written by: Jo-Anne Weltman B.Sc. PT, MRSc, DMI co-founder
Infants and toddlers face stressful events in their everyday lives, just as adults do. Infants and young children with brain lesions are easily over-stimulated and have difficulty in dealing with environmental stimuli, exhibiting neurobehavioral disorganization including poor self-regulation.6,11 Many children who have diminished coping skills due to neurological dysfunction, may initially cry during the first several sessions of therapy, as they are presented with novel environmental and sensory stimulation. This upset may be exacerbated by the fact that children with neurological insults have had less experience with motor, cognitive, and sensory demands because their ability to explore the environment independently has been limited. In order to help a child achieve developmental milestones and for neuroplasticity to occur a child must be challenged physically.
In short, therapy presents a demanding and novel challenge that these children may not have the coping skills to manage and will cry during therapy session. So what can we as therapists do to help a child learn how to emotionally regulate and how can we support already stressed parents during this time.
Emotional regulation in early infancy develops mainly through social interactions with caregivers and is a key process in socio-emotional functioning. When a baby feels stress, the brain responds by releasing the stress hormone cortisol, which activates the body’s stress response. If a young child’s stress response is activated in the context of supportive relationships with adults, the physiological effects of stress are buffered and return to baseline levels. In this way, the challenges of meeting new people, entering a new childcare setting, getting an immunization, or overcoming a fear of animals each can be positive stressors if a child has the support needed to develop a sense of mastery.1,10
Children who are protected from stress were found to have increased anxiety and depression, poor life satisfaction, physical health and self-efficacy.8
Cortisol secretion follows a natural 24-hr cycle. In healthy individuals, peak levels are reached about 30 min after waking—this early peak is known as the cortisol awakening response (CAR). The majority of bodily cells have cortisol receptors; therefore, it plays an important role in regulating and supporting the different functions in the body. Cortisol production helps to alert the system and can be used productively in therapy to switch on the brain and body.
There are studies that have shown that increased cortisol levels prevent learning. However we need to truly understand these studies and the population groups studied to understand that this statement does not apply to those who have a supportive adult who can help the child regulate their cortisol levels and learn to cope with stressors. Most of these studies are conducted on children in impoverished areas, abusive environments or those who are in foster situations without a constant adult support. These children have prolonged high levels of cortisol with little to no support to help them regulate, which affects them in many ways including the ability to learn. In a typical population group an example of prolonged cortisol inducing stress is during exam time at school or university. We can cope with this stress as we have the support and ability to regulate and clearly are able to learn under these circumstances.
Another way that our body copes with stress is by releasing endorphins. Endorphins are hormones that are produced in your brain and act as messengers in your body to improve and regulate emotion. Endorphins can be boosted by exercising or with intensive type therapy such as DMI.
Studies show the benefits of providing the neurologically immature infant with proprioceptive and vestibular input for the purpose of neurobehavioral organization.12 This organization is demonstrated in improvements in mature habituation, orientation, motor, and range of state behavior.4 These same principles are extrapolated for use in DMI, as organized proprioceptive, and vestibular input, and movement experiences are integral to the exercises- not only for normalizing motor behavior, but also to provide emotional regulation and higher level cortical activity.6 As neurological organization becomes the foundation for these children’s behavior, they are able to access untapped endurance and quickly adapt to more strenuous exercise. The result is increased confidence and even pride in their participation in therapy. As the exercises become more challenging the child eventually will need to concentrate and focus their attention to task. They will be required to navigate motor challenges which ultimately improves their ability to motor plan. The emotional regulation will further allow them to achieve this level of focus for cognitive development.
It is important to note, that a child’s crying is also associated with increased parental stress.2,7 This stress that can be lessened by the administration empathetic behavioral support from a helper.13 As such, a calm and confident approach from the therapist is required to allow both the parent and child to recognize that the situation is a learning experience and not one to be feared. Behavioral management (specific care taking suggestions) and education has been found to be most effective in helping caregivers support their children in emotionally regulation.13
Distraction is also a useful tool to start, until the exercise becomes easier. Distraction should not focus the child on what they are doing, but rather on something that will keep the child’s attention away from the task even for short periods. This will allow the brain to perform and make connections without the emotional overlay. Parents use distractions everyday to help their child succeed.
