Understanding and responding to excessive crying

Excessive crying in early infancy is associated with an increased risk of adverse outcomes for babies and their families.

Sally Hogg Sally Hogg is currently on maternity leave from her role as Development Manager at the NSPCC and Vice Chair of the Maternal Mental Health Alliance. She recently completed a Master’s thesis on the impact of excessive infant crying.

Excessive crying in early infancy is associated with an increased risk of adverse outcomes for babies and their families. It is widely believed – by both parents and professionals – that this crying is ‘colic’, caused by digestive problems. This is rarely the case. This article argues that it is important to challenge traditional discourse and to support parents to care for their baby, rather than trying to ‘cure’ the cause of babies’ crying.

All babies cry, but some cry much more than others. Between 10 and 20 per cent of babies exhibit ‘excessive crying’ in the first three months of life. This causes distress for families during a significant and formative period for the child, parents, and their relationship. It is one of the most common reasons that parents seek professional help during this time (Kaley, Reid & Flynn, 2011; Canivet, 2002). Excessive infant crying is associated with an increased risk of negative outcomes such as maternal depression, child abuse and childhood behavioural problems (e.g., Papousek & Von Hafacker, 1998; Forsyth & Canny, 1991). 
There is no clear definition of excessive crying. The most commonly used threshold, ‘Wessel’s Rule of Three’ involves crying for more than three hours a day, for more than three days a week, for more than three weeks.  However, Wessel’s rule sets an arbitrary line above which crying is defined as excessive, whereas actually, excessive crying lies at the end of a spectrum of individual differences (Barr, 2001). Families may struggle with their baby’s crying, even if it does not fully meet Wessel’s criteria, particularly if they have lower social or emotional resources.

The causes of excessive crying: colic
Excessive crying is traditionally known as colic, a word defined as meaning abdominal pains or problems (Oxford English Dictionary, n.d.). This reflects a widely held belief that it is caused by digestive problems - trapped wind or food allergy - which cause a baby pain (Helseth & Begnum, 2002). Whilst often recognising that the causes of excessive crying are not certain, both professional and parent discourses refer to excessive crying as colic, and reflect these traditional beliefs (e.g. NCT, n.d.; Netmums, n.d ; Patience, 2013; Waddell, 2013; Wall, 2013).
In fact, it has been known for more than two decades that excessive crying in early infancy is rarely caused by digestive problems. Only a small subgroup (around 5-10%) of infants who cry excessively have any identifiable problems with their stomach or gut (Garrison & Christakis, 2001; Gormally, 2001; Miller & Barr, 1991). 
The literature suggests that just because a baby cries a lot, this  does not mean that there is something physiologically ‘wrong’ with him – digestive or otherwise. There is no clear biological marker, symptom or behaviour that distinguishes excessive criers from other infants (Soltis, 2004; Green & Gustafston, 2001; St James-Roberts, 1999).  

Excessive crying is rarely caused by digestive problems


Difficult temperament and parenting behaviours
Parents may worry that excessive crying is the sign of a difficult temperament that will continue into childhood. Babies who have a difficult temperament may cry more, but the evidence is clear that excessive crying is not always due to difficult temperament. In many cases, excessive criers have poorer regulation only in the first three months of life, and this seems to result from neurological immaturity rather than differences in underlying temperament (Stifter, 2005; Barr & Gunnar 2000; White et al., 2000; Barr et al., 1988; St James-Roberts et al., 1998).
Whilst some babies will be more sensitive, irrespective of how they are cared for, the amount that a baby cries may also be influenced by parents’ characteristics and behaviours before and after birth.  A number of prenatal characteristics such as stress, young age, low social support, attitudes to parenting, self-efficacy and smoking in pregnancy are associated with excessive crying (e.g., van den Berg et al., 2009; Sondergaard et al., 2003; Stifter et al., 2003; Canivet, 2002; Raiha et al., 2002; Reijneveld et al., 2002). However, whilst research demonstrates associations between some parental factors and excessive crying, the causal pathways are far from clear. Caution is also needed because many studies rely on parent reports of infant crying – leaving open the possibility that systematic differences may be because some groups of parents are more likely to report that their babies cry more. 
The evidence is unclear as to whether or how early caregiving behaviour contributes to excessive infant crying. St James-Roberts (2001) argues that caregiving behaviour has little influence on excessive crying, citing evidence that first born babies do not cry substantially more than later babies; family socio-demographics and feeding decisions are poor predictors of how much babies cry, and some mothers of excessive criers display sensitive care. However, his argument is based on research looking for a single cause of excessive crying. It may be that a subset of babies who cry excessively does so as a result of caregiving behaviours such as enforcing a feeding or sleeping routine that is not suited to the baby’s needs. There are few prospective studies to shed light on this hypothesis; intervention studies give mixed evidence, and confounding factors make it difficult to draw conclusions from cross-cultural studies.
Much of the research into the causes of excessive crying seeks to establish group differences between excessive criers and other babies. Such differences are hard to find. One reason for this is that excessive criers are very unlikely to be a homogenous group. Excessive crying is a behaviour exhibited by different babies for different reasons, and not a discrete clinical condition. More research is required to identify subgroups of excessive criers and to understand the different causal pathways at play.

