Sleep and childhood behavior problems: a complex relationship

A study published in the July/August issue of the Journal of Developmental and Behavioral Pediatrics showing a connection between hours of sleep and childhood behavior problems has received a lot of media attention. Children who slept less than 9.4 hours of sleep had more impulsivity, anger, tantrums and annoying behavior. The obvious conclusion-more sleep, better behavior. If only it were that simple.

If one takes the time to look closely, one will discover that what is correctly described as an "association" in the original article is in fact two interlinked phenomena that have a common underlying cause. Sleep problems are behavior problems. To know the cause, one must know the family story.

Sleep is a developmental phenomenon. In infancy a child learns what is commonly called "sleep associations." The breast, a pacifier, a lovey or even a parent's hair may be what a child associates with falling asleep. Frequent night wakings, expected by parents in the early weeks and months, can become a problem if that sleep association requires a parents' physical presence. As the months wear on parents become severely sleep deprived, and often find that this pattern is not so easy to change. In toddlerhood as a child in a normal healthy way begins to assert his independence, he may resist bedtime in the way he says "no" to many things. Further complicating the picture is the fact that sleep represents a major separation. A child who handles the first day of preschool with grace may suddenly refuse to go to bed, or begin waking during the night.

Given the complexity of this process, there are many ways it can get derailed. If parents do not agree about teaching a child to sleep independently, a child in the bed can cause significant marital discord.  When  parents struggle with depression, and this includes both fathers and mothers, they will have aggravation of symptoms, which often includes irritability. in the setting of sleep deprivation. When a parent is quick to lash out at a child, he may become anxious. Sometimes this anxiety leads to "acting out" in the form of oppositional behavior. It seems illogical, but a two-year-old doesn't know how to say "I need you to be with me and I feel sad when you are angry." He may simply see that when he is "difficult" his parents are more engaged with him. Separation anxiety is common in these situations, and sleep is a major separation.  Bedtime refusal and frequent night wakings are common in this setting. This leads to a vicious cycle as both parent and child become increasingly irritable.

These are some examples, and there are as many different stories as there are families. By the time parents come to see me at the Early Childhood Social Emotional Health Program with behavior problems, which in my experience always include sleep problems, they may be hard pressed to describe moments of joy with their children.

I feel for the parent who reads an article with the title More Sleep Might Help Tots' Tantrums, with its recommendation to have a child get more sleep to improve behavior, and is unable to change the situation because the underlying cause is not addressed. This is where our culture of advice and quick fixes can lead parents to be overwhelmed by feelings of inadequacy and guilt.

The key to treating these complex problems is to give parents space and time to tell the full story. When parents themselves feel heard and understood, they are in a better position to be curious about the meaning of their child's behavior.

This study is important because it calls attention to the need to address sleep in the setting of behavior problems. However, when a child and family are struggling, simple recommendations have a child get more sleep are not only not helpful, but may make parents feel worse. A downward spiral of sleep deprivation and behavior problems will likely persist.

If a family and clinician has the time, then it is possible to make sense of the situation and take steps to set the whole family on a better path; to bring joy back in to relationships.  The younger the child, the easier this is to do.

Taylor Swift Captures Secure Attachment Relationship

If my book, Keeping Your Child In Mind, were to have a theme song/video, it would be Taylor Swift's The Best Day. I have included the lyrics below, but suggest watching and listening (with tissues!) It offers a "right brain" emotional experience of what D.W. Winnicott termed the "holding environment." As I write in my book:

Winnicott describes this way of being with a baby as the “holding environment.” The mother’s ability to tolerate and contain her baby’s distress helps him to make sense of and learn to manage his experiences. Even though holding a baby may seem to be simply a physical act, it is her emotional presence that is important to the baby.

The video speaks for itself, but here are a few points that stood out for me.

As a young child Taylor's mother physically contains her after a long day playing outside: "I hug your legs and fall asleep/
on the way home" She feels safe and secure with her mother who is "not scared of anything at all."

The video captures the way in which she was included in the arrival of her baby brother. Her love for him is clear in the later lyrics, "Inside and out, he's better than me."

At thirteen she experiences inevitable social trauma, with her friends being "so mean.". Her mother does not try to fix it. Rather, Taylor receives her mother's undivided and playful attention as they go for a ride in the car. One feels confident that though, as she says, "Don't know how long it's gonna take to feel okay," Taylor, refueled and fortified by mother's love, will work it out herself.

While the song is primarily about her mother, Swift brings in her father "whose strength is making me stronger."

Overall, the video perfectly captures the great value of simply being present with our children. In our culture of "advice" about "what to do" about any range of problems, this is a breath of fresh air. The challenge is clear our own minds and lives enough to offer our children this kind of holding. If we can, we are setting the foundation for their healthy emotional development and future success, in every sense of the word.

