Managing the Unsettled Infant

Hornsby-Ku-ring-gai General Practitioners

Professional Update May 2006

Principles of attachment Mother-infant psychotherapy The crying baby The sleep disturbed baby

Dr Ian Harrison - Perinatal and Infant Psychiatrist

Karitane Residential Unit Carramar

© Dr Ian Harrison. For private use only.

Attachment and Evolution

How have infants (ie humans) survived?– What were the causes of infant mortality in 200,000B.C.?– how long does it take for a baby to die?– Starvation is one thing, but safety is of the essence.– evolutionary pressures: genetic selection favours

attachment behaviours – lack of proximity is more risky for infant than lack of food– biologically based desire for proximity gives particular

survival advantage vs. predators– Could crying in late afternoon, “colic” be a defence

against being eaten by predators?

Biological Basis of Attachment

Attachment behaviour has the predictable outcome of increasing proximity of the child to the mother.

Attachment behaviours:– Signalling (smiling and vocalising) these alert

mother to the child’s interest in interaction– Aversive (crying) brings the mother to terminate

the behaviour– Active (approaching and following) move the

infant/toddler/child to the mother

Introduction

“There is no such thing as a baby.” D. Winnicott

There is only a baby and its mother. A baby and its environment.

The Unsettled Baby

Unsettled babies exist along with unsettled mothers and by extension unsettled families and neighbours and communities.

Everyone is unsettled by an unsettled baby. Everyone will offer their advice. The mother will have been given lots of

advice.

1. Know what you believe about babies.

When working with mothers and babies, get to know what babies “do” to you.

Understand your own thinking about babies, your own baby “rhetoric”.

How or what you think about unsettled infant/toddler behaviour has an important bearing on how you manage it

2. When Starting with the New Mother

If we consider the new mother antenatally, or early postnatally, they are often best left to their own devices.

By that I mean they need to be given an opportunity to do things how they want.

The ones who you think might get into trouble have a way of surprising you.

Certainly we know the mother who seems destined to sail through who “inexplicably” doesn’t.

Let mothers start where they wish with their babies.

Let parents get a chance to establish their own choices in the way they manage their infants.

It is rarely helpful to prescribe at the outset. Try to have confidence in their choices. “What are you planning to do?” you might ask. The correct answer to any reply is always. “Good!

That usually works well.” Don’t prescribe “sleep strategies” for mothers who

want to do their own thing.

3. Hear the “story” of the baby.

Ask the mother the questions that tell you the mother’s story of the baby.

What are the facts and what are the “fictions”. These begin to merge.

Who if anyone celebrated the baby’s conception has she been given permission to be a mother?

Giving birth is one of the few level playing fields left to women of all stratums of society.

Was the birth a successful transition?

The story of the baby (continued)

Was the birth a “failure”. Did the baby threaten to leave? NICU? Did the nursing staff care? or were they

“Agency staff” and “Not usually on this ward” Was she helped with breastfeeding or

badgered into it. Did she get taught any mothercraft skills?

LISTENING TO CAREGIVERS USING ATTACHMENT PRINCIPLES

Traumatic (disorganised) attachment and the importance of listening.

We listen to the mother so that she can “listen” to the baby.

Selma Fraiberg “Hear the mother’s ‘cry’ and she will hear

the cry of her baby”.

4. Be willing to accept and meet the new mother’s dependency.

Healthy mothers will wish to become dependant on you as their GP.

Do not fear creating dependency; it is already there. It will last as long as it is needed. Nothing with a baby lasts for long. There are limited time frames for intervention with a baby.

Accepting the mother’s dependency in turn helps the mother to accept the dependency of the baby.

Primary Maternal Preoccupation.

Model a secure attachment.

Be as available as possible for the new mother. Schedule frequent sessions, preferably weekly. Don’t make the new mum fight your secretary for an appointment.

Function as a secure object for the mother. An attachment figure. Model secure attachment by being available.

This is not to be confused with being nice, or having a friendly chat. This is powerful evidence-based medicine. Your time is very valuable and in turn it ought to be paid for.

This avoids the well baby being brought along as a “ticket” for the mother to see you.

MODELLING A SECURE ATTACHMENT

Frequency doesn’t matter so much as the “security” of contact. Set yourself up as a “secure base” This relates to being (appropriately) “available”

and being highly “reliable”. Even if the frequency and total duration of

contact are limited it is possible to act as a secure base.

We can be a secure base even if we hardly ever see the client but secure attachment requires some “comings and goings.”

5. Remember transference. It exists! You will feel it!

When we feel that we are seemingly of not much help with patients and they give us the “yes but”, offer an interpretation.

“I guess it seems that a lot of the time it doesn’t matter what you do. It just doesn’t work.”

“I guess you are feeling at times that you know nothing about looking after a baby.”

Try to monitor how you feel and feed it back as a trial interpretation.

