Baby Lost and Found: Mothers' Experiences of Infants Who Cry Persistently
Article Outline
Abstract
Introduction
The purpose of this study was to describe mothers' experiences of parenting an irritable infant. Although “colic” is regarded as a “self-limiting” condition that usually disappears by 3 to 4 months of age, the entire family is affected by the infant's crying; no definitive cause or cure has been identified.
Method
Sample and setting: Twelve middle-class married mothers (mean age
=27.6 years) of irritable infants were interviewed. The women responded to open-ended questions, beginning with a description of the “typical day” with the infant. All interviews were tape recorded, transcribed verbatim, and entered into the AtlasTi qualitative analysis program. Grounded theory methods were used to analyze the data. Transcripts were read repeatedly to verify coding and emerging concepts.
Results
The basic social psychological problem was the loss of the perceived baby and competence as a mother. The psychosocial process was the search for the baby and sense of self as mother. Processes involved cycles of hope and despair and trial and error as mothers became more isolated.
Discussion
Implications for practitioners include support and listening to mothers during this difficult period.
Key words: Irritable infant syndrome, colic, mothers, grounded theory
Infantile colic, a condition of early infancy, is characterized by persistent, excessive, and inconsolable crying. Occurrence rates vary widely (from 3% to 40% of infants) depending on the study's design (prospective studies: 3% to 28%; retrospective studies: 8% to 40%) (Lucassen et al., 2001). The original criteria for the diagnosis of colic were published in 1954 by Wessell, Cobb, Jackson, Harris, and Detwiler. These criteria became known as the “rule of three”: beginning at 1 to 2 weeks of life, colicky infants have bouts of crying for 3 or more hours per day for 3 or more days per week, and the condition lasts 3 or more weeks. The cause of the condition remains unknown, and effective treatments are elusive (Roberts, Ostapchuk, & O'Brien, 2004). Keefe (1988) suggested that the term “colic” is misleading and proposed the term “irritable infant syndrome” instead. Irritable infant syndrome is “characterized by excessive crying, increased activity, and difficulty falling asleep” (p. 76). Keefe attributed this syndrome to the infant's inability to regulate state. Nevertheless, many authors persist in using the term colic for this disorder.
Preliminary evidence indicates that a variety of treatments may have some effect on excessive crying (see review by Savino, 2007); however, most have not been studied in randomized, controlled trials (Garrison & Christakis, 2000). Keefe, Lobo et al. (2006) developed and tested a complex environmental modification and parental support intervention involving four home visits by a master's prepared pediatric nurse, which effectively reduced crying and decreased parental stress in the experimental group. Interestingly, parental stress also was decreased in the control group of mothers, who received home visits for data collection. van Sleuwen et al. (2006) tested use of regular routines and reduced stimuli with and without swaddling. These authors reported a significant decrease in crying in both groups; however, there was no control group in this study.
While informing parents that their child will outgrow the colic often is reflective of the typical course of the condition…it may seem insensitive to the parents' need to “do something now” about the colicky baby's seemingly incessant crying.
For parents, the search for ways to soothe the crying infant is often frustrating and exhausting (Roberts et al., 2004). Because most symptoms of colic resolve around 4 months of age (Barr, 1998), health care professionals often advise parents that their child will outgrow the problem in time. While nurses indicated that they recognized that colicky babies' crying was problematic for mothers, it was a symptom of a transient condition (Helseth, 2002). These nurses focused not on the crying but on gaining the parents' trust. While informing parents that their child will outgrow the colic often is reflective of the typical course of the condition (Barr, 1998, Wessel et al., 1954), it may seem insensitive to the parents' need to “do something now” about the colicky baby's seemingly incessant crying.
Compared with the large number of studies conducted to identify effective treatments for the baby's distress, a relatively smaller number of studies have focused on the effect of the baby's crying on the parents. Therefore, this study used grounded theory methods to explore the experience and perceptions of mothers whose infants cry persistently.
