| A Newsletter About Caring for the High Maintenance Child |
by Kate Andersen, M.Ed.
Issue Theme: Fussy babies-working with infant temperament.
Volume 21, Issue 8, April, 2019.
Here is my situation. I have a 9 month old who sleeps fairly well (10 hours a night usually). Not a problem until lately, she wakes up and can't go back to sleep. I don't believe it's teething, and she's definitely not hungry. But, the serious issue is that she refuses to take naps during the day. She definitely needs them after being awake for about 2.5 hours she becomes very fussy, rubbing her eyes, dropping things, falling (she started walking a couple weeks ago), etc. So I put her down for a nap, which she refuses to cooperate with. She has always hated taking naps but would eventually have to give in because she wasn't strong enough to keep fighting. But as she becomes stronger, she fights longer. Before she would sleep for 30 min. on the dot, after crying for 20/25 min. Now she cries for an hour and sleeps for 30 min. sitting up holding on to the rails of her crib, with her forehead resting against it. Not to mention the slightest noise starts the whole process over again. If I try to lay her down after she falls asleep sitting up, it starts all over again.
I try to be as consistent as possible, but nothing seems to work. It may not seem like a serious problem, but it is. I've tried to stay in the room and comfort her, but she just keeps trying to stand up, and I'm sure it would drag on for as long as I'm in there. I've tried putting her down at the first hint of being tired I've tried keeping her awake for hours. It all ends up the same way.
Another insight to her personality is that she never sits down. She has to play with her toys standing up with them elevated on something. She skipped crawling because she hates laying down.
There is a lot more detail I could give, but I don't want to waste anymore of your time if you are unable to consider this problem. I've taken advice from many people, but nothing works. Usually it is a mystery to anyone I talk to.
I talked to her pediatrician, and he doesn't seem to be concerned. If I let this carry on like this, she will be spending 50% of each day in a dysfunctional state of mind.
Thank you for your consideration.
You sound pretty concerned so I sure hope my comments will be helpful. Your story reminds me so much of my own first daughter when a few months younger, only she had not yet learned to walk. She had just learned to pull herself to stand. She seemed to be so over-stimulated by this new learning that she literally stood up in her crib while asleep. When she did this she woke herself up and was in a frenzy. We panicked, too, because she was, as you say, "in a dysfunctional state". My guess is it is a type of over-stimulation from new learning. We tried all the things you did, but eventually had to close the door and let her cry. It stopped in a couple of days. I am pretty sure she fell asleep standing up and then eventually keeled over.
Nine months is very young to start walking. Another child I know who did this was so excited by his new mobility (which in a sense he really wasn't ready for) that he walked constantly, wearing himself and everyone else out. Of course, you need to check with a pediatrician that there is nothing else going on. My feeling is that some youngsters are very driven to achieve tasks like walking early, perhaps because they are bright and see what other children can do. I must admit that both families were rather achievement-oriented with these babies and tended to make a big fuss over new milestones. We became more laid back with our later-born children and had fewer of these problems. The two children I have described (my own daughter and the other little boy) are now 20 and 18 respectively. They are still prone to getting over-stimulated, still push themselves to achieve things beyond their year sand are wonderful, bright and well-adjusted young people. I hope you find that reassuring.
Good luck. I hope your little girl settles down soon. Then get ready for the next achievement!
I was concerned about the expectations of the parent who wrote to you in a recent issue. It seems that she was not aware of the impact of all the changes that her young son had faced (new house, baby and another baby on the way). She seemed to blame him for the fact that she was not able to teach him new skills.
Isn't it more important to suggest she change her expectations than to suggest her child may really be hard to teach?
Without more information about the situation, it is difficult to know whether the main problem is excessive expectation or a child who has intrinsic difficulties changing behavioral habits. There are so many parents who have been criticized for having the wrong expectations only to discover down the road that their child has a learning disability or some other difference. In such cases, expectations often do need to be revised but without information about all the contributors to the problem, the parents and child may continue to struggle. In short, I believe that often parents are accused of having inappropriate developmental expectations when the problem is far more complex than that. Their expectations may be individually inappropriate, too. That was the thrust of my response because I think it's time that researchers and clinicians explored the role of temperament and other features of individuality in programs for changing behavior.
Certainly one has enormous empathy for the child coping with many changes in his life, especially given that he appears to have difficulty with adaptation. There are, however, vast numbers of young children who move house, have new siblings and a pregnant parent and who nevertheless remain on a healthy behavioral track.
