Later, I will explain why so many so-called “high-needs” children are really very overtired children/difficult temperament children.
Of the original group of infants Thomas and Chess studied, about 10 percent fell into the difficult temperament category. These infants also tended to be irregular in biological function such as sleep schedules and night awakenings. They were more likely to have behavioral problems—particularly sleep disturbances—when they grew older. One of the most interesting differences between difficult and easy babies is the way they cry when they are past the extreme fussiness period—that is, when they are three or four months old. Published research found that mothers listening to the taped cries of infants rated difficult (not their own babies), described the crying as more irritable, grating, and arousing than the crying of easy infants. They said that the first group sounded spoiled and were crying because of frustration rather than hunger or wet diapers. An audio analysis of cries helped explain why this should be. The crying of the difficult infants was found to have more silent pauses between crying noises than that of the easy babies. These silent pauses caused the listener to repeatedly think that the crying spell had ended. Also, at its most intense, the crying of difficult infants was actually pitched at a higher frequency. These two differences can make the crying seem much more frightening, piercing, and annoying.
What causes the difficult temperaments? Do they learn to be this way? Is it genetically prewired or are they overtired?
Here's how child development specialist Laya Frischer described a postcolicky baby.
JANE AT AGE FOUR MONTHS
Jane is difficult and unpredictable, with less than average sleep and cuddling and more than average crying. Observations over five weeks have revealed an extremely sensitive infant. For a period of time, she could not even tolerate touches on her abdomen. Swaddling helps a little, and the rhythmic swing movement gives her some relief. If these things fail, the parents walk her around. Sometimes these efforts quiet her fussiness, but at other times it escalates to panic crying. Jane seems to have no capacity to console herself, and very little capacity to be consoled by usual methods of touch. The pacifier has been helpful, but not always successful. Jane does not have good state regulation. She can be in a panic cry state when she seems to be asleep.
Jane goes from sleep to distress in seconds. She becomes overtired and cannot sleep, which contributes to her irritability. She does not habituate easily to sensory stimulation of light and touch. Jane requires a very protective environment, which puts great stress on her parents, particularly her mother. Her cries are very hard to read; her parents feel she is unpredictable, and often uncommunicative.
Connecting Sleep, Extreme Fussiness/Colic, and Temperament
Different Approaches for Different Babies
As you read earlier, for every hundred babies, about 80 percent will have common fussiness, and of these, 49 percent (thirty-nine babies) will have easy temperaments, 46 percent (thirty-seven babies) will have intermediate temperaments, and only 5 percent (four babies) will have a difficult temperament. However, for that 20 percent of babies who had extreme fussiness/ colic, the outcome at four months is quite different. In this group, only 14 percent (three babies) will have easy temperaments, 59 percent (twelve babies) will have intermediate temperaments, and 27 percent (five babies) will have difficult temperaments. It is important to recognize that the largest group is the intermediate temperament group comprising of forty-nine babies, or 49 percent of the total. Some of these babies will be closely but not quite resembling easy-temperament babies or difficult-temperament babies. So, for almost half of all babies, the advice regarding common fussiness leading to an easy temperament and extreme fussiness leading to a difficult temperament fits only approximately. So please read the entire section and take out of it only that which applies to your baby.
The risk of developing sleeping problems after four months of age probably looks something like this:
LOWEST RISK FOR SLEEP
PROBLEMS AFTER FOUR MONTHS
39 percent of common fussy babies who develop easy temperaments
3 percent of extremely fussy/colicky babies who develop easy temperaments
37 percent of common fussy babies who develop intermediate temperaments
12 percent of extremely fussy/colicky babies who develop intermediate temperaments
4 percent of common fussy babies who develop difficult temperaments
5 percent of extremely fussy/colicky babies who develop difficult temperaments
HIGHEST RISK FOR SLEEP
PROBLEMS AFTER FOUR MONTHS
Different temperaments and perhaps different paths to these temperaments will lead to different sleep strategies for each child. It appears to me that the difficult temperament at four months mostly represents an extremely overtired baby while the easy temperament represents an extremely rested baby. But keep in mind that biological factors within the baby, such as elevated serotonin levels or immature development of sleep/wake rhythms, may contribute to a baby's behavior during the first four months. It is equally important to remember that there is enormous variability regarding the resources with which parents are able to soothe their babies. These are factors within the mother (for example, baby blues or postpartum depression), the husband (forcing a too-late bedtime, not helping to soothe the baby), the marriage (disagreements regarding family bed or breast-feeding), and the family (too many conflicting time pressures regarding other children, career events, not enough bedrooms, ability to hire housekeeping or baby care help, and so forth). So it is important to look at the big picture, your baby and your total soothing support structure, and resources that you have available. What will work for one family may not work for you. The goal is to develop a caring environment for the family, not a cure for extreme fussiness/ colic.