Review of Literature
Effect of Persistent Infant Crying on Mothers
Characteristics of families of infants with colic, as well as maternal outcomes of living with a colicky infant, have been studied since the 1980s. Raiha, Letonen, and Korvenranta (1995) found that families of babies with severe and moderate crying were more chaotic and enmeshed than were control families. The families in the colic group possessed less energy and flexibility and had more anxiety and problems dealing with daily activities. Raiha and colleagues questioned whether these characteristics would have developed had the babies not cried persistently.
Humphrey and Hock (1989) found that mothers in the colic group reported more stress, more problematic parenting, and more anxiety about leaving their infants for short periods than did mothers in the non-colic group. Similar results were obtained by Papousek and von Hofacker (1998), who measured mothers' perceptions of parenting. Having an infant classified as an extreme or moderate crier was associated with higher scores for depression, exhaustion, frustration/anger, and anxious overprotection. These mothers also scored significantly lower on self-efficacy than did control mothers. St. James-Roberts, Conroy, and Wilsher (1998) also found that mothers of persistent and evening criers rated themselves as more depressed than did control mothers at 5 to 6 weeks postpartum. By 5 months postpartum, the amount of crying in all groups of babies had dropped by more than half; nevertheless, the mothers of infants with severe colic still showed significantly more depression than did other mothers and continued to regard their infant as “difficult.” More recently, Stifter, Bono, and Spinrad (2003) documented that mothers of infants with colic continued to report more stress and felt less supported and effective as parents at 6 weeks postpartum. Despite reported stress and low self-efficacy, mothers of infants with colic reported secure mother-infant attachments that were maintained at 18 months postpartum (Stifter & Bono, 1998).
In contrast, Levitsky and Cooper (2000) used structured interviews with mothers to examine the effect of their infants' colic on their emotional state. All of the mothers experienced physical and psychological symptoms during the colicky period, and 79% revealed explicit aggressive thought and fantasies. Some mothers (26%) described thoughts of infanticide during the colic episodes. These mothers felt incompetent and many secluded themselves to avoid public judgment about their inability to calm their infants.
The isolation that parents impose upon themselves and their colicky infants was mentioned by several authors (Ellett et al., 2005, Levitsky and Cooper, 2000, Long and Johnson, 2001). Parents feared for their infant's safety in the hands of a babysitter and often did not want to burden another adult with their crying infant. The mothers also stayed at home because of what may have been perceived as inadequate parenting if their colicky infant wailed out of control in a public area.
Two studies were found that purported to use some form of grounded theory methods in studying how parents coped with colicky babies. Thompson, Harris, and Bitowski (1986) interviewed 50 parents, nurses, and physicians to understand the phenomenon of colic and its effect on the family. The metaphor “Parenting Banking Theory” was developed to capture how parents' emotional reserves were replenished and depleted while caring for their colicky infant. The “adapted” grounded theory study by Long and Johnson (2001) involved 25 parents of colicky infants. The families' disruption encompassed “almost every aspect of family life” (p. 155). Supportive health visitors were vital in helping parents through the colicky periods.
Neither of the aforementioned grounded theory studies arrived at a core psychosocial problem leading to an understanding of the effect on the mother of a baby who cries persistently. This study was conducted to provide a comprehensive understanding of the mother's experience of parenting an infant with irritable infant syndrome.
Methods
Grounded theory methods were used to conduct this study (Glaser, 1967, Glaser and Strauss, 1967, Hutchinson and Wilson, 2001). Because grounded theory is based on symbolic interactionism, the researcher's task is to “discover and conceptualize the essence of complex interactional processes” (Hutchinson & Wilson, 2001, p. 212). In grounded theory, individuals are believed to construct meaning from social interactions; therefore, this method seems appropriate for the study of mothers attempting to parent an infant who cries persistently.
