Coping with Crying Babies: A Qualitative Study of Mothers’ Experience

By Joanne Oaten, MChiro, DC, MRCC and Joyce Miller, BA, DC, PhD

Abstract

Introduction: Excessive crying and fussiness in infants is a complaint commonly presented to healthcare professionals such as chiropractors. Clinicians that gain an understanding of this personal experience will be able to take an effective biopsychosocial approach to the treatment and the management of these cases. Aim: The aim of the study was to explore the personal experiences of parents coping with infants that cry excessively with a goal to further improve the management of these pediatric cases. Method: The study was an explorative study that used a qualitative design. Six mothers who presented to the AECC University College outpatient clinic with their infants, less than 6 months old who cried excessively were interviewed. The chiropractic impression and diagnosis of the cases were similar and there was no other serious diagnosis given alongside the excessive crying in any case. One-to-one semi-structured interviews were conducted with the participating mothers. Tapes of the interviews were transcribed as a dialogue and then thematically analyzed. Results: Four main themes emerged. These were: (1) how the lives of the mothers were disrupted by the crying, (2)the emotional fatigue experienced by the mothers, (3) the sense of failure that was present at some point during the experience and (4) the support that the mothers did or did not receive. Conclusion: This study was able to gain insight into the lived experience of mothers with crying babies. The results show that the whole experience is very difficult and can be quite distressing for those involved. A biopsychosocial approach to the management would be beneficial to the mothers to give them some needed support.

Keywords: Biopsychosocial model/approach, Colic, Excessive crying, Postnatal depression, Qualitative research.

Introduction
Approximately 21% of parents around the world present their children to health care professionals with excessive crying.1 It is therefore considered a widespread problem which exerts a serious impact on families’ lives. A range of 25-63% of pediatric cases under six months old presenting to the AECC University College out-patient clinic are cases of excessive unexplained crying.2,3 The literature shows that this type of behavior may have consequences in the future, not only for the infant involved but also for the family having to cope with the situation.4 There are a number of studies that look into the reasons for excessive crying in children and how these can be managed. However, there are very few studies that address the problems involved with coping by the parents.

Background
For this qualitative study on the lived experience of mothers with crying babies, a review of the published literature was conducted on a search of electronic databases relevant to medical and allied health professions. PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Cochrane Library were searched. Medical subject heading (MeSH) terms, keywords, natural language terms were combined in the appropriate Boolean combinations in the search strategy. The search terms used were excessive crying, postnatal depression, colic, biopsychosocial model/approach. Primary studies that addressed or described lived experience or coping strategies of families with infants that cried excessively, stress levels and depression of mothers with excessively crying babies, and the effects of childcare in cases of cry babies. All study designs were included with no restriction in terms of publication or date. Only articles published in the English language were included. In all, 100 studies were identified during the electronic search process. These studies sourced were screened by title and abstract for relevance and their content assessed for additional references meeting the inclusion criteria. A total of 21 articles formed the background information of this research.

Effects of excessive crying on the family
Kurth et al. (2009)5 conducted a systematic review on the evidence of crying babies and tired mothers. The search for literature in the study by Kurth et al. used PubMed, CINAHL, Cochrane and PsycINFO search engines and included studies published in English, French and German from 1980-2007. Despite the extensive search which generated 100 studies, only ten studies were found to meet the inclusion criteria set by Kurth et al, signifying the lack of research in this area. The review found that crying is associated with the experience of tiredness and fatigue in new mothers. Exhaustion reduced parents’ ability to concentrate, which raised the fear of harming their children and triggered depressive symptoms, resulting in burdening the parent-child interaction. These findings correlate with the findings of Long and Johnson’s qualitative study on living and coping with excessive infantile crying.6 The outcomes of their study showed that almost every aspect of family life was disrupted by the excessive crying and this resulted in strained relationships, feelings of guilt and concerns about losing control.

There is some evidence to show that excessive crying can affect the attachment process; some parents felt rejected by their child because it was difficult to establish contact with them.7 They found that crying was a sign that their baby was suffering and the parents felt an urgent need to find a way to alleviate it. Another study8 agreed that parents of children who cry excessively are more likely to provoke greater efforts to deal with the problem.