These interpretations can be enormously helpful.

6. Avoid over-reacting to parental distress.

When there is stress and chaos there is the temptation to take extreme measures. Some parents get into acting out. They over-react and can become histrionic in their responses to their infants.

Be the voice of calm and reason. Help parents to avoid acting out their own

past hurts.

We try to avoid “Cry it out” strategies.

We may say “Leave the baby if you can’t cope”, but that is different. That is not advocating “cry it out” as a strategy.

The caregiver should only leave the baby if they have to and even then it is obviously best if they can hand the baby over to someone else.

At worst, cry it out strategies are dangerous for the infant’s attachment relationship, the mother’s bonding, and the baby’s neurological development, especially the developing limbic system.

7. Get fathers or someone else involved.

When babies are very unsettled (usually but not always at night) i.e. the screaming baby, they often need to be held firmly while the parent walks around slowly. Dads may be best to do this because by this stage the mother is usually upset and the father usually has some more distance.

Babies fortunately recognise the other caregiver so potentially they know they are safe.

Soothing voice, firm hold, keeping limbs from flaying about, avoiding eye contact

8. Psycho-education regarding attachment.

Become an informal attachment educator of your clients.

Often termed psycho-education. Here we adopt attachment ideas/thinking into our everyday “conversation” with clients.How do we do this? In general we look for the infant’s

attachment behaviours and we are ready to comment on them.

9. Reframe “negative” behaviour to promote empathy.

We reframe behaviour using attachment principles to promote empathy A mother might say, “He’s a controlling

little buggar. He just wants to manipulate me/us.”

We might say something like, “Yes, he needs to be near you at times.” or “He likes you so much he wants to be near you more often.” or “He feels so much safer when you are near.”

Positive Reframing of Behaviour.

In reframing: We try to find the “good” in the infant’s

behaviour (and the mother’s as well) With attachment theory you will always

find something that is good. You have a valid theory for reframing.

10. Use positive “suggestion”.

Here we try to “predict” the future with regards to secure attachment using positive suggestion. We might say to the caregivers: “You will find that they will want you to do this. Or

they’ll get anxious when this happens, or that happens”. We predict the baby’s attachment behaviours in advance. The baby’s dependency and also their need to be independent.

(How the toddler will want to explore, and how they will then want to return to the “safe base” to be reassured and comforted).

The use of positive suggestion.

“You will find that as you begin to hold him more he will become more relaxed and feel safe”. “You will notice that you will

understand her communications more and she will be more settled when she is with you.”

The use of positive suggestion.

i.e. you simply speak as if this will definitely happen, that they will do these things. This is a form of ‘waking suggestion’. Related to hypnotic techniques. You can “see” them being a sensitive

mother.

The use of positive suggestion

Drawing a new “dotted picture” of the client which the client later fills in. You draw the picture of their future

behaviour. The client fills it in later with their

behaviour. A case example.

11. Try to “speak” on behalf of the baby.

In its simplest form we say what (we think) the baby wants.

We might say, “Perhaps she wants you to pick her up” or “She might want you to feed her” or “She might be too hot” etc

We might say “Oh you want mummy to pick you up. Yes well here she comes, (as mother picks up the baby). “Oh now I’m feeling better mum. Yes you are feeling better now aren’t you”.

12. ASKING QUESTIONS USING ATTACHMENT

PRINCIPLES

Making your questions work for you. e.g. “How does your childhood and your

experience of your parents affect the way you interact with your baby?

The mother may say: “What do you mean?” At this point you have to be ready to give an

“attachment spiel” but you can make it up as you go along; it doesn’t have to be perfect. The more spontaneous the better.

ASKING QUESTIONS USING ATTACHMENT

PRINCIPLES

“What sort of mother-baby experience do you think you had when you were an infant?” “What sort of mother was your mother?” (Some

people have not thought about it.) We might say, “When you have a baby we know that

‘a lot of these things’ come up from childhood for the first time. They seem to be buried until a person becomes a parent”.

13. As a general principle always try to see the mother with the infant.

We try to see the mother and baby together. This is especially true if the infant is difficulty or

unsettled. This is also true if the session with the mother and

baby has been particularly “bad” and the infant has been particularly “disruptive”.

If you can’t stand the infant for a brief period of time, how can the mother be expected to cope?

There are enormous opportunities to model attachment behaviours when the infant is unsettled.

SEEING THE MOTHER AND INFANT TOGETHER

What about the mother’s own therapy? Some will say, “But the mother needs her

time to cope. She needs her time to talk”. “The therapist or doctor needs to be able to

give the advice or the therapy (or whatever)”. One needs to flexible while remembering the

principle

14. Try to help the mother succeed in settling the baby rather than soothing the baby yourself.

We avoid showing that we are better at soothing/feeding/etc the baby than the mother.

