at the family level.

7. Parent/Infant Distress Dynamic interaction between infant and parent factors Often beginning during pregnancy With more disorganized infant behavior Families with more limited resources and higher risk Crying infant, troubled parent, distressed relationship

8. What are the three major variations in excessive early infant crying? Excessive crying Colic Reflux

9. What is Excessive Crying?Rule of Three’s More than 3 hours per day More than 3 days per week More than 3 weeks in a row --not necessarily every day—”good days and bad days”; unpredictable --hold your breath kind of thing--- when will this happen; where will we be; what will we do --part of the pain of colic—for baby and parent is: inconsolible crying --you can’t stop it—very easily --wonderful awful truth: babies can cry incosolably despite excellent parenting What see in colicy riers is bouts of screaming attacks, explosie and inconsolable crying Noise and rumbling in the gut, gas and apparent stomach pain—legs drawn up; fists clenched Very important to note that parents respond not just to the sound of the ry but ot hte non-verbal—watch those little faces become red, “ angry” --not necessarily every day—”good days and bad days”; unpredictable --hold your breath kind of thing--- when will this happen; where will we be; what will we do --part of the pain of colic—for baby and parent is: inconsolible crying --you can’t stop it—very easily --wonderful awful truth: babies can cry incosolably despite excellent parenting What see in colicy riers is bouts of screaming attacks, explosie and inconsolable crying Noise and rumbling in the gut, gas and apparent stomach pain—legs drawn up; fists clenched Very important to note that parents respond not just to the sound of the ry but ot hte non-verbal—watch those little faces become red, “ angry”

10. How to Use the Cry Diary to Help Parents Identify Patterns See Handouts: Behavior Diary Instructions for Competing the Behavior Diary My Baby’s Day

11. What is COLIC!!!!!!!!!! Give your immediate answer

12. What is colic? Physical Signs Paroxysmal Onset Cry Sound Consolability What is colic? first identified by british ped. Illingsowrth violent, rhythmical, screaming attacks which did not stop when the babies were picked up for which no cause such as underfeeding could be found prolonged crying—really not more bouts, but much longer often unpredictable—good days and bad days most crying for all babies in evening, but not always higher pitch—cry studies that higher pitch is more aversive to adults resists soothing—what makes it so hard—unsoothable crying paroxysmal--Sort of like a big mac attack--explosive can come out of no where; intense; begin and end without warning seemingly unrelated to other events whole body cry: fits—our Emily—late afternoon fist shaking rage flushed face, red, arching back, legs drawn up gas, stomach may be hard,intense, rumblings ·Wonderful picture of Rebecca’s cousin’s baby Ms. Fussy, Formerly known as Emily ·In her father’s works—late afternoon fist shaking rage ·He mused—about these Bic Mac attacks, I wonder where Emily goes when Ms. Fussy takes over her body ·In his wisdom, shared their realization that: ·To create calm, first you must possess it. ·What a lesson Ms. Fussy brought to the family. What is colic? first identified by british ped. Illingsowrth violent, rhythmical, screaming attacks which did not stop when the babies were picked up for which no cause such as underfeeding could be found prolonged crying—really not more bouts, but much longer often unpredictable—good days and bad days most crying for all babies in evening, but not always higher pitch—cry studies that higher pitch is more aversive to adults resists soothing—what makes it so hard—unsoothable crying paroxysmal--Sort of like a big mac attack--explosive can come out of no where; intense; begin and end without warning seemingly unrelated to other events whole body cry: fits—our Emily—late afternoon fist shaking rage flushed face, red, arching back, legs drawn up gas, stomach may be hard,intense, rumblings ·Wonderful picture of Rebecca’s cousin’s baby Ms. Fussy, Formerly known as Emily ·In her father’s works—late afternoon fist shaking rage ·He mused—about these Bic Mac attacks, I wonder where Emily goes when Ms. Fussy takes over her body ·In his wisdom, shared their realization that: ·To create calm, first you must possess it. ·What a lesson Ms. Fussy brought to the family.