Much of the research suggested there is an association between excessive crying and the development of depressive states of the parents. No cause and effect conclusions can be drawn from the research designs as it is not known which comes first and it seems that the two phenomena occur mostly simultaneously.5 However, there was also some mention of an association between family tension and paroxysmal fussiness of infants which suggests that the development of postnatal depression may further fuel the problem of excessive crying resulting in a negative feedback cycle.9 This, along with the prevalence of postnatal depression and the effects it can have on the child, prompts the need to address the crying and depression as early as possible.

One such study was carried out in 2009.10 Despite some reliance on retrospective data, their study concluded that both infant colic and prolonged crying (classified as crying three hours per day for three days per week at six months old) were associated with high maternal depression scores. More than a third of mothers experiencing prolonged crying were seen to be at risk of depression. The results were shown to be statistically significant and clinically relevant. However, it must be noted that mothers experiencing depression may have overemphasized problems with crying and factors associated with it. These findings are consistent with several other cross-sectional studies.11-14

Not only depression, but anxiety is common in parents of excessively crying babies. One major anxiety found in a qualitative study6 was the danger of non-accidental injury to the baby. This was said to further feed the parents’ feelings of guilt, stress and desperation. This finding was supported by another study which found an association between maternal depression, family stress, family breakdown and child abuse.15 Further, persistent crying can cause the mothers to lack empathy, make hostile comments or maltreat their baby.12 It follows that emotional unavailability of the child means the parents struggle to understand their child’s behavioural cues. This could then affect the care the child receives and may also lead to the occurrence of blunted emotional responses from the parent to the child.

It has also been suggested that postnatal depression impairs the ability of a mother to care for and form a secure attachment with her infant and is an independent risk factor for the child to develop emotional, cognitive and behavioural problems later on in childhood.16 Attachment is a behavioural pattern established between a child and a parent in the first year of life. It reflects emotional connection and the reciprocal relationship between children and parents and impacts on human development.16

The Clinical Problem
From a clinical standpoint, it seems important to understand what the parents are facing. Even though chiropractors care for the child in an effort to improve the fussy behaviour, it is also important to address any presenting psychosocial issues with the parents. Future work should include researching the kind of support that would be most beneficial to parents trying to cope. However, in order to provide the correct support, it is imperative that the experience of living with a cry baby is known and understood.

Aim
The aim of this study was to explore and compare the personal experiences of mothers coping with children who cry excessively with a goal to further improve the management of these cases.

Method
The study was a qualitative study involving semi-structured interviews between researcher and parent. Data were analyzed using constant comparison thematic analysis.17 Interviews took place in treatment rooms of the AECC University College outpatient clinic directly after the first encounter between the child and the chiropractor. A pilot interview highlighted any questions that needed adapting. From this, some of the questions were modified to make it easier for the mothers to understand and answer. In total six interviews were carried out. All mothers were of Caucasian ethnic origin. No pilot data were included in the final analysis.

Ethics
The project proposal was approved by an AECC-BU University Ethics panel before the study commenced. The information sheet explained the risks and benefits of taking part in the study. Mothers were given the opportunity to ask any questions before being asked to sign a consent form. They were assured complete confidentiality and anonymity. Subjects were assigned a number and recordings were deleted once they had been transcribed. It was emphasized that the mother could withdraw at any time and could refuse to answer any question.

Participants
Mothers who presented their babies to the AECC University College outpatient clinic were asked if they would like to take part in the study if they met the criteria, see Table 1.

Table 01

Interviews
Each interview began with an introduction to the interviewer and the study. The mother was presented with an information sheet and was then given the opportunity to ask any questions. It was assured that all information gathered would be completely confidential and anonymous. If the mother agreed to take part in the study, she signed the consent form and the interview commenced. The interviews were one to one and semi-structured lasting approximately 15-20 minutes. All interviews started with a general question asking them to describe their child’s behaviour followed by the broad, open ended main questions. These questions were the basis for more specific questions that would be used if the mother seemed to need guidance. If the mother provided information that could be interesting for the purpose of the project which had not been suggested by the researcher, spontaneous in-depth questions were used. After the mother had answered, respondent validation17 was used to ensure that the researcher had interpreted the answer correctly. At the end of the interview the mother was asked if there was anything else that she would like to add that had not already been covered.