The Best Day

I'm five years old
It's getting cold
I've got my big coat on

I hear your laugh
And look up smiling at you
I run and run

Past the pumpkin patch
And the tractor rides
Look now -- the sky is gold
I hug your legs and fall asleep
On the way home

I don't know why all the trees change in the fall
I know you're not scared of anything at all
Don't know if Snow White's house is near or far away
But I know I had the best day
With you today

I'm thirteen now
And don't know how my friends
Could be so mean

I come home crying and you hold me tight and grab the keys

And we drive and drive
Until we've found a town
Far enough away

And we talk and window-shop
Until I've forgotten all their names

I don't know who I'm gonna talk to
Now at school
I know I'm laughing on the car ride home with you
Don't know how long it's gonna take to feel okay
But I know I had the best day
With you today

I have an excellent father
His strength is making me stronger
God smiles on my little brother
Inside and out
He's better than I am

I grew up in a pretty house
And I had space to run
And I had the best days with you

There is a video
I found from back when I was three
You set up a paint set in the kitchen
And you're talking to me

It's the age of princesses and pirate ships
And the seven dwarfs
Daddy's smart
And you're the prettiest lady in the whole wide world

Now I know why all the trees change in the fall
I know you were on my side
Even when I was wrong
And I love you for giving me your eyes
Staying back and watching me shine

And I didn't know if you knew
So I'm taking this chance to say
That I had the best day
With you today

Colic and Migraines: A Complex Relationship

In a new study, neurologists at the University of California, San Francisco who surveyed new mothers at their pediatricians office found that mothers who suffer migraine headaches are more than twice as likely to have babies with colic than mothers without a history of migraines. Proposing a genetic link, they hypothesize that colic may represent an early form of migraine.

Before we can launch any meaningful conversation about colic, it is essential to recognize that when we talk about mothers and infants, we are talking about an intense passionate love relationship (see my previous post). When all goes well, the caregiver, who is usually the mother, is highly attuned to the needs of her infant, who in these early months is completely helpless. In a natural and healthy way that accompanies this state of falling in love, a mother is, to quote D. W.Winnicott,, "preoccupied" with her baby. They are engaged in a beautiful dance, in which the mother, by supporting and containing the baby, helps him to learn to regulate himself in the face of all the new experiences he has out in the busy, bright, loud world.

It is not as simple as "the mother has migraines, so maybe the baby has migraines." The exquisite dance of mutual regulation, that goes on naturally when both mother an baby are well, is severely disrupted. It is replaced by a dance of mutual dysregulation.

The baby may be more sensitive to sensory input, as the authors postulate. This difficulty with sensory processing is thought to be a significant component of colic, even if the mother does not have migraines. But the other person in the dance, far from being "preoccupied" with her baby, may be" lying prostrate on the couch for 10 hours," as one migraine sufferer wrote on her blog in response to this study. Certainly her ability to respond to her baby will be in some way impaired by her own distress. The crying, in turn, may worsen the migraine. This is not meant to be a judgment, but simply a fact.

The growing discipline of infant mental health looks at colic not only as a problem in the baby, who may have a variety of biological vulnerabilities, (sensitivity to sensory input being one of them) but as a problem in a relationship. For a new mother, who had anticipated this period as a time of bliss but is instead faced with baby who is either crying or sleeping, with few moments available for gazing adoringly into each others eyes , colic can be a devastating experience.

Recently I had the privilege of teaching about infant mental health to a group of psychologists and psychiatrists who work with very troubled adults, many of whom had significant disruptions in relationships starting in infancy. My students wanted to know what questions to ask when taking early developmental history. I found that they know what to ask, as in "did he have colic?" but they don't know what to listen for in the answers. I told them that my aim was to give texture to colic -to give them sense of what colic felt like, how it was experienced by both the baby and caregiver.

Interestingly this word "texture" came up again last week. I have been taking a wonderful online course on regulatory and sensory processing disorders taught by Rosemary White, who worked closely with the late Stanley Greenspan. White used the word "tailor" to describe how mothers are attuned to their babies, preferring this word to the word "calibrate" that she has used in previous courses. She said that the word "tailor" gives more "texture" to the experience.

There is yet another layer to the "texture" of colic. Mothers, even in the absence of migraines, may struggle with intense feelings of inadequacy in the face of a baby who cries all the time. Add to that chronic sleep deprivation along with an illness like migraines, and there may be a slide into depression.

Recognizing and exploring this "texture" of colic has significant implications for treatment. Rather than exclusively focusing on the baby, it is important to listen to the mother. A mother will need to know that another caregiver who she trusts, be it a spouse, close friend or relative, can watch the baby when she has a migraine. If she can count on such a person, it may lessen the guilt she will likely be experiencing. She may need to attend a group with other mothers facing similar challenges so that she does not feel so isolated. She may need to work on-on-one with an infant mental health specialist who can help the "couple' to manage the stresses on their relationship.

Even in the absence of colic, a mother needs to feel heard, valued and not alone in order to be free to provide that "primary maternal preoccupation." But when she is not well, and her infant is crying all the time, that kind of supportive environment is even more essential. When a mother has such a "holding environment," to again quote Winnicott, she is better able to provide that holding environment for her baby. Together they can make their way thorough these early months when the baby is totally dependent and helpless. It is important in those difficult months, to keep in mind that by "hanging in there," the time will come when a baby can reach for a toy, bring his thumb to his mouth, and begin to learn to comfort himself. This is a skill he will, with the help of his caregivers, continue to develop and refine as he grows increasingly more independent.