13. What does colic ‘look’ like? Physical Signs (grimace, clenched fists/flushing, gas/distension) Paroxysmal Onset (sudden, undpredictable) Cry Sound (high pitch) Consolability (hard to soothe, prolonged cry bouts)

14. View Tape of Crying Infant and Parent 1. Complete Cry Characteristics Questionnaire (see handout) 2. What might mother be feeling? 3. What ‘strategies is mother using?

15. Getting a Better Description of Baby’s Cry-Related Behavior Review Handout Symptoms of Colic Questionnaire

16. Who gets colic? Birth order Feeding style Cultural Groups SES Healthy babies Can occur in spite of excellent parenting Anyone— --about 20% of all babies—700,000 a year --been there since the beginning; not caused by our modern life --not birth order—experienced parent or new parent --first time families bring it to attention of pediatrician more --not feeding style—breast or bottle fed babies --seems to be in all cultures: In Asian cultures more likely to be viewed as part of normal development Chinese: 1000 days of crying Vietnamese: “three months plus ten days” crying Japanese: “Evening Crying” We call it colic: derives from greek word meaning colon middle class, Caucasian parents tend to report more colic and seek help for colic more do know that babies in continuous carrying societies—where baby always held and nursed almost continuously look a little different --same crying peak at 6 weeks that is in all cultures studied --have same number of bouts of crying --bouts don’t last as long --overall less crying know that colic occurs in healthy babies know that it can occur in spite of excellent parenting these two alone—organic problems in the baby or problems in the family are not thought to explain the majority of cases of colic Anyone— --about 20% of all babies—700,000 a year --been there since the beginning; not caused by our modern life --not birth order—experienced parent or new parent --first time families bring it to attention of pediatrician more --not feeding style—breast or bottle fed babies --seems to be in all cultures: In Asian cultures more likely to be viewed as part of normal development Chinese: 1000 days of crying Vietnamese: “three months plus ten days” crying Japanese: “Evening Crying” We call it colic: derives from greek word meaning colon middle class, Caucasian parents tend to report more colic and seek help for colic more do know that babies in continuous carrying societies—where baby always held and nursed almost continuously look a little different --same crying peak at 6 weeks that is in all cultures studied --have same number of bouts of crying --bouts don’t last as long --overall less crying know that colic occurs in healthy babies know that it can occur in spite of excellent parenting these two alone—organic problems in the baby or problems in the family are not thought to explain the majority of cases of colic