Data Analysis
To find themes in this qualitative study, each interview was analyzed individually, picking out substantive statements and forming categories until no new categories could be identified. A numerical reference was given to each substantive statement found in the transcript which corresponded to the category it related to. Against each core category a short definition was made. Every substantive statement found in each transcript was checked against the existing core categories. If the statement fitted under any of the existing categories it was referenced accordingly; if it did not, it was regarded as a new category and was given a new numerical reference. The list of core categories was sorted into sub-categories by similarity of topic, resulting in the emergent overall themes.

Results
The results were split into four main themes which were the main emphasis from the mothers in the interview: disrupted lives, emotional fatigue, sense of failure and support.

Disrupted Lives
This theme was interspersed through each of the interviews. All the interviewed mothers described how the excessive crying of their children had disrupted their lives in every aspect. They talked of their child’s crying habits, describing how long they would cry: most mothers (mothers 1, 4, 5, 6) described it as constant whereas others described cycles of alternating crying and contentment. Where mothers talked about constant crying, they said nothing would work to abate the crying and the child was inconsolable (mothers 1, 4, 5, 6). One mother saw it as a long-term problem and could only take so much (mother 5). However, other mothers seemed to be fairly realistic about their child’s crying; there was a sense of acceptance (mothers 1, 2, 3, 4, 6) “it’s not his fault, he is just a baby, he doesn’t know” (mother 2), “you know it is just one of those things that he cries” (mother 1). Some mothers also stated how they tried to keep some normality in their lives and would try as often as possible to take time for themselves and relax (mothers 1, 4). Night time crying was common, and the lack of sleep seemed to fuel negative emotions (mothers 1, 2, 3).

All previously normal activities of daily living for the mothers were affected by the crying. Although there was some acknowledgement that this was to be expected after the birth of a baby, the excessive crying accentuated this disruption (mothers 1, 2). Even getting dressed in the morning became a burdensome task for one (mother 4).

Socially, the mothers suffered because they felt like they were “tied to the house” (mother 4). They felt like they couldn’t go out for fear of the baby screaming, which some stated they found very embarrassing and “would rather struggle on my own” with it (mother 5). One mother described how she would get very tense if other people, such as family were around (mother 2). Every mother stated how this made them feel very lonely.

All of the mothers interviewed were married and had husbands living at home, except for one who was a single parent (mother 2). The five mothers all expressed that there was now an added strain on the relationship with their husband, which they found upsetting. However, they were also quite realistic about this situation and at the same time said that their partners were a great help and support for them (mothers 1, 4, 6).

Emotional Fatigue
This theme emerged when the mothers were asked to describe how the crying made them feel. Every mother described a feeling of sadness and emotional upset at the excessive crying, saying it was stressful as well as disappointing because it is supposed to be a happy time. There were also feelings of anger and frustration toward themselves and their child which added to feelings of guilt and sadness.

The general lack of sleep and constant struggle throughout the day caused all mothers to be fatigued. This also increased any negative emotions the mother was feeling; “the smallest thing would suddenly become the end of the world” (mother 5). One mother said that she knew she wasn’t looking after herself properly and this may have affected the care of her child (mother 2). Every mother said that the need for a break was all important because they couldn’t keep going otherwise.

One mother confided that she was suffering with “baby blues” which was aggravated by her child’s excessive crying (mother 3). Another mother said that she had to have counselling following the progressively worsening crying habits of her child because she felt so “down” (mother 5). There were constant feelings of worry for the child in all cases, with their health being of upmost importance. Being unsure of the reason for the crying lead to catastrophizing in most cases and numerous trips to the doctor. There was a common want or an aim for the baby to become “normal” and in some mothers, a tendency for comparison with other children (mothers 1, 3, 6).