Research Surprises About Infant Temperament. When temperament researchers first started systematically studying temperament, they had the idea that temperament was something that was noticeable in the early months of life and stayed quite similar throughout childhood. Indeed, parents of more than one child described each of their babies as different from the others from the start. It was only later, when the results of twin and adoption studies became available, that they came to understand that, contrary to expectations, infant temperament is not strongly influenced by genetics. In fact, researchers Carey and McDevitt (1995) have stated that newborn temperament, in particular, appears to be more closely related to factors that occur before and during birth. These factors include maternal hormones, maternal infections and the birth experience itself. Although genetic factors are not strongly influential in the newborn period, temperament can be measured at this age. Genetic factors become more influential as infants grow older and can influence temperament change as well as continuity.
What should parents do if their newborn is fussy and difficult to soothe? Once you have ruled out medical problems (see the letter above, for example), it can be very helpful to understand your newborn's individuality. While you may not be ready to call your baby's behavioral profile a sign of later temperament, he or she surely needs a special approach that "fits" what he or she needs. Some infants don't care much for a lot of handling. They get over-stimulated and cry as a result. Others need a lot of carrying time and settle if given a bit more attention. Learning to read your baby is the first step in developing a good fit and a positive relationship with him or her.
Infants Are Social Beings. Healthy babies have an amazing set of signals to let their caregivers know what they need but often tired parents tend to read the signals as meaning the same thing. "He's crying, he must be hungry." "She's quiet, she must be fine." If your baby is sending out different signals and you are not picking them up, the communication system between you will feel less than satisfactory to both of you. Your baby may cry more or shut down and become withdrawn because of the mismatch between signal and response. You may feel unrewarded by your baby or find him or her unpredictable and "difficult".
The Question Is Not "Can You Spoil A Baby?" Researchers studying infant temperament and development have brought the field a long way ahead of the days when people thought that the important question was "Can you spoil a baby?" They now know that infant behavior can be strengthened by the attention it gets but that it is not necessarily excessive attention that causes infants to be fussy. Rather, it is the way the attention fits what the baby needs at the moment and whether there is a good match that counts. So, yes, you can be making your baby cry more than he or she needs to by the way you respond but it is not as simple as "you pick him up too much" or "you let him or her cry too much".
Parent-Infant Intervention Programs. Clinicians have been studying ways to help parents read their infants more successfully and some important new programs have been developed. If there are no such intervention programs available in your own community, a pediatrician, community health nurse or infant development consultant may be able to help you to develop your own observation skills, have confidence in your ability to know your child well, and to feel more supported in your role as a parent. Meanwhile, learning about temperament differences in infants and finding ways to work around them can help a great deal. The temperament traits that parents find challenging are manifested somewhat differently in infancy than in older children. Let's go through them and consider some examples.
High Activity Level -- an active infant may be squirmy and difficult to diaper; he or she may be restless and seen as "demanding" before he or she can be mobile; once crawling he or she may be a whirlwind and into everything at an unbelievable speed. Watch that baby carefully and don't underestimate his or her ability to get into trouble! As a toddler, this child may demonstrate delight at all the wonders of the world that have now become accessible. Find lots of safe channels for this child's energy but remember that this little one can get overtired without knowing it. Be sure to make the environment conducive to naps and adequate sleep at night.
Low Approach/High Withdrawal--an infant who is high on the trait of initial withdrawal may be harder to leave with a new sitter; he or she may cry when unfamiliar people approach. Give your baby plenty of time to get used to new people but model a confident demeanor when introducing your child to the world. Don't make this child "sink or swim" in social situations but give him or her a gradual entry to day care and other novel situations.
Low Adaptability--the infant who is low in adaptability may resist new foods, new toys, new clothes and new routines. Go slow and give your baby time to adapt; he or she will adapt IN TIME. Show your pleasure when your baby is trying something new and be satisfied with very small steps in the right direction. "Wow! He ate two peas" is a more helpful thought than "Why's he/she so picky?"
Short Attention Span, High Distractibility and Low Persistence--these separate traits don't have to go together but often do and are described as the "Task Orientation" triad. Yes, even a baby can be lower in "task orientation" than other infants of the same developmental level or age. What kinds of tasks does a baby need to pay attention to? There are social tasks, such as playing peekaboo and "smiley face" with parents and siblings, and cognitive tasks such as figuring out how to stack cups or play with a new toy. This infant may get bored with your social games and may not stick to playing with toys for long, either. These tasks are important for your infant's development so find ways that might help your infant stick to things longer. For example, remove distracting things and people and be very patient and focused yourself. Irritable moods in parents and reactive parenting (Stop! No! Don't Touch!) appear to break infant and toddler focus and disrupt the development of good attention.
