The Developmental Expressions of Behavioural Dysregulation in a 25-Month old Infant Presenting with Sleep Problems: The Case of Emily.

Emily was 25 months old when she was referred by her pediatrician because of her severe sleep problems. Her parents reported that she had never been a good sleeper but during the preceding nine months she would wake up every 1–2 hours and then scream for between 45 and 60 minutes without either parent being able to calm her. As her bedtime was between nine and ten PM and she would be up by six AM, this made for short nights and insufficient sleep for Emily overall. Once or twice weekly she would “collapse” around six to seven PM and sleep until about midnight but then demand to be entertained for the rest of the night. At daycare, which she had entered at age 13 months, she sleeps for one hour during the two hour nap at noon and lies quietly in her crib for the other hour without ever crying. Emily is the only child of her parents. However, her father has a seven year old son from a previous marriage who lives with his mother but visits Emily’s family every second weekend. Both the boy and Emily are very close and miss each other when they are apart. Both parents of Emily have jobs at the airport, mother working from two AM to 11 AM four days per week and father from midnight to 12 noon three shifts per week. When their respective shifts overlap, the maternal grandparents sleep over at their house. The developmental history of Emily is unusual. While mother’s early part of her pregnancy was described as normal, mother was involved in a car accident while she was abroad on business during the fourth month of gestation and hospitalized for 48 hours because of concerns about her pregnancy. As there were no serious injuries, she returned home. However, during the subsequent prenatal visits it was noted that the baby had stopped growing and also seemed to have stopped swallowing amniotic fluid, leading to a significant size and weight gain of mother. This condition persisted for two months, after which the infant began to grow again and mother’s weight gain slowed down as well. Because of this unusual episode, mother was induced at 37 weeks. However, problems occurred during this process, necessitating an emergency Caesarian section, causing extreme stress for mother. However the Apgar ratings of Emily were eight and nine respectively and her birth weight was five pounds, leading to a discharge home after five days. While Emily took a minimal amount of fluid in the hospital, she stopped taking any fluids after her discharge home, leading to a re-admission to a university associated children’s hospital where she was diagnosed as “failure to thrive” and the Feeding Disorder Team was called in to support the needed medical care. Once she was rehydrated she was transferred to the “Day Hospital”, a newly developed program within the hospital that allowed children to sleep at home but spend their days at the hospital to continue needed rehabilitation from professionals such as the Feeding Disorder Team. After two weeks, Emily was discharged home from the Day Hospital but followed closely by the Feeding Disorder team up to the age of eight months. She weighed eight kg at 12 and 11 kg at 24 months. During the second year of life, Emily was found to have a “sun allergy”, requiring her to avoid any direct exposure to the sun. She also was diagnosed to have a gluten intolerance. However, she passed her motor milestones at the expected ages and became an active youngster who is learning to talk and can be very charming and interested in others. She slept in her parent’s bed until her mother returned to work after six months but found it very hard to fall asleep in her new crib. Both parents dealt with that by cradling her in their arms until she was fully asleep and then placing her into her crib. They stopped this practice after her first birthday, initiating the above mentioned disorganized sleep pattern of Emily.

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