Participants and Setting
Thirteen mothers of infants who cried persistently participated in the study. Women were recruited at a Midwestern health science university via newsletter, as well as through posters placed on bulletin boards around the campus, recruitment from a rural pediatric clinic, and by word of mouth. Inclusion criteria were being the mother of a “colicky” infant, being older than 19 years of age, and being English speaking. Mothers were excluded if the infant had a medical diagnosis other than “colic” that was associated with persistent crying. The mean age of the participants was 29.4 years (range: 24-36 years). All women were middle class and had partners. Twelve women were White; one was Hispanic. The mean age of the infants described as “colicky” at the time of the mother's interview was 13.5 months (range: 3.5 months-4.5 years). Eight of the mothers interviewed (61.5%) had two children. Approximately half (53.8%) of the infants described as “colicky” were first-born.
Procedure
Following Institutional Review Board approval and informed consent, each participant was interviewed once; interviews lasted approximately 60minutes. Interviews were conducted using an interview guide consisting of open-ended questions. This guide was modified over time as interviews were analyzed. The purpose of the interviews was to obtain the mother's story of daily life with her colicky infant. Questions were posed to elicit what the mother thought caused the crying, what was done to try to comfort the infant, who was consulted in an attempt to find answers and support for the mother's distress, and the effects of the baby's crying on the mother and all other members of the nuclear family. All interviews were tape recorded and transcribed verbatim.
Data Analysis
Grounded theory methods were used to analyze the data (Glaser, 1967). Each transcribed interview was analyzed as data were collected. Each transcription was entered into the AtlasTi qualitative analysis program and coded line by line searching for first-level (in vivo) codes (Glaser). Members of the research team also recorded memos with ideas and thoughts about the data (Montgomery & Bailey, 2007). Level one codes were grouped into more conceptual categories (level two codes). Level one codes such as “staying at home,” “feeling judged as a parent,” and “protecting image of perfect infant” became the level two code “isolation.” Interviews were repeatedly read to verify coding and to develop emerging concepts. Extensive memos were written to develop thinking about the basic psychosocial problem, process, and consequences. Data collection was stopped when categories were saturated and the core variables were identified.
Results
…the mother had a sense of loss: losing the baby she took home from the hospital, as well as losing her sense of self as a competent mother.
The basic social psychological problem identified in this study was “baby lost and found” in which the mother had a sense of loss: losing the baby she took home from the hospital, as well as losing her sense of self as a competent mother. The basic social psychological processes involved were searching for her baby and searching for herself as a “good” mother. Searching involved cycles of seeking potential causes of the crying and treatments to soothe the baby, seeking help, isolating self and baby as protection from judgmental others (stigma), and experiencing hope followed by discouragement. Consequences of the cyclic search processes included exhaustion, frustration, guilt, helplessness, and disappointment on the part of the mother.
Basic Social Psychological Problem: Baby and Motherhood Lost
When an infant was irritable and not responsive to soothing strategies, the natural, typical maternal-infant interaction was disrupted. The mother, especially a first-time mother, was in a developmental process of learning to interpret her infant's cry and body language. Crying is a social signal and the primary way an infant communicates. Typically, mothers quickly learned to distinguish types of cries (e.g., hunger, discomfort, and fatigue). This process was enhanced when the infant responded to the mother's strategy by quieting. The mother learned the meaning of that particular cry. Successfully learning to communicate with the new infant was positive feedback for the mother's sense of competence as a mother.
Media images reinforced the common perception in today's society that babies cry occasionally and that the parents' job was to learn how to comfort and meet the needs of their children. Mothers were not prepared for an infant who cried persistently. Parenting classes and self-help books on parenting typically do not address the colicky child. Mothers of colicky infants worried that they were not meeting their child's needs and feared being perceived as incompetent. Mothers did not want people to think they did not know how to parent. Mothers clung to the notion that they should appear prepared and knowledgeable. Hopes of a smiling, cooing baby and a neat, orderly household were dashed as the picture was replaced by relentless crying. As one mother put it: “…he was up every 3hours for the first 6½ months. So we were not sleeping at all…by the time the night came, of course, my husband was coming home from work, so he comes home to all chaos.”