Low Sensory Threshold--the infant who is very sensitive to physical stimuli may be fussy for a reason that you can't figure out, until you factor in this temperament trait. Is he or she too warm? Is the baby's diaper soggy and uncomfortable? Did the sound of the telephone ringing awaken him or her too often during nap-time? This baby can't tell you what's bothering him or her but careful observation and a temperament rating may help you recognize this factor underlying many areas of struggle--first for the baby and then for you. It's hard to BE a sensitive infant and some parents find it hard to HAVE a sensitive infant--until they understand him/her.
Negative Mood--the baby who is fussy and irritable for no apparent reason may merely be wired to slide into negative mood more easily than other infants. Be sure to rule out medical problems, food sensitivities, sleep deprivation and parental depression before you make this determination. If your baby is temperamentally moody, try to maintain a positive and patient outlook yourself. Mood is contagious even when you are a baby so take care that your baby's mood doesn't make yours negative, too! Many parents report that it is helpful to get reassurance from a pediatrician that the baby is healthy. As well, lots of support from partners, along with frequent breaks from parenting, are the keys to coping with a fussy baby over the long term.
Irregularity--Babies who are wired to have an irregular body clock are sometimes inconvenient for parents who try to put their infants on a schedule. Or the unpredictability of the baby causes some frustration or confusion. Mostly, though, in my experience, irregularity seems to be linked with some other traits that parents find hard to cope with, such as negative mood and a short attention span. Sometimes improving the baby's sleep will bring about improvements in the traits that often accompany irregularity.
High Intensity--the very intense infant cries loudly and laughs loudly. It's not hard to see how a fussy infant who is also intense can cause significant stress in the family. An important aspect of coping is realizing that your baby's volume doesn't mean that the message is as important as it sounds. This is just the way this child responds. He or she may be able to wait for a feeding just as much as any other child. Learn not to jump every time your baby screams.
What Does The Future Hold? Will your temperamentally challenging infant become a "difficult" toddler and a preschooler with behavior problems? Research says there is no inevitable link. Focusing on the here-and-now and working to have a positive relationship with your infant can prevent the development of later problems. However, some infants do retain their challenging traits. Continuing to understand temperament and learn ways of coping with it successfully may be an important part of your long term journey as a parent.
High Quality Child Care Is Important. Child care professionals recognize the fact that some infants in day care require more attention, and more sensitive attention, than others. Some research has suggested that temperamentally difficult infants are at greater risk of being insecure if they are placed in low quality day care for many hours a week. These infants are also at greater risk in home care if the fit is poor so the answer to their difficulties is not necessarily "keep the baby at home". What is needed is sensitive caregiving that provides for sufficient individualization of the infant's needs.
Learn About Temperament. Like parents, child care professionals can benefit from understanding temperament and learning ways of coping with temperament differences. There are special dynamics in group settings, however. Infants are affected by the presence of other babies, for example. Some babies with low sensory threshold may have difficulty coping with the noise at nap-time. Active infants may face more restrictions than they would at home and this can frustrate them. Caregivers may find it harder to develop an attachment to the more challenging babies when those babies need individual and affectionate care perhaps even more than "easier" infants.
Accept Infant Individuality. Accepting the fact that babies are different and have a right to be that way is an important first step in understanding and coping with their temperaments. If caregivers are too quick to assume that an infant has a neuro-developmental problem, a dietary problem or insensitive parents, then they may "write off" a baby rather than learn to relate to him or her. Some caregivers have reported to me that they have found it helpful to reframe the "difficult" infant as an infant with "high needs" rather than "special needs". This normalizes the infant's temperament and behavior guides the caregiver into making sure that the baby gets his or her needs met.
'High Needs' Doesn't Necessarily Mean Do More. Take care that in framing an infant as having "high needs" that you don't just respond reactively by giving the baby "more attention". Increased attention can increase undesirable behaviors even in infants. Instead, make sure that the attention is the right kind of attention that helps steer the baby in a healthy direction developmentally. For example, if an infant who reacts intensely to frustration gets "angry" with restrictions, don't automatically remove the restriction but calmly enforce it while distracting the baby to something he or she is allowed to do. Otherwise, you may train this toddler to scream whenever he or she is thwarted.
Some Infants Need More. There are times, though, when an infant does need more because of temperament. For instance, a baby who is very persistent and low in adaptability may need more time to adapt to a new routine. Giving an infant more time may require more patience from adults. Some infants need more frequent changes of toys and other activities to keep their interest. And some infants and toddlers need more reassurance and displays of affection, especially if they are experiencing a poor fit in the group and/or at home. Mostly, though, temperamentally challenging infants need "the right kind" of response. Matching your responses to the baby's true needs means understanding his or her temperament, developmental level and other features of individuality.