Soothing someone else's baby is rarely helpful. On the surface the mother will be grateful. “I’m so glad he’s settled”. She may even say, “I’m so glad now I know

that he can be settled.” and “Can you show me that again?”

15. Help promote attachment behaviours between mothers and babies more directly.

There is a place for direction and advice once all the previous conditions have been attended to.

How to encourage infant engagement with mother

check distance between the two. ensure proper head support encourage mother’s response to infant cries show mother how to imitate or affirm the infant’s

expressions slow down the pace of adult speech give clear expressions to infant repeat phrases wait and give “space” for the infant to reply

Point out the infant’s Social Signs

eye to eye contact, right from the start facial expression of interest active movements of the tongue mouth movements “pre-speech”, as if the infant is talking

Helping promote attachment - practical considerations.

Build on what is already there to increase the caretaker’s sensitivity.

Help mother to get to know the baby’s likes and dislikes.

Try to notice any early signs of distress. Try to manage the environment to prevent distress

before it occurs rather than re-settling all the time. In general if the baby is especially sensitive cut

down on the level of stimulation but do not remove yourself if the baby protests.

How to help increase the mother’s responsiveness

Never critique or undermine the mother. Make mother feel supported. Make sure you find or seize on something the

mother is doing right. Enhance the mother’s perception of the infant’s

unique characteristics. Take any opportunity to comment on the

infant’s positive experiences with their mother.

16. Never give up. Development and Attachment is an Ongoing Process.

SLEEP AND SETTLING

The Behavioural Strategies - Karitane

Sleep and settling routines

0-4 months - Hands on settling 4-7 months - Comfort settling 6-11 months - Progressive settling 9 + months - Progressive waiting

The Basic Principles

What you need to know

Know The Tired Signs

They are: grizzling, crying clenching fists, grimacing rubbing eyes incoordination, jerky movements Depends on age

Create a predictable wind down routine

This signals to the baby that sleep is on its way. Has soporific and/or hypnotic-suggestive elements. The routine begins to create associations or cues to

trigger sleep. Both parents and toddler are focussing on the task of

going to sleep. It remains a joint process. Having a bath, then reading reading a book. The

infant will after weeks or months of consistent routine tend to allow the feeling of tiredness to come over them, sometimes quickly, sometimes like a slow wave.

Move towards the cot.

The move towards the cot is, according to behavioural methods, best done with baby still awake but sleepy.

It is done in a calm but definite way.

Say goodnight, kiss and leave the room.

Parents says something soothing but pertinent to sleep, like “goodnight”, “sweat dreams”.

They do not linger as if to give the infant mixed messages.

Small babies 0-3 months may need some gentle patting off to sleep (comfort settling).

Mothers need to be aware of any worries leading to ambivalence on their part.

Ambivalent attachment?

Does the mother wish the baby to play longer? Is she lonely and on her own? Does she need company?

Is she worried, frightened? Afraid the baby will stop breathing. Is it “safe” for the baby to sleep?

Will there be an argument between the parents. Is the baby being used as protection.

Or “You have upset me and now look, the baby is upset as well”.

When parents are aware of our ambivalences we are less likely to act in contradictory ways towards the baby.

Return if baby is distressed

Allow some fussing and grumpiness as some babies will not go off to sleep without going through this phase.

Distressed crying means the baby is not ready to separate. It does not mean they are not needing to sleep but that their attachment needs have been activated.

Distress means the baby can’t sleep without more help from the caregiver.

The central principle is maintain the attachment relationship.

We want to teach the baby the process of sleeping while feeling OK, not the process of sleep based on distress and exhaustion (some adults still can’t get to sleep without exhaustion).

Sleep is sleep. It should not be the same as abandonment and separation.

The mother is not abandoning the baby. For time poor parents, sleep cannot be used as a rationalisation for rationing their time with their babies.

The caregiver remains available

The presence of the mother or more precisely a reduced part of the mother is crucial.

The baby may not want to sleep but they are not given any alternative.

The caregiver says in effect, “I will be here for you but we are not doing anything else. We are only doing ‘sleep’”. “You can have me but we are not doing anything else”.

The mother gives up her time for the task. The baby gives up its other activities. A fair trade.

Caregiver always helps to resettle distress.

The caregiver does what is necessary to resettle.

they return to the room but they – try not to lift the baby out of the cot– or they try not to leave the cot area– or they try not to leave the room

Sometimes if the baby will not settle after 30 minutes the caregiver my decide to try again later.

A supportive partner or relative or friend is invaluable.

The partner or friend is not there to embolden the mother to thwart her baby’s dependency needs but to help the mother to meet them.

Pretty soon a securely attached baby likes nothing better than to drift off to sleep.

If the mother can be suported in her bonding with the baby and made to feel the baby is a worthwhile human being, someone to be proud of, someone who is worthy of a fair amount of attention then she and the baby will settle and the baby will sleep.

GOODNIGHT