17. Normal end of crying curve GI problems Allergies Sensory Thresholds Immaturity To be determined Why do babies get colic? --colic can be viewed as the normal end of the crying curve: not a condition or an illness but just those high end cryers doing what babies do but more of it; extreme end of nomral continuum; there is this issue though of the big mac attacks—that kind of crying is typically not in the normal curve and some of these high end criers have that and some don’t Weissbluth vies not realy different that regular fussiness but moreintens, last s longer --gassiness is from air swallowed during crying --No evidence for real GI problems: typicall don’t have problems with weight gain, diapherr, consti, spittin up Noe stron evidence for food alleries or feeding problems; alothoug some small percentage of babies are lactose inoterant and worth checking out Some of the babies are stimlus sensitive—have to be careful around them—sensitive babies—perceptinve babioes—esaily startled, easily awakened, lots of night waking—but this is not true of all babies --general immaurity of nervous system-catch up idea—come a little unfinished: --fourht trimester idea fits in here—Harvey Karp—Happiest baby on the Bolsk—babies not ready to be born need another trimester in the pouch—like a knagaroo---to soothe them need to creat cirumlstance of womb kick in their calming reflex --systems theoryLbabies need this high level of arousal for brain development; a necessary energy expenditure! why these we don’t know; but the crying serves a neurodevelopmental putpose; accomplishes its goal, it stops other systems can take over—know that reframing helps under stress: he is doing what he needs to be doing?? --Weissbluth takes the position that the more you know about extreme crying the less worried you will be; not an illness or a condition --in this view, after it passes it is over --most frequent long-term problem and what you want to try to prevent is long-term sleep problems Larry is going to talk about —feels this comes from families who have not had a normal life; no strcutr possible… --RE Learn to parent a Normal Baby—you can have a schedule; you can put baby down to sleep,even though he may have learned that falling asleep means being held --colic can be viewed as the normal end of the crying curve: not a condition or an illness but just those high end cryers doing what babies do but more of it; extreme end of nomral continuum; there is this issue though of the big mac attacks—that kind of crying is typically not in the normal curve and some of these high end criers have that and some don’t Weissbluth vies not realy different that regular fussiness but moreintens, last s longer --gassiness is from air swallowed during crying --No evidence for real GI problems: typicall don’t have problems with weight gain, diapherr, consti, spittin up Noe stron evidence for food alleries or feeding problems; alothoug some small percentage of babies are lactose inoterant and worth checking out Some of the babies are stimlus sensitive—have to be careful around them—sensitive babies—perceptinve babioes—esaily startled, easily awakened, lots of night waking—but this is not true of all babies --general immaurity of nervous system-catch up idea—come a little unfinished: --fourht trimester idea fits in here—Harvey Karp—Happiest baby on the Bolsk—babies not ready to be born need another trimester in the pouch—like a knagaroo---to soothe them need to creat cirumlstance of womb kick in their calming reflex --systems theoryLbabies need this high level of arousal for brain development; a necessary energy expenditure! why these we don’t know; but the crying serves a neurodevelopmental putpose; accomplishes its goal, it stops other systems can take over—know that reframing helps under stress: he is doing what he needs to be doing?? --Weissbluth takes the position that the more you know about extreme crying the less worried you will be; not an illness or a condition --in this view, after it passes it is over --most frequent long-term problem and what you want to try to prevent is long-term sleep problems Larry is going to talk about —feels this comes from families who have not had a normal life; no strcutr possible… --RE Learn to parent a Normal Baby—you can have a schedule; you can put baby down to sleep,even though he may have learned that falling asleep means being held

18. What is it like for parents? “My baby cries so much; I cry with him” “I haven’t hurt her.....but I feel like it.” “Do you ever get over the resentment?” “When will this be the best experience of my life?” ·Can be very hard ·Literature most lasting effect may be on the parents and on family’ s functioning ·What have we heard: ·My baby cries so much, I cry with him ·From a 20 year old mom on Chicago’s south side ·I haven’t hurt her…but I feel like it. ·From a slightly older new mom on the north side ·Do you ever get over the resentment? ·From the dad that asked me at a holiday party ·When will this be the best experience of my life? ·From the dad of a 6 month old baby ·Can be very hard ·Literature most lasting effect may be on the parents and on family’ s functioning ·What have we heard: ·My baby cries so much, I cry with him ·From a 20 year old mom on Chicago’s south side ·I haven’t hurt her…but I feel like it. ·From a slightly older new mom on the north side ·Do you ever get over the resentment? ·From the dad that asked me at a holiday party ·When will this be the best experience of my life? ·From the dad of a 6 month old baby

19. Begins early: 100% by 3 weeks End varies: 50% by 2 months 80% by 3 months 90% by 4 months (Weissbluth, 1998) How long does colic last? Begins early: 80% by 2 week, all by 3 week End varies: 50% by 2 months 80% by 3 months 90% by 4 months Moral of story: you can’t promise parents when it will be over. Remember, that babies without colic, crying peak is about 6 weeks begins to diminish Colicky babies continue to cry—a lot—for 2, 3, 4 more months— families begin to feel like your baby is really different than others; like your experience as a parent is different quote a dad: my wife is very patient and has an innate love for Grace—I am not as patient and sad. This whole experience has discolored our first months with our baby.” --if crying persists after 5-6 months and is accompanies by other challenges such as difiiculty self-soothing, stress around tranisitons, and hypersentivities-begin to think about something else—this of the possibility of regulatory challenges or a regularoy disorder.. Begins early: 80% by 2 week, all by 3 week End varies: 50% by 2 months 80% by 3 months 90% by 4 months Moral of story: you can’t promise parents when it will be over. Remember, that babies without colic, crying peak is about 6 weeks begins to diminish Colicky babies continue to cry—a lot—for 2, 3, 4 more months— families begin to feel like your baby is really different than others; like your experience as a parent is different quote a dad: my wife is very patient and has an innate love for Grace—I am not as patient and sad. This whole experience has discolored our first months with our baby.” --if crying persists after 5-6 months and is accompanies by other challenges such as difiiculty self-soothing, stress around tranisitons, and hypersentivities-begin to think about something else—this of the possibility of regulatory challenges or a regularoy disorder..