When the irritable infant could not be soothed, it seemed as if the baby were speaking a foreign language the mother did not understand. The mother believed if she could just interpret the cry correctly or determine the cause of the crying, a solution would be obvious. One mother asked her husband, “What are we doing wrong?” Failing to understand the baby's cry and the reason for it took a toll on the mother's sense of competence as a mother. As one mother said, “My baby is telling me I'm not a good mother.”
Some mothers made frequent requests of the health care provider to investigate possible medical diagnoses to determine what is wrong with the infant. One mother's baby was hospitalized following a visit to the emergency department because of incessant crying. No physiological cause of the crying was determined. As the mother explained, “So, after everything [laboratory tests] came back, there's nothing wrong with her, and they're [doctors] like, ‘We don't know.’ There was no explanation. I just sensed they didn't know what to do.”
When an explanation and solution were not provided by the health care practitioner, the mother learned she would need to manage the baby's crying on her own. This involved the basic psychosocial process of searching to recover her baby, as well as her sense of self as a competent mother.
Social Psychological Process: Searching for Baby and Self as Mother
Some mothers described “losing” their babies: the baby was “lost” when the baby began to cry persistently, and the mother sensed this child was different from the infant she had taken home. One mother described her experience: “…he was fine until he was 2 weeks old. He was very calm, laid back…and he was sleeping better than our first son had. Then right at 2 weeks his whole personality really changed…. It was like a light switch….”
Cycles
Mothers' responses to the persistent crying of their infants were characterized by cyclic social psychological processes. The basic cycle was the endless search for the “real baby” through finding the etiology of the baby's crying. This cycle resulted in generating one or more hypotheses about the cause of the crying, followed by trials of several sequential strategies to “treat” the persistent crying in the hope of “getting my baby back.” For example, if the etiology was perceived to be gastrointestinal distress related to food intolerance, then the baby's formula was changed (often several times to progressively more expensive formulas). If the mother was breast-feeding, then her diet became more and more restricted over time until, as one mother said, “The only thing I could have was meat, potatoes, and Italian bread.” One mother decided this was a pain cry; her infant may have a low pain tolerance. Other mothers sought a gastrointestinal explanation such as gas, or “It must be something I ate.” Solutions included remedies such as diluted pear juice, chamomile tea, and “Gripe Water;” movement, such as baby swings, rocking, and riding in the car; white noise, such as fans, vacuuming the living room, and ocean wave audio tape recordings; and medications such as simethicone to decrease gas or sucrose for pain. “Trial-and-error” was the predominant evaluative approach to solutions as the mothers tried them, appraised effectiveness, and moved on to new solutions when current ones were no longer effective. This process was a spiraling form of intermittent reinforcement; ultimately, mothers were left feeling as if they were “grasping at straws.”
Within the cycle of searching, numerous other cycles occurred. One cycle involved intermittently reaching out to others for advice and support. Initially, strategies suggested by credible professionals and other resources were attempted (e.g., new formulas, dietary changes, homeopathic and herbal remedies, sensory changes for the baby such as white noise, and movement). Strategies were used as long as they were perceived to be at least somewhat effective or until the baby “tires of it.” Some advice, usually received from family members, was rejected immediately because it was unacceptable to the mother (e.g., put baby to sleep on his or her abdomen, stop breast feeding, or start giving the baby cereal when the baby was too immature). One mother stated: “Both grandmothers were just confident that she needed to be fed cereal and if she was fed cereal then she would just calm down…. Whereas you had your physicians say, ‘Don't even touch it [cereal] yet.’ So, that was a big battle.”
Another mother's mother-in-law said she was quite possibly “over-nursing” the baby and this might be contributing to the colic; this unwelcome advice stifled that mother from seeking further advice from her mother-in-law. Non-breastfeeding mothers also told this woman that she was “catering to your baby too much” in her attempts to comfort the infant. As one mother explained: “…the worst part is that everyone has something to try. And of course, it's stuff you have already tried and you know it's not going to work…. Finally, you just get tired of explaining it. What you really need is support and all you get is advice. All I needed was them saying, ‘Gosh, that must be hard.’ Instead of ‘Do this and this and this,’ just saying, ‘Oh, that must be tough.’