Outcomes associated with excessive crying
Excessive crying is associated with a range of negative outcomes for parents and their babies, including poor parental mental health, relationship breakdown, abuse and childhood behavioural problems (e.g., Helseth & Begnum, 2002; Papousek & von Hofacker, 1998; Pinyerd, 1992; Forsyth & Canny, 1991; Lester et al., 1990). 
Although a large number of infants who cry excessively have positive and attuned interactions with their parents, excessive infant crying can inhibit some parents’ ability to provide sensitive and responsive care which is so critical to their baby’s social, emotional and cognitive development (e.g., Raiha et al., 2002).  A review of the literature reveals four different mechanisms through which  excessive crying may inhibit parents’ ability to respond appropriately to their baby (although these are not mutually exclusive):


• Babies who cry more may provide parents with fewer cues about their feelings and needs.
• The stress, exhaustion, and/or conflict caused by an infant crying may limit parents’ emotional capacity to hold their baby’s needs in mind.
• Parents may change their parenting in response to their child’s crying and reduce their reliance on intuitive behaviour (for example, by imposing routines and parenting styles that are less responsive to their baby).
• Parental self-efficacy may decline so that parents are less motivated to try and respond to their baby’s needs.

Crying does not affect all families in the same way. The literature suggests that excessive infant crying is more likely to have an adverse impact on parents, parent-infant relationships and infant outcomes if it occurs in the context of other individual or environmental stressors (summarised in Box 1).  When families are experiencing low social or emotional capital, they have fewer resources to ‘buffer’ the impact of the crying (Ablow et al., 2013; ; Groh & Roisman, 2009; Altimier, 2008; Paulussen-Hoogeboom et al., 2007; Leerkes & Siepak, 2006; Soltis, 2004; Stifter et al., 2003;  Zeifman, 2003; Fox & Polak, 2001; Leavitt, 2001; Murray & Cooper, 2001; Pauli Pott et al., 2000; Papousek & von Hofacker, 1998; Stifter & Bono, 1998; Crockenberg & McCluskey, 1986; Crockenberg & Smith, 1982).

Excessive crying generally resolves by the time a baby is three months old, but its effects can last longer. No major differences have been identified in the everyday behaviour of children who cried excessively and their peers, but there is evidence of some specific behavioural and emotional problems, including significant increases in the incidence of sleeping problems and temper tantrums (Canivet, 2002; Rautava et al., 1999; Canny, 1991). These behaviours might be the result of excessive crying affecting early parent-infant interactions in a way which hinders children’s social and emotional development. There is some evidence to suggest , for example, that mothers who have low self-efficacy and whose babies cry excessively may stop trying to soothe their babies in difficult situations where they do not believe they can make a difference (Leerkes & Crockenberg, 2002; Crockenberg & McCluskey, 1986). This low maternal sensitivity to distress may impair children’s developing self-regulation, which could explain children’s sleeping problems and difficulty regulating their temper (Leerkes et al., 2012).