“No Cry” versus “Let Cry”
Some parents are strong believers in only one approach to soothing to sleep. They believe there should never be any crying and that by always holding their baby, frequently nursing their baby, and sleeping with their baby, they can prevent extreme fussiness/colic from occurring and prevent sleep problems. They characterize their approach as “gently to sleep,” “attached parenting,” a gentle, warm, child-centered style that enhances a sense of security because the baby is taught that the mother is always there. They characterize other approaches as “cry it out,” “detached parenting,” a cold, rigid, parent-centered style that creates a sense of abandonment because the baby is taught that the mother is unresponsive. These parents say that when the baby stops crying and sleeps, he “has given up” trying to communicate with his mother. This stark contrast in parenting styles is supposed to produce differences in babies and differences in the bonding between the child and her parents. However, there are some major problems with this way of thinking. First, there is no evidence that one style or another produces a specific outcome. Second, babies themselves contribute a lot to what will easily work or not work. Third, fathers, siblings, and real-life family issues help shape your ability to soothe, comfort, and put your baby to sleep. Fourth, there are methods in between always attending to night crying and never attending to night crying such as “check and console” or “controlled crying,” whereby the child is allowed to cry for only short periods of time (see page 104).
“Attachment parenting” may or may not be your decision, but it may work well for 39 percent of babies who had common fussiness and developed an easy temperament. For these babies, everything you read in popular books about soothing and sleeping will likely “work.” This might even be true for the 40 percent (3 percent plus 37 percent) of babies in the next two groups of babies at a low risk for developing sleep problems. So, perhaps the majority of families (39 percent plus 37 percent) will have a fairly smooth course to easy soothing and sleeping, and an additional 3 percent will struggle to get to a place where sleeping becomes easy at four months of age. Perhaps, for the majority of parents, the path does
not involve any crying. There is no reason to be judgmental and criticize other parents who are not so fortunate.
There is an unfortunate minority (9 percent) of families whom I believe become distressed or overwhelmed with the arrival of their baby because they lack sufficient resources to soothe the baby and/or the baby has extreme fussiness/colic so she develops into an overtired four-month-old with a difficult temperament. These parents may have started out with the crib and decided later to use the family bed for soothing and sleeping, and were still frustrated later because after four months the baby still did not sleep well. Flexibility and sensitivity to your own baby and your own family situation is key.
Common Fussiness: Low Risk for Sleep
Problems After Four Months
Breast-feeding becomes much easier around four months of age or sooner for these babies because everyone is better rested and life is more predictable. At three to four months, your baby will start to show drowsy signs earlier in the evening. Instead of becoming sleepy at 8:00 to 10:00 P.M., she will become sleepy at 6:00 to 8:00 P.M. Respect her need to sleep and begin the soothing process at night at the earlier hour. If you are using a crib, simply put her to sleep earlier; but if you are using a family bed, you have to make some choices. The first is to go to bed much earlier yourself, but this is not usually practical. The second would be to lie down with her in your bed and create a safe nest or use a cosleeper where she will sleep, and then leave her after she has fallen asleep. The danger in this is that she might roll off the bed and injure herself. The third is to transition her to a crib for the beginning of night sleep and until she awakens for her first night feeding, and then bring her to your bed for the remainder of the night. Because these are well-rested four-month-old babies, they are more adaptable and easy to transition to a crib. One strategy is to breast-feed at night, pass your baby to his father, who soothes him in his arms, and then puts the baby down in the crib. This breaks up the previous pattern of mother-breast-feeding-sleep in parents’ bed. If your baby cries, soothe him without picking him up. But if this fails, pick him up and, after soothing, try again.
If you are bottle-feeding (formula or expressed breast milk) or breast-feeding and using a crib around four months of age, expect to feed your baby about four to six hours after her last evening bottle and again early in the morning around 4:00 to 5:00 A.M. until about nine months of age. Some bottle-fed babies are fed only once, around 2:00 or 3:00 A.M. If you are breast-feeding and using a family bed, you might feed your baby many times throughout the night.
If you are using a crib, there is more social stimulation as you pick up the baby, more time required to prepare the bottle, and more handling as you put the baby down to sleep again. Under these circumstances, feeding your baby more than twice at night after four months is likely to create a night-waking habit. If you are breast-feeding, the obvious question is whether the awakenings at night, other than the two times mentioned, are due to hunger. If your breast milk supply has not kept pace with your baby's needs or has decreased, then your baby will awaken more at night because of thirst and/or hunger. Are you thirsty throughout the day? If so, you are not drinking enough fluid. Are there some unusual stresses in your life such as an important trip that you have to take, are you worried about balancing child care and working, or worried about returning to work and continuing to breast-feed? Is your baby producing less urine? Has the volume of your expressed breast milk decreased? When offered a bottle of expressed breast milk or formula, does your baby now take a much larger feeding? Does he sleep better or longer after taking a bottle? If you think your child is hungry and you want to continue breast-feeding, then contact a lactation consultant through your pediatrician or maternity hospital.