In conclusion, stress in childhood cannot be avoided. The encounters with stress are learning experiences and help children learn resilience to cope with further challenges in life. Children often endure NICU stays, attend daycare and school, doctors and dentist visits etc. It is the supportive relationship of an adult that can help them reduce the stress response and learn how to regulate their emotions. Therapy sessions to help a child overcome developmental delays may need to be challenging to be effective. The relationship between the therapist and child is a very important part of the therapy. A calm, confident approach with lots of tactile (back rubs), proprioceptive (deep pats or cuddles) and vestibular (rocking) breaks helps to develop a sense of trust and calm. The strong tactile, proprioceptive and vestibular component of the therapy will also help to regulate the child’s sensory system over time. Education and behavioural management of the parent/caregiver is key to continues success. Emotional care and emotional development is an important part of therapy, but should not be the reason or excuse to avoid proper care, which in itself will result in a better long term quality of life.
- Albers, E. M., Beijers, R., Riksen-Walraven, J. M., Sweep, F. C., & de Weerth, C. (2016). Cortisol levels of infants in center care across the first year of life: Links with quality of care and infant temperament. Stress, 19(1), 8-17.
- Beebe, S. A., Casey, R., & Pinto-Martin, J. (1993). Association of Reported Infant Crying and Maternal Parenting Stress. Clinical Pediatrics, 32(1), 15–19.
- Bernard, K., Dozier, M., Bick, J., & Gordon, M. K. (2015). Intervening to enhance cortisol regulation among children at risk for neglect: Results of a randomized clinical trial. Development and Psychopathology, 27(3), 829-841.
- Field, T.M., Schanberg, S.M, Scafidi, F, Bauer, C.R., Vega-Lahr, N., et al. (1986). Tactile/Kinesthetic Stimulation Effects on Preterm Neonates. Pediatrics, 77 (5) 654-658.
- Grunau, R. E., Holsti, L., Haley, D. W., Oberlander, T., Weinberg, J., Solimano, A., … & Yu, W. (2005). Neonatal procedural pain exposure predicts lower cortisol and behavioral reactivity in preterm infants in the NICU. Pain, 113(3), 293-300.
- Ohgi S, Akiyama T, Arisawa K, et al. Randomised controlled trial of swaddling versus massage in the management of excessive crying in infants with cerebral injuries. Archives of Disease in Childhood 2004;89:212-216.
- Rattaz, V., Puglisi, N., Tissot, H., & Favez, N. (2022). Associations between parent–infant interactions, cortisol and vagal regulation in infants, and socioemotional outcomes: A systematic review. Infant Behavior and Development, 67, 101687.
- Reed, K., Duncan, J. M., Lucier-Greer, M., Fixelle, C., & Ferraro, A. J. (2016). Helicopter parenting and emerging adult self-efficacy: Implications for mental and physical health. Journal of Child and family Studies, 25(10), 3136-3149.
- Russ, S. J., Herbert, J., Cooper, P., Gunnar, M. R., Goodyer, I., Croudace, T., & Murray, L. (2012). Cortisol levels in response to starting school in children at increased risk for social phobia. Psychoneuroendocrinology, 37(4), 462-474.
- Slopen, N., McLaughlin, K. A., & Shonkoff, J. P. (2014). Interventions to improve cortisol regulation in children: a systematic review. Pediatrics, 133(2), 312-326.
- Urfer, A., Turpin, H., Dimitrova, N., Borghini, A., Plessen, K. J., Morisod Harari, M., & Urben, S. (2021). Consequences of Prematurity on Cortisol Regulation and Adjustment Difficulties: A 9-Year Longitudinal Study. Children, 9(1), 9.
- White‐Traut, R.C. and Nelson, M.N. (1988), Maternally administered tactile, auditory, visual, and vestibular stimulation: Relationship to later interactions between mothers and premature infants. Res. Nurs. Health, 11: 31-39.
- Wolke, D., Gray, P, and Meyer, R. (1994). Excessive infant crying: A controlled study of mothers helping mothers. Pediatrics, 94(3): 322-332.