New study asks; what happens to the dysregulated infant?

When I see children in my behavioral pediatrics practice, whether they are 2, 5 or 15 it is very common to hear from parents that as a baby their child "cried all the time" never slept" had "terrible feeding problems" or some variation of this. Therefore I was not surprised by the findings of a large longitudinal study published this week in Pediatrics: Long-term Outcomes of  Infant Behavioral Dysregulation. The researchers in Australia had information about over 5000 babies starting at 6 months, and found that when mother's reported symptoms of "dysregulation" at this age, they were significantly more likely to report of behavior problems at age 5 and age 14. This association was affected by such things as mother's level of education, marital status and presence of anxiety and/or depression. The authors conclude that:

By facilitating early referral to appropriate professionals, such as public health nurses, family therapists, psychologists, and social workers, clinicians may aim to improve not only behavioral out- comes in childhood and adolescence, but also parents’ perceptions of their children and the needs of the parents themselves.

While I am pleased that this conclusion is reached in a prestigious journal, what is lacking in this study, is understanding of how infant dysregulation and later behavior problems are linked, and so in how to treat these problems. Here are three points that speak to this issue.

1) This model places the "dysregulation" squarely in the baby. However, any new mother (I refer to mothers because that is what the study does- see below for thoughts about fathers) will tell you that the baby's behavior has a huge influence on a mother's behavior and emotional wellbeing.  The mother and baby regulate and dysregulate each other. For example, if a baby has difficulty settling to sleep, a parent will likely be severely sleep deprived. This in turn may affect her ability to respond to her baby's cues. If she is struggling with postpartum depression, the sleep deprivation likely will worsen her symptoms. When a mother is herself struggling in this way, it may lead to further symptoms of "dysregulation" in the baby. But conversely, if a baby is dysregulated and the mother gets help,  in the form of such things as a mother-baby group, yoga and/or therapy, and she is able to be calmer, she will be better able to help her baby manage his symptoms of dysregulation. In turn, as her baby becomes more calm, she will feel more competent and better about herself as a parent.

2) Fathers have a critical role to play. A study published last year in Pediatrics showed a significant link between paternal depressive symptoms and later child behavior problems. Again, looking at the positive side of this, when a father's emotional wellbeing is supported, he can be more emotionally available for both his partner (this study does identify stability of partner relationships as well as marital status as an important factor) and his child.

3) Symptoms of dysregulation are usually present before 6 months of age. For example babies born prematurely are very likely to be behaviorally dysregulated. One particularly vulnerable population is what is referred to as the "late preterm." When babies are born at 35-37 weeks, they are often in the regular nursery and parents have an expectation that they are "normal." However, these babies may be difficult to feed, have difficulty settling to sleep as well as increased sensitivity to sensory input. When there is this kind of mismatch between the parent's expectations and experience, significant feelings of inadequacy may emerge. In turn, these feelings, together with sleep deprivation may lead to symptoms of depression in a parent. This is another example of mutual dysregulation.

I was motivated to develop the Early Childhood Social Emotional Health program at Newton Wellesley hospital exactly because of the findings that this study calls attention to. I wanted to help families before their child was 5, 10 or 16 and being diagnosed with ADHD. Recognizing that the roots of these problems are usually present very early, it made sense to  devote resources to helping families of young children.

The risk of this study however, is that "infant dysregulation" becomes the new "ADHD," placing the problem squarely in the child, and failing to recognize that the problem occurs in relationships.   As it stand now, the study adds to the rapidly growing body of literature offering evidence that devoting resources to early childhood is important. But it is only by focusing on interventions that promote healthy relationships, and for vulnerable parent-child pairs starting these interventions at or close to birth, that this research can have a positive and meaningful impact.