Mothers also received unwelcome advice about the crying from well-meaning health care providers. The message from many health care providers was, “All babies cry and yours will grow out of it.” These health care providers were perceived by the mothers as downplaying the baby's crying and lacking recognition of what the mother was experiencing. Mothers came away from health care visits feeling as if the provider thought they were overreacting to a normal variant of infant behavior. As one mother said, “You feel bad calling the doctor and saying, ‘My daughter's being a beast, can I bring her in?’…cuz…she has no symptoms.” Being told “This will end” was not perceived as helpful or supportive by the mothers. Some mothers were angered at this response by health care professionals, who should have known how to help her and the baby. Health care providers as well as family members were seen by the mothers as discounting or minimizing the emotional effect of the crying. Over time, the search for resource support was extinguished as the mother received unwelcome or unhelpful advice.
Each day had its own cycle of waiting and watching to see how the baby responded throughout the day. Will this be the day the baby grows out of the colic? If not, hopes were dashed again, and additional, new strategies must be identified and tried. For varying periods of time each day, relief and hope were “shattered” as nothing that worked did so for long. The daily cycle ended yet again in frustration, disappointment in self as a competent parent, continued worry about the baby's condition, and uncertainty about what was really causing the baby's distress. Some mothers planned ahead, developed a daily routine with several evening strategies (e.g. bath, rocking, feeding, white noise when baby is put down to sleep), and had a list of one or two new strategies to try if the “tried and true” no longer worked. Some mothers used self-talk, telling themselves over and over that “this is only colic and it can't last forever.” Thus, while each day fell into its own cyclical pattern, there was a certain amount of unpredictability to each day. Mothers experienced some hope and relief only to have it shattered, and this pattern was repeated many times. The paradox for these mothers was attempting to remain hopeful for themselves, the baby, and other family members as they grew more exhausted and concerned about maintaining themselves as mothers for an indefinite period. Over time, the mothers' attempts to obtain advice became fewer and farther between, and the mothers became more and more isolated.
Isolation and Stigma
The mother's perceptions of what others may be thinking of her contributed to a negative sense of self as a mother. Some mothers believed others were judging them: “Why can't you figure out why your kid is crying?” Because of negative feedback from people in the community, as well as some family members, mothers began to stay at home to protect themselves and the baby from unwanted advice and criticism. Mothers relayed their experiences of a self-imposed isolation. Because they were fearful of how the infant would be perceived in a public setting, many mothers restricted excursions out of the house with the baby. Part of this response had to do with actual experiences of the child wailing uncontrollably in public and part of it reflected their desire to maintain an image of a happy family with a peaceful, placid infant.
The normal mechanisms for respite and relief became limited. Ordinary sources of social support were not available for a mother who continued to isolate herself in her home. The mothers were not only unhappy with how the child was behaving but considered it punishment to inflict this inconsolable infant on anyone else. Mothers felt guilt and a desire to shield the potential caregiver from the unrelenting cries of the infant. As one woman reported about her unwillingness to take her infant to day care, “No one wants to hear my screaming kid.” Mothers reported receiving fewer offers to care for their colicky infants from relatives and friends once the situation was discovered. The offers they did receive were frequently rebuffed because they “felt sorry for the person they were dropping them off to.” “It would be punishment for a babysitter” [to care for this infant]. Instead of focusing on their own need to take a break from an emotionally draining situation, they continued to further isolate themselves as a way to manage the situation. They often relayed feelings of “being stuck in the house” but usually remained at home to avoid the need for a babysitter. “We didn't go to church much because that was like sitting there with a ticking time bomb.”