Sense of Failure
Every mother had feelings of guilt and a sense of failure at some point, although most, if not all, had moved on from these views, “we are in a different place now” (mother 5). It was a key issue driving mother’s emotions and affecting behaviours and relationships; it therefore was apparent when answering each of the questions.

The aim to be a good mother, make their child feel better and protect them was a driving factor in the constant search for answers and solutions to the problem in every case. Every mother in their interviews stated that they had “tried everything” and were willing to “try anything” to help their child. In failing to stop the crying there were feelings of helplessness, blame and failure (mothers 1, 2, 3, 4, 5). They knew the crying was not normal (mothers 1, 3, 4, 5) and in not being able to stop it, many concluded that it was their fault; this led to the production of negative thoughts which reinforced the sense of failure. A few mothers wondered if they were good enough parents and were not sure if they could do it anymore, comparison with other children reinforced this. In one very emotive interview, one mother admitted that at one point she said to her husband “I don’t think I can do this anymore, I think you should take her away, give her to someone else, I just couldn’t do it” (mother 5).

Support
All mothers emphasised their need for support in order to be able to cope in the situation. This support was sought in many places: partners, family, medical doctors, health visitors and chiropractors.

The husbands of the five mothers who were married, and the family of the single parent were the main source of support for each. This support involved encouragement but mainly the chance for a break. When the husband came home from work it was a chance for the mother to have some hands-free time and time to do things she needed, for example cooking dinner. All the mothers recognized the support provided by their husbands and were very grateful for it. However, the strain put on the relationship sometimes made this difficult.

All mothers had visited the doctor regarding their child’s crying, looking for answers as to why their baby cried so much. One mother mentioned the lack of support she got from the medical system and felt that she was treated like a “paranoid parent” (mother 4).

Most mothers felt that the health visitor was a very good source of support for the mothers and were able to offer reassurance to the mother. However, one mother talked about getting a different kind of support from them. She stated that the health visitor helped her more with “teaching him the difference between night and day and how to try and soothe him” (mother 2) which was very useful to the mothers but it still wasn’t offering them a solution to the persistent problem that is excessive crying.

In most cases the mothers came to the chiropractor with fairly low expectations and a “give it a go” attitude (mothers 1, 5, 6). Sometimes there was hope that this may help from referrals and recommendations (mothers 2, 3). However, having already tried a number of health care options, there seemed to be a sense of not wanting to get hopes up. One mother was unaware of the possible help the chiropractor could offer her child’s crying and first presented for other reasons (mother 6).

Mothers presenting to the chiropractor seemed to be looking for similar things, namely, confirmation that there was a problem and willingness from a healthcare professional to try to improve their child’s behaviour. These were things they did not get elsewhere in their support system, especially improvement. Some mothers described their visit as “another avenue to explore” (mothers 1, 4, 5) having exhausted all others. However, some mothers had come straight to the chiropractor either from referral or recommendation from a friend or family member (mothers 2, 3). All mothers appreciated the treatment times available for them, the understanding shown to them and the chiropractor’s experience in the area, and finding out that there were other mothers in the same situation. They stated that this was a good level of support as there was something being done; this was described by all the mothers as the best kind of support.

Discussion
The goal of this study was to understand the lived experience of mothers of excessively crying babies. The four main themes that emerged from this study give an idea of the important factors that affect the lives of mothers coping with children that cry excessively. Although each theme appears in each interview, the emphasis given to the themes varied between mothers. For example, the theme emphasised most by subject 4 was “support,” whereas the theme emphasised most by subject 5 was “sense of failure.” This shows the importance of treating each case individually. The themes in the transcript seemed to weave in and out of each other and the main couple of themes were interspersed throughout. This is a sign that there is interconnection between all themes which are to be expected due to the intimate content of the subject matter.

The themes “disrupted lives,” “emotional fatigue,” “sense of failure” and “support” found in this study have all been seen before in previous research.6,7 Other studies were done from a nursing perspective and although all the above themes were found, they also found other themes including search for a diagnosis, coping strategies and gaining trust in professional relationships. These results seem to suggest that the problem of excessive crying is still present when the interview is taking place, and therefore the main aim to find a treatment to reduce the crying is emphasized.