A Caregiver Describes A Challenging Child
"Cameron was a very challenging toddler to care for--until we learned how to work with his temperament. He is very active and very intense. This means that he gets overexcited very easily and spirals out-of-control. We now anticipate that Cameron will need an extra pair of hands on outings and when there is a new and exciting activity in our day care. Cameron is also irregular and is hard to settle at nap times. He WILL settle, though, if he has the same caregiver patting him the same way every day. That's because he is low in adaptability. Cameron is also very sensitive to sound and cries when we have music. We don't remove him from music but we tell him we understand and we have a caregiver sit by him when the music starts. This is enough to help him cope. We realize that Cameron is a little trooper. So many of our everyday tasks that are joyful to the other children are difficult for him to cope with. We admire his gusto and his good intentions. He is really trying so hard and his 'melt-downs' are very understandable. We admire his parents for their positive approach and dedication to him. We have learned a lot from them. What we are learning about and from Cameron is going to help us be better caregivers to the many children like him."
Here are some other approaches recommended by seasoned caregivers:
1. Assign A Primary Caregiver. " Assigning a primary caregiver is good practice in general. It seems to be especially helpful to the slow-to-warm up baby as well as the infant whose parents describe him or her as difficult. This helps make the infant feel secure."
2. Add More Adults Cautiously. "You really do need more adults with some groups of children, but adding a new adult can stress individual children and the group, so plan the introduction of extra people as carefully as you do any program change."
3. Review The Physical Environment. "Observe how well the arrangement works for this year's group of infants. Sometimes a careful reorganization--separating infants who don't sleep soundly, for example--can make all the difference."
4. Remember That Parents Are The Experts On Their Infants. "Invite them to discuss their child's individual temperament with you and to share with you the methods that are successful with their child."
5. Take Care Of Yourself To Prevent Burnout. "We discovered that two of our staff had clinical depression. These two staff members were also the ones who most often described some infants as challenging."
6. Network With Community Professionals. "Work to get the pediatricians in your community interested in what goes on in day care centers. We send a trainer to the local medical school, with videos, to let doctors-in-training know more about child care and what they can do to help."
7. Lobby For Infant Specialists. "Having consultants available to your program is important but beware of mental health professionals who don't have training and experience with infants and toddlers. They can make things worse by recommending ideas that are developmentally inappropriate!"
8. Enjoy The Babies In Your Care. "They grow up so quickly and these earliest years are so important. Get to know each of them as an individual and appreciate their wonderful differences."
Child Care Professionals - An Important Part of The Family's Support System. Child care professionals realize that by caring well for the temperamentally challenging infant and toddler they constitute a very important part of the parents' support system. They realize that their less strained emotional involvement, their training and their dedication can be beneficial in helping everyone maintain a more positive and more realistic approach to the child. Pediatricians and society-at-large need to understand the critical importance of supporting high quality child care. It is important for all families and children. It may be especially so for infants who are at risk but who are healthy and normal and therefore ineligible for many intervention programs. Caregivers deserve more respect and higher pay for the extraordinarily important and skilled work they perform. Our children deserve well-treated caregivers!
Kate: Dr. McDevitt, can you please tell me about the different temperament scales for the very young infant and toddler. Why are there different scales for different age-groups?
Dr. McDevitt: There are 3 different temperament scales for children under 3: The EITQ is for 1-4 month old infants, the RITQ is for 4 to 11 month olds and the TTS is for toddlers 1 and 2 years of age. All measure the nine NYLS temperament categories and allow for assessment of temperament to improve the 'fit' between the care giver who completes the questionnaire and the infant, or for research purposes. The different scales are needed to take into account the drastic changes in the capabilities of infants and toddlers and in their environments. Rating an infant who can't sit up is quite different than rating a climbing toddler! When statistical data showed that questionnaire items became too strongly 'age related', a new questionnaire was fashioned.
Kate: I know that earlier some researchers said that infant temperament scales measured the parents' perceptions of the infant and not the way the infant really is. Can you clarify this issue, please?
Dr. McDevitt: There are two types of data that are measured in the CTS temperament questionnaires: ratings and general impressions. The ratings are based on all of the questions asked about a certain temperament trait-activity level for example. These scores are compared with how a large group of normal infants were rated to determine where the infant stands on each scale: high average or low. The general impressions or perceptions are based on the caregiver's view of how active, how intense, how distractible, etc.--the baby's behavior is 'in general.' By comparing the general perception with the standardized score, more can be learned about the infant. Sometimes parents are quite surprised about how their child's temperament comes out, and learn a lot from the experience!
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