Regulatory Disorders in Infants and Toddlers (Crying Babies) - Specialists and Information

About 15 to 25 percent of all infants exhibit behavioral abnormalities in the first months and years of life. These include, for example, excessive crying or restlessness. This is referred to as regulatory disorders.

An infant with regulatory disorders is unable to regulate their behavior appropriately. This can place an extraordinary burden on their caregivers.

Common situations in which regulatory disorders manifest include:

• Crying
• Sleeping
• Feeding
• Interaction and play
• Brief separation
• Setting Boundaries

The child is then unable to calm itself sufficiently.

After birth, an infant gradually breaks away from the initial symbiotic relationship with the mother. The infant begins to develop increasingly independent regulation of physical, emotional, and social functions. In doing so, the infant adapts its behavior to the conditions of its environment.

These are referred to as “developmental tasks” that the child must accomplish. For example, during certain stages of development, the child learns to crawl, walk, and speak. Developmental tasks also include

• adjusting the sleep-wake cycle to day and night,
• food intake and digestion,
• the immune system, as well as
• the ability to self-soothe.

The child thus learns to self-regulate in various areas of development. Later, the regulation of arousal and attention control are added.

Toward the end of the first year of life, the focus shifts to regulating closeness and distance, as well as attachment and separation. In the second year of life, the child learns

• to regulate dependence and autonomy, as well as
• acceptance of rules and boundaries.

Crises in the Adaptation and Development Process of Infants and Toddlers

Within the context of these aforementioned adaptation and developmental processes, short-term “crises” may occur. In such cases, the child reacts with

• restlessness and irritability,
• crying, or
• sleep disturbances.

For an infant, crying is the most basic, natural means of expression and communication. Crying, therefore, does not always indicate a “distress” requiring care.

Such “crises” represent transitional phases. Through these adjustment and learning processes, the child initiates the next stage of development. They are therefore normal and temporary in nature, but can cause parents to worry about their child’s well-being.

One in five families struggles with their infant’s crying during the first few months of life.

The Three Types of Infant Crying

Not all crying in infants is the same. A distinction is therefore made between:

• physiological crying due to physical and emotional needs, e.g., hunger, a wet diaper, or a need for attention
• pathological crying due to organic causes, e.g., acute illnesses
• nonspecific crying with no apparent cause

Non-specific crying stems from the developmental processes described above. It occurs in almost all infants. Crying episodes begin in the second week of life and peak in the sixth week. By the third month of life, they subside again.

In the past, this difficult period was referred to as “three-month colic.” This was based on the assumption that the cause of the crying spells lay in gastrointestinal disturbances (e.g., cramps, bloating).

However, studies have shown that digestive problems are rarely the cause of these crying spells. In most cases, the non-specific crying should be viewed as an expression of physiological arousal.

Synchronization with the Primary Caregiver

Infants and toddlers can regulate their behavior only through direct interaction with their primary caregiver. A consistent, secure “partner” is essential for, for example, reducing tension or developing an appropriate sleep rhythm.

The infant needs constant synchronization with their caregiver in order to establish

• eye contact,
• emotional resonance,
• physical contact,
• nurturing, and
• rhythm

to find their inner balance.

Ideally, the caregiver is able to respond appropriately to the infant’s phase-related restlessness and crying spells. This creates a positive feedback loop:

The infant cries –> the primary caregiver provides care and attention –> the child calms down –> the primary caregiver also calms down, and the parent’s sense of competence is strengthened.

This sense of competence is important for the caregiver in the long term for coping with further crisis situations. As a result, the caregiver gains the feeling of understanding the child better and better and feels more confident in interacting with the child.

Causes of a lack of synchronization with the caregiver

Even minor disruptions to this interaction with the caregiver can upset the infant’s inner balance. This can lead to severe behavioral problems.

Psychosocial stressors that place the primary caregiver under stress often play a significant role here:

• Stress before and during pregnancy
• difficult circumstances surrounding the birth
• Relationship problems
• The caregiver’s own mental health issues
• Problems within the extended family
• Everyday stress, restlessness, and a hectic pace

Excessive crying can be a sign of a regulation disorder © Ilka Burckhardt | AdobeStock

The infant appears overstimulated, fussy, and restless. Crying spells occur suddenly and without any apparent reason. The infant is barely able to self-regulate. This is referred to as “unconsolable crying,” as even the caregiver’s attempts to soothe the infant are unsuccessful. Children who cry excessively are also known as “cry babies.”

Key symptoms of excessive crying include:

• episodic restlessness and crying spells
• lack of response to soothing measures
• short daytime naps with significant difficulty falling asleep
• reduced total sleep
• Frequent episodes in the evening
• possibly distended abdomen, bright red skin color, muscle hypertonicity

A rule of thumb for excessive crying is the so-called “rule of three”: An average duration of crying or restlessness of

• more than 3 hours per day
• at least 3 days a week
• for at least 3 weeks

The mutual regulatory coordination described above no longer functions. Parents lose their sense of competence in dealing with their child and can no longer confidently interpret the crying. They try every possible way to soothe the child until they themselves are on the verge of exhaustion.

As a result, parents come under increasing pressure: The constant failure of their attempts to soothe the child leads to helplessness and powerlessness, but also to anger and aggression. “I did everything for him,” one mother reports, “but he just kept crying—I didn’t understand my child anymore!”

This gives rise to further problems. The primary caregiver feels unable to connect with their child anymore. As a result, they may feel that the child’s behavior is directed against them—as rejection, defiance, and deliberate provocation.