The isolation perceived by the mothers came, in part, from the stigma of dealing with a child who was not perfect in every way. They felt ashamed and at fault for the state of the child and the negative responses they perceived from others. They felt disconnected from their instincts, which were to comfort the crying, inconsolable child. The mothers isolated themselves for protection from negative advice and to hide from the judgmental views of others. Mothers initially may have sought advice when the infant's crying crossed the upper limits of normal, but this response turned to avoidance when the advice became unhelpful and unsolicited. One mother relayed that she was “not able to take the baby out” because she had grown adverse to others who were “throwing advice” at her about ways to calm the crying infant. Dealing with the judgmental advice was particularly stinging to one mother, who relayed, [Everybody is] “just going to say, ‘Suck it up,’ or, ‘You're a mom, deal with it.’” When asked who volunteered advice related to her colicky baby, one mother answered, “Everybody I talked [to]. Everybody I saw.” These mothers eventually avoided contact with others in person and by phone to shield themselves from more unwanted advice.
The mothers seemed to be on a course they did not intend but knew they could not change. They felt alone and frustrated. They felt isolated because they could not readily invite people to visit. They could not go to all the places they wanted to go. They did not have a quiet, peaceful, sleeping infant who could be transported easily in and out of the car while the mother completed her errands. They had a child who was explosive and unpredictable.
Isolation also took the form of less and less verbal contact with others as a means of avoiding negative advice. Avoidance of others may reveal the mothers' attempts at impression management (Goffman, 1963). The mothers feared a negative perception from outsiders. One mother described only wanting others to “think that my baby was perfect and not that he cried all the time.” Even when the feedback was nonverbal, the mother expressed anxiety over the encounters: “People would look at you like, ‘What are you doing to that kid?’ ” The mothers wanted to preserve an intact and positive perception of their infant so relatives and friends would look favorably on the child in the future.
Mothers also discussed their awareness of possible harm coming to the baby because of the persistent crying, either from others or themselves. A mother mentioned awareness of the possible risk of hurting her baby: “It was so disappointing to have that urge where you're like, I might hurt my child because I'm so tired.” One mother made an indirect reference to the possibility of harm to her infant by discussing recent news: “You know we just had an infant killed last week by the boyfriend or dad or something because the baby wouldn't quit crying…. That just made me cringe…. Nobody prepares you for the intensity.” A new mother explained her need to leave the baby for periods of time when she herself was frustrated: “[It's] very frustrating. I had to leave him in there, talk to myself. It would be okay. I do feel guilty letting him cry, but I for the first time understand why people shake babies. It's not your intention, but it could happen…. I noticed my husband say, ‘Be quiet!’ And I said, ‘Don't do that.’ That kind of scared me….”
Consequences
The consequences of the search process involved a variety of emotional responses. Some mothers blamed themselves for not understanding the cry behavior and not finding a solution that soothed the infant. As one mother expressed, “We stand up, we sit down, we rock, we bounce…. Why can't I fix this? What's wrong? …I can't figure it out.” The lack of success in interpreting the infant's cry led to frustration, unmet expectations, a sense of guilt, and feeling consumed by the child.
Some mothers depersonalized the experience, as exemplified by one mom who talked about “the witching hour” in the evening when the crying began. “We called it the ‘witching hour,’ the moonlight hours…because he was just howling at the moon….” A similar metaphor was used by one mother, who stated that “Then she went into the colic and it was like, ‘You're a demon…. Get away!'” Another mother stated, “I found that other people had trouble consoling him, too, because it's not like a fussy baby; it's like a raging animal, almost.” Objectifying the less than perfect baby put some distance between the mother and child, and in the process, painted a picture of a mother who did not want to claim her screaming infant who was impossible to soothe.