20. Many ask: Are mothers to blame? Are the babies in pain? Mothers are not to blame for colic—even though they feel like they are.really begins early; bvasically consitutional, mothers are not causing the basic problem— Yes, babies can be more irritiblity in highly stressed pregnancies; babioe sexposed to smake and substance pr3natially may be more irritible, but not always; l -but true colic is not caused by the way the baby is handled, if it were, we could fix it; not caused by how parents think about baby; ithought about, Are the babies in pain? --curerntly pediatric htinking is no: if give colicy baby sucrose, does not stop the cyring—typical sucrose will stop cries of pain --pain medications don’t stop colic --only dilemma here is cry reserachers say really only two kinds of cry patterns: hunger and pain; looks like baby is in pain; --whether in physical pain or not, wonder what is the baby’s experience of long periods of extreme distress ; what is it like for them? Mothers are not to blame for colic—even though they feel like they are.really begins early; bvasically consitutional, mothers are not causing the basic problem— Yes, babies can be more irritiblity in highly stressed pregnancies; babioe sexposed to smake and substance pr3natially may be more irritible, but not always; l -but true colic is not caused by the way the baby is handled, if it were, we could fix it; not caused by how parents think about baby; ithought about, Are the babies in pain? --curerntly pediatric htinking is no: if give colicy baby sucrose, does not stop the cyring—typical sucrose will stop cries of pain --pain medications don’t stop colic --only dilemma here is cry reserachers say really only two kinds of cry patterns: hunger and pain; looks like baby is in pain; --whether in physical pain or not, wonder what is the baby’s experience of long periods of extreme distress ; what is it like for them?

21. If babies crying does not persist past 6 months and if there are not other family/environment risk factors, there probably is no higher chance of difficult temperament, behavioral problems, or developmental concerns. Will colicky babies have trouble later on? Let me try and answer the question first and then explain some of the debates in the literature: If babies crying does not persist past first 6 months and if there are not other family/enforn risk, then there probably is no higher risk of difficult temperament, behavioral problems, and developmental concerns, Parents can be reassured by booklets such as this that say: --this really is just the high end of crying and someone had to be there and it was your little one. He’ll be fine…and, with time, so will you. --look at large community samples of infants who cry, researchers tend not to find later problems with difficult temperament, evidence that basic sleep ryhthm not different, cortisol stress hormome levels not different, --lasting problems with sleep-wake organization— that that was why they had the problem in the first place—disorder of state, transietn motor immaturity and difficult temperament Let me try and answer the question first and then explain some of the debates in the literature: If babies crying does not persist past first 6 months and if there are not other family/enforn risk, then there probably is no higher risk of difficult temperament, behavioral problems, and developmental concerns, Parents can be reassured by booklets such as this that say: --this really is just the high end of crying and someone had to be there and it was your little one. He’ll be fine…and, with time, so will you. --look at large community samples of infants who cry, researchers tend not to find later problems with difficult temperament, evidence that basic sleep ryhthm not different, cortisol stress hormome levels not different, --lasting problems with sleep-wake organization— that that was why they had the problem in the first place—disorder of state, transietn motor immaturity and difficult temperament

22. What helps? Treat medical problems Formula Change Reduced Stimulation More than one regulating strategy at a time ·Creative ·Colic Pillow ·Look at evidence based med ·what do they know ·What passes clinical drive ·Creative ·Colic Pillow ·Look at evidence based med ·what do they know ·What passes clinical drive