If you are using a family bed, feeding often throughout the night is not likely to create a night-waking habit. This is because your baby is partially asleep or barely awake when fed. Therefore, the risk of sleep fragmentation for both mother and baby from too much social stimulation is low. With early bedtimes in place, the family bed does not create any sleep problems, and in fact, the family bed may have been part of the soothing solution during the first few months.
After the development of an earlier bedtime, the next sleep change is the evolution of a regular nap around 9:00 to 10:00 A.M. This nap may initially be about forty minutes, but it will lengthen to one or two hours. The rest of the day may be snatches of brief and irregular sleep periods. After the morning nap develops, when the baby is a little older, the next regular nap occurs around noon to 2:00 P.M. This nap will also lengthen to become about one to two hours. There may be a third mininap that is irregular and brief in the late afternoon.
These sleep rhythms are maturing for night sleep and day sleep. A common mistake is to approach the timing of naps and night sleep by strictly enforcing a “by the clock” (BTC) routine. A temperamentally very regular baby might appear to be sleeping BTC, but watching your baby's behavior for sleepy signs is more important than watching the clock.
Consider our original group of one hundred babies. At four months, of the forty-nine babies with an intermediate temperament, thirty-seven babies (about 76 percent) had common fussiness when younger. Also, at four months, of the forty-two babies with an easy temperament, thirty-nine babies (about 93 percent) had common fussiness when younger. So, out of the original eighty babies with common fussiness, the vast majority, seventy-six (thirty-seven plus thirty-nine), or 95 percent, is at a low risk for developing sleep problems because:
Parents are not likely to be stressed
Infant is likely to be well rested
Infant is likely to be able to self-soothe
At night, consolidated sleeping (long sleep duration) develops early
During the day, regular and long naps naturally develop
early, without parental scheduling
If sleep problems exist, “no cry” solutions usually work
Extreme Fussiness/Colic: High Risk for
Sleep Problems After Four Months
Consider our original group of one hundred babies. Out of the original twenty babies with extreme fussiness/colic, a minority of only five, or 20 percent, is at risk for developing sleep problems. However, at four months, of the nine babies with a difficult temperament, five babies, or a majority of 56 percent, had extreme fussiness/colic when younger. Another way to look at this is that only nine out of the original hundred babies, a tiny group, or 9 percent, develop a difficult temperament and subsequent sleep problems because:
Parents are likely to be stressed
Infant is likely to be overtired
Infant is likely to be only parent-soothed
At night, fragmented sleep (night waking) persists
During the day, irregular and brief naps persist
If sleep problems exist, “let cry” solutions might be
necessary
I believe it is in this small percentage of babies that you have the most severe and hard-to-solve sleep problems. There are two reasons for this. The first is that the biological factors that led to extreme fussiness/colic in the first place in five of the nine babies might persist and frustrate parents’ best efforts to solve sleep problems. The second is that the social or family factors that led to parents’ distress and difficulty in soothing for four of the nine babies who had common fussiness might persist and interfere with establishing healthy sleep habits. These social or family issues of course might also be a factor for those babies with extreme fussiness/colic, either caused by the extreme fussiness or independent of the extreme fussiness/colic.
Breast-feeding these babies may be difficult because everyone is tired. As the biological need for an earlier bedtime develops, the best strategy is to temporarily try to do whatever it takes to maximize sleep and minimize crying. The plan is to keep your child as well rested as possible in order to buy time for the development of more mature sleep/wake rhythms. Once these rhythms are developed, they may be used as an aid to help your child sleep b
etter. For example, the breast-feeding mother might have to take the baby into her bed and nurse her to sleep at the earlier bedtime. However, real life events, such as returning to work or caring for other family members, might not permit the luxury of always sleeping with our baby whenever he appears to be sleepy.
You may have wanted to practice “attachment parenting” and spend much of the first four months soothing your baby, but now, she is heavy when you carry her all day. More important, she is more alert and curious and able to resist and fight sleep for the pleasure of your company even when she needs to sleep. This “natural” desire for social contact may interfere with the “natural” development of healthy sleep habits. It is difficult to have clarity of thought and purpose when everyone is tired. As outlined in Chapter 1, it is not always clear what really is “natural” or “unnatural.”
It is “natural” for all babies to fuss or cry, for all mothers to want to soothe their babies and to be distressed by their babies’ fussiness or crying, that the more fussiness/crying for the baby means less sleep for the mother, that mother's distress increases with her own sleep loss, and that in some tribal cultures other people are available to help care for the baby. It is “natural” to breast-feed, to change when soiled, to feed when hungry, to soothe when fussy, to sleep when tired, to sleep with your baby, and to carry your baby everywhere in most, but not all, tribal cultures. In some tribal cultures, for example Yemen, mothers leave their baby totally alone all day while they work.
Healthy Sleep Habits, Happy Child Page 19