CHALLENGING the ‘colic myth’
Parents with a baby who cries excessively are often very driven to find a cause for the crying and a cure for it. The traditional and widespread narrative about ‘colic’ results in many parents behaving as if excessive crying is the result of a curable medical condition related to stomach problems (Kaley et al., 2011). However, parents’ focus on trying to treat a stomach problem – for example through increased winding, use of medication and changing bottles and formulas - is likely to be unhelpful for the baby, who may simply need calming, sensitive care. This approach may also be difficult for the parents who will feel increasingly helpless when their efforts to soothe their baby do not work, as this quote illustrates:
‘I just keep being told by the health visitor and midwife that he’s just a colicky baby … but even after winding him, he cries and cries. I just don’t know what to do, it makes me feel like a bad mother.’ (ITV, 2014)
The perpetuation of the colic ‘myth’ around excessive crying may also exacerbate its negative longer-term impact. For example, research suggests that if parents believe that they cannot influence their baby’s crying, this may impair their self-efficacy and motivation to soothe their baby (Donovan & Leavitt, 1985).  Early attributions may also impact on parents’ perceptions of their child. Forsyth and Canny (1991) found that children who had cried excessively were more likely to be perceived as vulnerable three years later if their mothers had tried changing their formula in order to stop the crying. Similarly, Power et al. (1990) found that mothers who perceived their six week olds’ difficult behaviour as the result of physical discomfort were more likely to describe their infant as ‘fussy’ three months later. In contrast, mothers who saw perceived difficultness as a reflection of the infant’s preferences and response to a situation were more likely to conclude that their infant had ‘a mind of his or her own’. These studies suggest that parents’ lasting perceptions of their children can be affected if it is believed that their child has a physiological problem in early life.
Health professionals and parent educators should therefore be attuned to how their attributions and explanations of excessive crying influence parents’ understanding and responses. Whilst it is clearly important to establish whether a child has an underlying medical condition that might be causing their crying, professionals should be clear that such conditions are rare.  To avoid the adverse outcomes described above, it is important to challenge the idea that crying means there is something ‘wrong’ with a baby.  We must reframe the narrative around excessive infant crying and move the focus from ‘curing’ the infant, to one that responds to his or her early characteristics and behaviours.

HELPING FAMILIES COPE WITH CRYING
Despite the fact that there is no single ‘cure’ for excessive crying, there is a lot that professionals can do to support families with a baby who cries a lot. Intervention studies suggest that an appropriate response to excessive crying is one that provides parents with reassurance and structured ways to help them think about how they respond to infant crying (eg. Salisbury et al. 2012; Keefe et al., 2006; Wolke et al., 1994). Rather than prescribing a single response to excessive crying, professionals should support parents to respond most appropriately to their baby. 
There is value in helping all families to cope with their baby’s crying, whether or not it is excessive, as the NSPCC’s ‘Coping with Crying’ intervention demonstrates (see Richards’ article in this issue). Any additional response to excessive crying should be informed by an understanding of the wider risk and protective factors within the family involved, as the evidence is clear that this will influence their ability to cope with their baby’s crying. For example, professionals can build resilience within the family by increasing parents’ self-esteem and self-efficacy (such as through helping them to utilise different soothing techniques and affirming them when these work); or by supporting the parental relationship, and by helping the parents to develop wider social support networks.

There is value in helping all families to cope with their baby’s crying

Professionals working with higher risk 
families affected by excessive crying should consider how they might strengthen parent-infant relationships. This would involve helping parents to respond sensitively and appropriately to their baby’s crying, and also to recognise and respond to the positive features and interactions that can be so easily overshadowed by crying. Interventions like Video Interaction Guidance may be useful to facilitate this.

Conclusion
Many new families are affected by excessive crying, and current myths and misconceptions about ‘colic’ are unhelpful and potentially harmful. A change in the discourse around excessive crying is needed in recognition of the fact that this is rarely caused by digestive problems and to support parents to cope with their baby’s crying and respond sensitively to their child, rather than becoming focused on seeking an underlying cause or cure.  Supporting families – particularly those with higher levels of need – through periods of excessive crying could bring broad benefits, improving experiences and outcomes for children and their parents immediately and in the longer term.


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