Unique child Regulatory disturbances - Bringing calm

Babies and infants who are hard to comfort and settle, and seem to cry regularly in an inconsolable way for no obvious reason, may be struggling with a regulatory disorder. It is important that early years practitioners always consider this as a possible cause.

Recognising that a baby's screaming and arching away from a feed stems from a neurological condition can help you defuse a tense situation and redefine a seemingly intractable problem.

Bringing about a change is often remarkably easy. When I was filming a friend with her new baby for some teaching material, the little girl began to cry uncontrollably as she was fed. The mother told me the baby had screamed continually since coming home, leaving both parents at the end of their tether.

When I viewed the film, I noticed that the baby kept her gaze on an abstract painting and turned her face towards it when she was carried around the room. I explained to the mother that the baby may have a regulatory disorder (she was born premature, which made it more likely), and that fixating on the painting was her attempt at self-soothing by limiting the sensory input.

I suggested that the parents limit the baby's stimulation by, for example, avoiding making eye contact, talking while feeding, playing music and having bright lights when talking and playing. This would give the baby's nervous system a chance to integrate at its own pace. It worked.

UNUSUAL EXTREMES

It is useful for early years practitioners to be aware of the concept of regulatory disturbance, even though, as some suggest, there might be comparatively little empirical data available to support the idea that this is a discrete clinical diagnosis.

It has been suggested that such disturbances are, in fact, no more than unusual extremes of normal variations in nervous system reactivity and/or temperament. However, there is little doubt that specific difficulties in sensory, sensorimotor or processing capacities can lead to behavioural patterns that make life difficult for both babies and their parents.

Infants with such a problem struggle to deal with normal life events and to remain calm for even a brief period of time. These troublesome behaviours can be seen as a risk factor for a relationship disturbance later on.

Of course, only the parents can describe the 'problem'. However, children with regulatory disturbances are often reported to show problems with self-regulation 'out of the blue' and to be distressed and tearful when struggling with sleeping, eating, focusing attention, high motor activity, sensory overload and emotional reactivity.

Such difficulties are common in premature babies and those born to mothers who have been involved in drug abuse or been under severe stress during pregnancy. It may take several weeks of observation and reflection before the problematic behaviours and responses are understood.

The descriptions of regulatory disturbances are useful (see box), as they emphasise to parents that their baby may struggle to cope with some sensory inputs, and that it is possible for them to eventually work out how to adapt their style of parenting to their child's particular sensitivity.

It should be possible to spot signals of impending disorganisation and support the child. This applies to all children. The idea of regulatory disorder should not be used as a label. It should be seen as a starting point for observation and moving away from the idea that someone is to blame.

TYPES OF REGULATORY DISORDERS

The Diagnostic Classification 0-3 (see References) gives four types of regulatory disorders, defined as the presence of 'difficulties in regulating behaviour and physiological, sensory, attentional, motor or affective processes, and in organising a calm, alert, or affectively positive state.' Perhaps it is best to see these as pragmatic descriptions rather than discrete clinical entities.

Hypersensitive

Such infants have an unusually high sensitivity to the surrounding world of tactile, auditory and visual stimulation. Excessive crying is usually a feature. They may present as: Fearful and cautious, shown by: - restricted exploration

- timidity in novel situations - proneness to becoming upset - difficulties in self-soothing and recovering from distress. These infants can be - over-reactive to loud noises, touch (including some food textures) or bright lights

- easily woken - prone to tantrums triggered by sensory overload. Such babies may appear to have a short attention span, as they cannot selectively screen things out and so respond to everything anywhere at any time.

A first intervention is to reduce the number of channels of stimulation. Caregivers need to use empathy to encourage flexibility and assertiveness, offer support to exploration and keep firm but gentle limits.

Negative and defiant, shown by a tendency to be:

- negative, stubborn, controlling and defiant (because these children struggle to manage transitions and prefer things to stay the same)

- fussy

- over-reactive to touch and sound.

Caregivers should enhance flexibility using empathy, soothing and support, with any change being gradual, while avoiding power struggles.

Under-reactive

These children may present as:

Withdrawn and difficult to engage: They may:

- appear delayed or depressed

- seem lacking in motor exploration and responsiveness to sensations and social approaches

- appear apathetic, easily exhausted and withdrawn

- seek out sensory input through engaging in repetitive activities

- be under-reactive to sound and movement, but under- or over-reactive to touch. Caregivers need to provide intense interactive input, with high affective tone, and foster any initiative to help them interact with their environment.

Self-absorbed: They may:

- show great imagination and creativity

- tend to tune into their own inner world rather than to other people

- appear inattentive or preoccupied

- prefer solitary exploration of objects

- have a decreased capacity for auditory-verbal processing, with the ability to produce a rich range of ideas.

Caregivers should use all opportunities to promote two-way communication, and encourage a good balance between fantasy and external reality.

MOTORICALLY DISORGANISED AND IMPULSIVE

These children may:

- show poor control of behaviour, coupled with a craving for sensory input and stimulation

- show high activity (in constant motion) and lack of caution

- seek contact and stimulation through deep pressure, which can lead to people feeling intruded upon or objects being broken

- crave sensory input and motor discharge

- combine underactivity to touch and sound with stimulus-craving and poor motor modulation and planning, while showing general impulsive behaviour

- be a bad listener yet crave loud noises (due to underactivity). The baby can be unfocused and very active, and gets easily worked up when parents set appropriate limits to their desire for stimulation and exploration. Occasions when one would expect the infant to be calm, such as bedtimes and meals, can be fraught.

Caregivers need to provide a lot of nurturance and empathy, along with clear boundaries, with the aim of enhancing flexibility. The children need to be provided with constructive opportunities for sensory and affective involvement while being encouraged to learn self-regulation.

OTHER

A catch-all category for children who meet the criteria for regulatory disorder but whose behaviour does not fit the three previous categories.

REFERENCES

- (1) Barton, ML & Robins, D (2000) 'Regulatory disorders', pp311-325 in Zeanah, C (ed) Handbook of Infant Mental Health. 2nd Edition. New York: Guilford Press.

- (2) Greenspan, SI & Wider, S (1993) 'Regulatory disorders', pp280-290 in Zeanah, C (ed) Handbook of Infant Mental Health. New York: Guilford Press.

- (3) Maldonado-Duran, JM & Sauceda-Garcia, JM (2002) 'Excessive and persistent crying: Characteristics, differential diagnosis, and management', pp239-267 in Maldonado-Duran, J.M (ed) Infant and Toddler Mental Health. Washington DC: American Psychiatric Publishing

- Diagnostic Classification 0-3 (1997) Washington DC: Zero to Three. (Only available from www.zerotothree.org or from www.transatlanticpublishers.com in the UK).