Perhaps amplified by consequences such as exhaustion, helplessness, and frustration, mothers came to see parenting as a full-time job at which they were failing. The mother's expectations of the experience of having a new baby were not met, which created a sense of disappointment in herself as well as the baby. Loss of self-esteem also occurred, over and over, as mothers said to themselves, “I'm the mom and I should be able to stop this.” Tension developed between wanting the expected baby and parenting experience and realizing that this is not the hoped-for experience. Mothers wanted to enjoy being with the baby; simultaneously, they felt guilty about wanting time away from the persistently crying infant. Parenting became a struggle to care for and enjoy this baby; a struggle to care for the house, husband, and other children; a struggle to find time for herself and obtain needed help for herself and her infant; and a struggle to believe she is a good mother. As one mother stated, “This is the hardest thing I've ever done.”
Resolution: Baby Found
While every effort was made by the researchers to interview mothers still experiencing the colicky period, several babies had emerged from that period at the time of the interview. Some of these mothers described “finding” their babies when the colic ended. This process was more gradual than the onset of colic for most babies. According to one mother, “Right in between 9 and 10 weeks he started coming back…. It seemed like, okay, things are getting better…. We could see the improvement and then it was pretty much gone.” This rediscovery (“I got my baby back”) was greeted with immense relief and joy. Mothers whose colicky babies were “back” seemed to carry with them a picture of what the infant should be like during the colicky period, and “hung on” until that little person returned to them.
Discussion
Temporal Considerations
Mothers' perceptions of being judged by others, receiving unwanted or unhelpful advice, and continual efforts to deal with the crying baby resulted in exhaustion, depersonalization of the infant, frustration with some family members and caregivers, and gradual isolation from others.
Relationship to Existing Theory
The existing theory which resonated the most with the researchers during data analysis was Erving Goffman's (1963) theory of stigma. The social psychological process described by the mothers seemed similar to Goffman's process of managing the “disgrace” (p. 2) of the infant's persistent crying and the criticism (real or perceived) of the woman's mothering abilities that followed. Principles of stigma applied to the mothers' stories suggested that a mother who was unable to control her infant's unwanted behavior took on the management of the infant's condition, thus beginning the search for the “lost” baby. The mother came to question her own parenting skills (self-stigma) when criticism resulted and also came to believe that others will not accept the baby because of the crying. The mother attempted to carry on as if the baby were “normal.” Over time, as the crying persists, the mother may come to see her infant as Goffman described: “not quite human” (p. 5) or “a non-person” (p. 18). These perceptions illustrated that “A discrepancy exists between the individual's virtual and actual identity. This discrepancy, when known about or apparent, spoils his social identity; it has the effect of cutting himself off from society so that he stands a discredited person facing an unaccepting world” (Goffman, p. 19).
In the case of a mother with a persistently crying child, our data suggest that two persons are discredited: the baby and the mother for failing to stop the crying. In Goffman's (1963) words, the mother develops a “protective capsule” (p. 32) for her infant, which she sustains by means of “information control” (p. 33) and limiting the baby's “visibility” (p. 48) or exposure to others in the community. Self-imposed isolation allows the mother to avoid circumstances in which others could encounter the infant's unwanted crying and maintains the image to the public of the perfect baby.
Other authors on the topic of stigma add more recent notions. Link and Phelan (2001) described the components that come together to produce stigma as a process of negatively labeling a difference that an individual possesses. In the case of persistent crying, diagnosed as “colic,” the label can result in health care professionals discrediting the infant as a legitimate patient because the condition is time-limited and has no specific cure. Health care providers may believe the diagnosis of colic should be reassuring to parents, because there are no known long-term adverse effects of the condition. However, the seeming lack of concern on the part of the health care provider may leave the mother with the impression that no one wants to listen to her concerns and she will have to “learn to live with it” until the condition has run its course. Perceived criticism contributes to decreased self-esteem and depression in the mother and constricts her social networks. “Being cast out of the social community coupled with a diminished sense of worth reduces the capability of the affected person to seek help even when it is…easily available” (Link & Phelan, p. 4). Self-stigma leads to acceptance of blame for the infant's crying. This reinforces feelings of guilt, even though the mother believes she's “tried everything.”