In this present study, the attitude of the mothers seems more positive, perhaps because they have had an interaction with a professional who has found a treatable problem and they may feel they have found a potentially successful treatment and therefore the emphasis is different.

The themes of emotional fatigue and sense of failure have features within them that confirm the previous research, suggesting that excessive crying can be related to postnatal depression.15,16

Depression in the parent would be recognized in a biopsychosocial approach to treatment, which is a key part of medical education and should be used in every healthcare profession. However, it seems that use of the biopsychosocial model may not always occur.6 Long and Johnson found that mothers felt let down by the medical system and did not receive the emotional support they felt they needed.6 There is research to show that this approach would be beneficial in cases of excessive crying.6,7,12 The results of the current study confirmed this by showing that mothers appreciated the time spent with them and positive approach in the chiropractic office. Another qualitative study of new mothers attending a chiropractic clinic found that mothers want more than a “there, there, everything is OK“ type of reassurance.18 They want real, competent, specific, contextualized help; only then do they feel reassured.18

Of course, with regard to physician-patient relationship and communication in excessive crying cases, the main communication occurs between the physician and the parent. Therefore, the biopsychosocial approach is directed toward the parent. The literature shows that excessive crying may have consequences in the future, not only for the infant involved but also for the family having to cope with the situation.19 Therefore it is essential for the physician involved to not only treat the child medically but also to direct some of the care (or caring) toward the mother.

It has previously been found that attempts to establish a diagnosis and find a cure becomes all important for parents with excessively crying babies.6 Such failed attempts lead to a cycle of hope and disappointment for the parent and continued “doctor shopping.” A similar pattern is seen in parents with children who have chronic illness.20,21 These conditions can lead to the development of a chronic condition for the parents involved, possibly in the form of depression. Depression can be identified with the use of yellow flags; these can greatly impact the recovery, progression and recuperation from disease.22

Although reassurance was important, this could be gained from other sources such as the health visitor. However, it seems that confirmation, understanding and a willingness to try other options was all-important to every mother interviewed. Each mother stated that the best support they could get was an improvement in their child’s well being and behaviour (which was apparent in most cases). This was confirmed in a study23 that found that health visitors involved in excessive crying cases were more concerned about the emotional reactions of the parents and their level of tiredness in the situation. Although the parents involved also expressed feelings of uncertainty and anxiety and so on, these were subordinate to their worries about the child’s well-being. Studies have found that considering the parent’s point of view is key to addressing the issues appropriately.24,25 Despite years of research, there is still no medical answer to the disturbance that crying babies cause to parents and even their families.26

Limitations
The quality of the data collection and quality of the analysis was dependent on the skills of a fourth-year clinical student in a research project of the AECC University College with no past experience of interviewing technique or qualitative analysis. Although the study was carried out to the best of her ability, it is necessary to take into consideration when interpreting the results and the conclusions made in this study. However, students have full access to faculty supervisors.

Only six mothers were interviewed for this study. Although qualitative studies are notably small in sample size, the generalizability of the results to the larger population may be reduced. Another factor contributing to the reduced generalizability of the results is the lack of randomization of participants which is not a feature of qualitative research.

Further, there is a possibility that the responses given by the mothers were reserved because they were worried about how the interviewer may perceive them and therefore their answers may be more consistent with social standards so as not to present themselves negatively. The attempt to avoid this was made by ensuring complete anonymity and expressing understanding at the difficulty of coping with such a personal and disruptive experience.

The main strength of this study was the qualitative structure, which allowed mothers to elaborate on personal views of their experiences and emphasise what was most important to them. A quantitative structure might have obscured the complexities of the mother’s behaviour and emotions.

Conclusion
In this qualitative study of mothers with excessively crying babies, mothers emphasized a sense of a disrupted life, emotional fatigue, a real sense of personal failure and the need for and appreciation of support. Using a biopsychosocial approach and taking advantage of empathic listening, the chiropractor is in an ideal position to spot negative behaviours and make any necessary referrals in these cases, preventing negative long-term effects on the family, as well as having the ability to treat the baby for an effective outcome.

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