The helplessness and feelings of failure they experience can turn into anger and aggression toward the child. Excessive screaming is thus a common trigger for child abuse, such as

• shaking,
• hitting, or
• neglect.

The problem can spread relatively quickly to other areas of regulation. This leads to disruptions in the sleep-wake cycle and feeding problems. In the long term, this can result in a situation where there is hardly any relaxed interaction left in the family’s daily life.

A vicious cycle develops, leading to extreme psychological stress on both sides and ultimately to exhaustion. The relationship between parents and child deteriorates, as parents experience almost no positive interactions with their child. They themselves almost inevitably fall into a state of burnout caused by

• lack of sleep,
• stress triggered by the child’s crying,
• feelings of failure
• helplessness,
• aggressive impulses toward the child, and
• depression

.

Early childhood regulatory disorders are extremely complex. For this reason, when making a diagnosis, the physician takes into account the family constellation and all family stressors. To this end, the physician conducts a detailed medical history, i.e., speaks with the child’s primary caregivers and asks for details about the symptoms.

The first step is to rule out organic factors, such as

• infections,
• injuries,
• gastrointestinal disorders,
• allergic and neurological conditions, or
• sleep apnea syndrome.

The further medical history focuses on identifying the related factors:

• Child-related factors
• Interaction and relationship factors
• Parent-related factors

This information is gathered as part of the medical history. For a more detailed diagnosis of the issue, behavioral observations in the relevant contexts—either on-site or via

• video documentation,
• logs, and
• parents’ diary entries, as well as

, if necessary, the use of standardized questionnaires and scales.

Child-related factors:

• Onset, duration, and progression of the problem
• Contexts in which the disorder occurs
• Biological and psychosocial stressors and resources

Interaction and relationship factors:

• Daily routine and family environment
• The nature of the child’s care
• problematic, but also well-functioning, areas of interaction
• The child’s relationships with other people (grandparents, siblings, etc.)
• Parental attitudes and feelings toward the child
• Parental explanations for the child’s behavior

Parent-related factors:

• Subjective experience of stress
• Biological and psychosocial stressors and resources
• Own childhood experiences and trauma

Couple- and family-related factors:

• Dynamics of the parental relationship
• Coping with the transition to parenthood
• Quality of the relationship between parents and their own parents

Parents often feel uncomfortable admitting to themselves or others that they are currently struggling to cope with their child. As a result, they try to handle everything on their own—which is likely to further reinforce the vicious cycles described above. It is precisely when parents feel a loss of competence and a sense of powerlessness that they should seek help.

A regulation disorder cannot simply be attributed to parenting, emotional, or moral failure. Numerous factors must be considered in order to

• identify the exact causes and triggers of the crying,
• and to recommend a way out of the situation.

Professional help often brings significant relief and improvement in the problem within a short time.

The pediatrician is the parents’ first point of contact. He or she assesses the child’s physical condition and, as a first step, the psychosocial factors underlying the disorder. Afterward, the pediatrician can provide counseling or refer the family to further treatment options.

Outpatient Counseling and Therapy for Regulation Disorders

Outpatient counseling and therapy (e.g., in so-called “crying clinics”) take place through regular meetings with parents. This is supplemented by interaction-focused sessions with the child. These sessions include both observation and behavioral exercises for parents to perform with their child in play and challenge situations. Video recordings made by the parents at home may also be analyzed.

As part of the therapy, parents receive practical tips and behavioral guidelines.

Depending on the need, the sessions take place

• at shorter intervals as crisis intervention or
• at regular intervals to provide ongoing support.

The goals of treatment are

• to improve regulation difficulties,
• to relieve the parents’ burden, and
• to (re)establish a positive parent–child relationship.

Partial-Hospitalization Therapy for Regulation Disorders

In semi-inpatient therapy, the primary caregiver is also included. This approach is appropriate when parents are no longer able to implement the agreed-upon arrangements and behavioral rules at home.

Experts directly support parents in dealing with the specific situations related to the disorder. This helps reduce misperceptions and build safe, appropriate ways of handling difficult situations.

Inpatient Parent-Child Therapy for Regulatory Disorders

In severe cases, the parent-child system may be so disrupted that the child’s physical and emotional well-being is at risk. In such cases, those affected should consider full-residential parent-child therapy.

Such comprehensive inpatient psychosomatic therapy is also necessary when

• failure of outpatient counseling and
• severe exhaustion of the primary caregiver resulting from a sense of powerlessness.

Through inpatient therapy, the primary caregiver is completely removed from the home environment. This offers the best chance of breaking the vicious cycle of regulatory disorders and a sense of powerlessness as quickly as possible.

At the clinic, parents can be temporarily relieved through intensive nursing and therapeutic care. The child, too, usually quickly settles into an age-appropriate rhythm under structured, relaxed conditions. As a result, the paroxysmal crying fits and emotional outbursts subside.

As therapy progresses, relevant situations from everyday life are discussed, and new behavioral patterns are practiced. The primary caregiver is gradually encouraged to feel more competent. This positive mutual interaction enables her to interact with the child independently and confidently once again.

One mother reports: “I feel like I have a connection with my child again. I can now make sense of his behavior.”

As part of inpatient complex therapy,

• behavioral medicine,
• developmental psychological,
• systemic,
• attachment theory, and
• psychodynamic aspects

are given equal consideration.

At the same time, various situations are addressed therapeutically, such as

• feeding disorders,
• sleep disturbances,
• restlessness,
• separation anxiety, etc.

Inpatient comprehensive therapy and contact with a team experienced in dealing with these conditions yield the best results.