Corrigan (2007) agrees that medical diagnoses can worsen stigma and damage quality of life, particularly if the label prevents people from seeking assistance from health-care professionals. Further research is needed to determine health care professionals' attitudes toward mothers with colicky infants. Do health care professionals truly view this condition as a condition unworthy of their time and effort? Some mothers shared their perception that providers discounted their concerns, and curtailed contact with providers as a consequence. These perceptions may effectively erect barriers that block opportunities for support and respite for the mother from friends and family, as well. As one mother of a colicky child (now an adult) said to the researchers in an e-mail message when this research project was advertised by local newsletter, “Thank God someone thinks this topic (colic) is important enough to study!”
This study supports the work of earlier researchers who found adverse emotional outcomes in mothers of infants who cried persistently, as well as isolation experienced by the mothers (Ellett et al., 2005, Humphrey and Hock, 1989, Levitsky and Cooper, 2000, Long and Johnson, 2001, Papousek and von Hofacker, 1998, St. James-Roberts et al., 1998, Stifter et al., 2003). Our results add to the body of qualitative research on the topic of colic in several ways. First, the depth of the mothers' feelings of being discredited by well-meaning family and health care providers was not evident in earlier work. The mothers clearly indicated their need for supportive listening on the part of care providers and being given credit for persevering in circumstances they perceived to be very difficult. Secondly, the mothers' depersonalization of the baby as a consequence of living with the persistent crying may provide a conceptual link to the possibility of abuse to the infant. Third, the cyclical nature of the mother's emotions as well as her activities and the similarities between the process of living with a persistently crying baby and stigma add new conceptual dimensions to our understanding of the mothers' experiences.
Limitations and Recommendations for Nursing Practice and Research
This study is limited by the characteristics of the participants; generalizations can only be made from these results to White, middle-class women with partners. Further study with single mothers of diverse backgrounds is warranted. Additional opportunities for further research include exploration of health care providers' beliefs about colic and what kinds of treatments work best for the mother and baby. The effect of various methods of supportive care at home and in the clinic for mothers could be determined. Would periodic telephone calls or e-mail messages from the office nurse or health care provider decrease the number of calls and visits to the clinic and improve patient satisfaction with care? In one randomized clinical trial, the control group, who only received visits for purposes of data collection, had almost as much improvement in parenting stress as did the group who received a complex supportive intervention (Keefe, Karlsen, Lobo, Kotzer, & Dudley, 2006). Finally, the relationships between colic, depersonalization of the baby, isolation of the mother and baby, and the potential for abuse of the infant should be studied.
The following recommendations for practice seem reasonable, based on the results of the study. First, health care providers should rule out potential physiological causes of the crying. When a diagnosis of colic is confirmed, health care providers can inquire about strategies the mother has already attempted and offer additional suggestions for strategies that may be helpful. Above all, the provider should allow the mother time to talk about effects of the crying on herself and other members of the family and simply listen, acknowledging the challenges of the situation and the work the mother has done to care for the members of her family. Follow-up telephone calls from the health care provider may send the message that the mother's concern is an important problem and the mother is not alone. Keefe, Lobo et al. (2006) found that mothers valued a professional listener, liked sharing experiences with other parents, and found telephone calls helpful. In this way, support can be provided to the mother until her baby “comes back.”
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Mary Erickson Megel, Associate Professor, University of Nebraska Medical Center College of Nursing, Omaha, NE.
Margaret E. Wilson, Associate Professor, University of Nebraska Medical Center College of Nursing, Omaha, NE.
Katherine Bravo, Instructor, University of Nebraska Medical Center College of Nursing, Omaha, NE.
Nancy McMahon, Assistant Professor, Clarkson College, Omaha, NE.
Angela Towne, Pediatric Nurse Practitioner, Sanford Health Network, Sanford Sheldon Medical Center, Sheldon, IA.
Conflicts of interest: None to report.
PII: S0891-5245(09)00329-0
doi:10.1016/j.pedhc.2009.10.005
© 2011 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved.