23. What helps? Empathy alone is not enough, but helps Concrete strategies Sleep patterns Structure of day Calming strategies Social Support Relationship –Based Intervention

24. Guidelines for Supporting Families with Babies (see handout) 1. Create an opportunity for the parent to tell you just how challenging this baby has been for them 2. Allow the parent to tell you what they know about this baby

25. The Cry Interview Exercise 2 people: 1 = the parent; 2= the home visitor See handout – Parent’s description of crying behavior Home visitor asks questions using the Symptoms of Colic Questionniare

26. What is reflux? (take notes) ‘acidy’ milk is regurgitated To eusophagus To back of mouth Right out = spit up Infant is irritable – irritation to eusophagus Often fussy during or after feeding

27. Reflux Exercise Pairs: one person is parent; second person is home visitor Home visitor asks questions using the Reflux Questionnaire Parent uses Reflux Exercise Handout

28. Guidelines for Supporting Families with Babies (see handout) 3. Problem solve with parent 4. Dialogue with parent as they struggle to nurture the fussy baby

29. Self Reflection Exercise On a sheet of paper, answer: 1. What strengths do I have in helping parents with infants with cry / sleep / feeding problems? 2. What ‘gets’ to me, when working with certain families? How can I be a companion to myself during stressful interactions?

30. For some babies and families, the problems persist But there is another siide to the debateL Comes from clincia rserachers: papaekt an len; see early fusines as a non-tivial problem --Munic Germany seen over 1,800 families where excessive cyrin was complaint and found surprisingly that only 1/3 of the babies cabe before 6 motnhs—colic period. Older babies and toddlers with crying problems now accompanied by sleeping , feeeing, faliure to throve, excessive clinicng, and cosical withdrawal, separation anxiety, excessive tempertamturs, and early forms of aggressive behivaor—just what you most fears! 80-% of the older infathey with these issues had early histories of early unexplained infant crying. And 40% of the young babies were referred later on because of the kinds of behaviors mentioned. But there is another siide to the debateL Comes from clincia rserachers: papaekt an len; see early fusines as a non-tivial problem --Munic Germany seen over 1,800 families where excessive cyrin was complaint and found surprisingly that only 1/3 of the babies cabe before 6 motnhs—colic period. Older babies and toddlers with crying problems now accompanied by sleeping , feeeing, faliure to throve, excessive clinicng, and cosical withdrawal, separation anxiety, excessive tempertamturs, and early forms of aggressive behivaor—just what you most fears! 80-% of the older infathey with these issues had early histories of early unexplained infant crying. And 40% of the young babies were referred later on because of the kinds of behaviors mentioned.

31. What is correlated with fussing/crying referrals to you / your agency? List:

32. What can be correlated with fussing/crying referrals? Amount of distress in mother-infant relationship Infant dysregulation: sleep deficit; difficulty temperament Maternal pain: prenatal anxiety and stress and postnatal exhaustion

33. Primary Goal of Assessment 1. How much of the concern ‘resides’ in the infant? 2. How much of the concern comes from: (a.) maternal anxiety/stress; (b.) perceptions of baby; (c.) difficulties in managing infant; (d.) conflicts with partner, family; (e.) challenges in support (‘mixed’ support)?

34. What is a Family Plan? 1. Parent’s Goals 2. Soothing and Sleeping Routines 3. Enjoying Your Baby 4. Support from Family and Friends 5. Taking Care of Yourselves What mom needs What dad/partner needs

35. Discuss strategies from these viewpoints: Environment (where infant sleeps, etc) Baby’s experience of interactions Parent’s experiences

36. Approach to Families: Support parental self-confidence Support parent knowledge of baby – ‘observe together’ baby temperament, developmental agenda, responses to parents’ strategies Help parents set their own goals for soothing and sleep routines and establish those routines

37. Approach cont’d.: Support parents around emotional responses to baby and baby’s care Support parents in finding pleasurable, playful interactions with their child

38. What You Need to Know: Sleeping Review Handout Write down major comments and questions

39. Crying and Sleep persistent crying or colic peaks at an important development period -- called the biobehavioral shift neurobehavioral reorganization at 2-3 months of age results in increase crying and subsequent sleep problems

40. Is it the baby?

41. Is it the baby? systemic psychobiological model of the origins and consequences of persistent crying. According to this model, the infant’s self-regulatory competence develops within the context of the parents’ intuitive co-regulatory support; the infant’s self-regulatory competence is affective arousal, self-soothing, and transition to sleep [3]. Hence, the mother–child reciprocities in the contexts of soothing, feeding, transition to sleep, and playful dialogues can become dysfunctional and might well hamper the development of a well-adapted parent–infant relationship [1]. [1–3]. This parental support compensates for the infant’s maturational constraints in regulating affective arousal, self-soothing, and transition to sleep. Thus, the parents’ behavioural adjustments in interactional contexts of soothing, feeding, transition to sleep, and playful dialogues are pivotal in the prevention of infant crying and its causes. However, difficult infant temperament and other infantile or parental factors (pre-, peri-, postnatal biological and psychosocial risks, child care attitude, psychological condition) might encumber the intuitive parental competence resulting in dysfunctional interactions. In this view, excessive infant crying may both challenge the parents’ intuitive competence and be the result of dysfunctional mother–child interactions. The longer these dysfunctional interactions are maintained, the more likely they become automated and rigid [2]. The persistence of excessive crying beyond the 3-month barrier in almost 40% of the children experiencing this condition, therefore, might reflect mother–child dyads at risk of an unfavourable mother–child relationship.systemic psychobiological model of the origins and consequences of persistent crying. According to this model, the infant’s self-regulatory competence develops within the context of the parents’ intuitive co-regulatory support; the infant’s self-regulatory competence is affective arousal, self-soothing, and transition to sleep [3]. Hence, the mother–child reciprocities in the contexts of soothing, feeding, transition to sleep, and playful dialogues can become dysfunctional and might well hamper the development of a well-adapted parent–infant relationship [1]. [1–3]. This parental support compensates for the infant’s maturational constraints in regulating affective arousal, self-soothing, and transition to sleep. Thus, the parents’ behavioural adjustments in interactional contexts of soothing, feeding, transition to sleep, and playful dialogues are pivotal in the prevention of infant crying and its causes. However, difficult infant temperament and other infantile or parental factors (pre-, peri-, postnatal biological and psychosocial risks, child care attitude, psychological condition) might encumber the intuitive parental competence resulting in dysfunctional interactions. In this view, excessive infant crying may both challenge the parents’ intuitive competence and be the result of dysfunctional mother–child interactions. The longer these dysfunctional interactions are maintained, the more likely they become automated and rigid [2]. The persistence of excessive crying beyond the 3-month barrier in almost 40% of the children experiencing this condition, therefore, might reflect mother–child dyads at risk of an unfavourable mother–child relationship.

43. Helping to Document Infant Sleep See Handouts 1. Sleep Diary Instructions 2. Sleep Diary 3. Parent and Baby Sleep Habits

44. Sleep development Infant behavior is organized around 4 hour cycles with little variation at 3 months, infants begin to stay awake longer in the day and sleep longer during the night. Infants begin to better “self-soothe” during the day and at night There is a predictable age-related development of sleep patterns. By 6 to 7 months gestational age, rapid eye movement (REM) sleep can be discerned via fetal ultrasonography. Nonrapid eye movement (NREM) sleep develops around 7 to 8 months gestational age. At birth, infants have a basic pattern of quiet and active sleep states that alternate every 2 to 6 hours. The total amount of sleep at birth ranges from 11 to 23 hours, with an average of 16.5 hours and cycles lasting 50 to 60 minutes. Paralleling changes in neurophysiologic reorganization, the random distribution of sleep and wake periods gradually changes to cluster sleep and waking in longer periods but without any significant change in total sleep. The timing of sleep and waking is determined by environmental influences, the so-called zietgebers, the most powerful of which is light exposure. Feeding and social interaction also affect sleep-wake cycles and need to be coordinated in any interventions. By 3 months of age, stages III and IV sleep can be seen on electroencephalography (EEG), sleep begins with NREM, and babies begin the more mature pattern of sleeping for longer periods at night, with the possibility of sleeping through the night. By 4 months of age, quiet sleep comprises more of total sleep than active sleep, and most There is a predictable age-related development of sleep patterns. By 6 to 7 months gestational age, rapid eye movement (REM) sleep can be discerned via fetal ultrasonography. Nonrapid eye movement (NREM) sleep develops around 7 to 8 months gestational age. At birth, infants have a basic pattern of quiet and active sleep states that alternate every 2 to 6 hours. The total amount of sleep at birth ranges from 11 to 23 hours, with an average of 16.5 hours and cycles lasting 50 to 60 minutes. Paralleling changes in neurophysiologic reorganization, the random distribution of sleep and wake periods gradually changes to cluster sleep and waking in longer periods but without any significant change in total sleep. The timing of sleep and waking is determined by environmental influences, the so-called zietgebers, the most powerful of which is light exposure. Feeding and social interaction also affect sleep-wake cycles and need to be coordinated in any interventions. By 3 months of age, stages III and IV sleep can be seen on electroencephalography (EEG), sleep begins with NREM, and babies begin the more mature pattern of sleeping for longer periods at night, with the possibility of sleeping through the night. By 4 months of age, quiet sleep comprises more of total sleep than active sleep, and most

45. Acquiring Self-Regulation All aspects of human adaptation require regulation Transition from helplessness to competence in “regulatory capacity” Infants who better at self-soothing at 12 months had less sleep problems at 2 years Learning to sleep through the night Controlling emotional outbursts and learning to wait Reflect the growing maturity of the brainLearning to sleep through the night Controlling emotional outbursts and learning to wait Reflect the growing maturity of the brain

46. Trade off between crying and sleep… Infants that cry more should sleep less Parents report that fussy babies sleep less during and after the colic period Parents report up to 1 1/2 hours per day less have shorter sleep periods wake more often at night

47. Colic and non-colic sleep structure

48. Colic and non-colic sleep structure

49. Sleep problems (short term) Sleep associations Trained night feedings Trained night wakenings “Curtain calls” Circadian rhythm disorder

50. Sleep problems (long term) Interfere with parent-child relationship Externalizing disorders Attentional problems Anxiety and depression

51. Sleep recommendations 89 books Range of advice / tips / motherly wisdom Educate your baby? Train your baby? Help your baby? Create a relaxing environment?

52. Sleep recommendations II Establish a routine Planned response to struggles of self-regulation Night-time crying Prolonged crying Bedtime refusals Consistency

53. Sleep Recommendations Bath, reading a book, lullaby Place child in crib drowsy but awake Leave the room, sit by the bed, don’t touch Return if crying persists, tell her you love her, and leave/sit Be consistent and firm

54. Special Topics: Screening for Depression ‘Double whammy of maternal postpartum depression and cry/sleep/feeding concerns See Handout ‘Mood Assessment’ Mood Assessement is the Edinborough Perinatal Screen for Depression.(see websites for scoring criteria).

55. Special Topics: Formal Intake Assessment See handout: Infant Behavior, Cry and Sleep Center Intake Outline

56. Special Topics: Building support for your work with families 1. Identify colleagues, agencies 2. Plan to meet 3. Identify supervision 4. Identify ongoing training Erikson website: Fussy Baby Network

57. Special Topics: Tips for Treating Colic Review handout: Tips for Treating Colic

58. Final Statement:Intervention with Parents/Infants Take time to establish warm, attuned relationship with parents Sometimes, intervention alone is not sufficient to modify parenting behavior; know referral criteria and referral resources Use supervision to identify your issues and develop support for you (identify the “ghosts” and “angels” in your life experience)