When parents and children come to see me in my behavioral pediatric practice, they are angry, disconnected and sad. In moments of explosive behavior, both parent and child feel terribly out of control. My aim it to help them reconnect and in doing so, to calm down and find pleasure again in their relationship.

Recently I saw a 4 year old boy, David, whose mother, Anne, described him as "explosive." She told of a typical scene- a request to get ready for bed was met with a firm "no," and soon mother and child were head to head in battle. An hour later, David was kicking and screaming on the floor and Alice was crying, horrified at herself for having threatened to hit him.

Rather than launching right in to "what to do" I took some time to listen to Anne's story while David played on the floor. Many things emerged, but most striking was the fact that the family had moved three times in the past year after David's father, Ron, lost his business, leaving the family in financial ruin. Ron had been severely depressed, but according to Anne, they were settled now and he had a good job. When I commented that it sounded like a very stressful year, she immediately responded with," Yes, but we didn't let it affect David."

Seen from my position, this was clearly impossible. Such an experience is inevitably stressful for a four year old child. But for some reason, Anne, who was an intelligent woman, did not see it that way. Perhaps she felt so much guilt, or even shame, about what had happened to her family that could not let herself recognize this truth.

I saw my task at that moment as helping Anne to understand David's experience, to recognize that his increasingly frequent battles for control were likely in part due to his feeling that things were out of control for the whole past year. But I needed to help Alice recognize this without increasing her guilt and shame. It was a difficult and sensitive procedure.

When I saw them two weeks later, the explosive episodes had significantly decreased. Anne told me that his behavior no longer seemed so bewildering to her. Rather than getting angry, she listened to him, yet set more firm limits. She was delighted with the results and felt proud of her ability to regain a sense of joy and stability in her relationship with her son. How did this happen?

Over the past year, I have written in my blog about my experience as a fellow with the Infant Parent Mental Health Post Graduate Certificate Program at U Mass Boston, which is lead by Ed Tronick. At our first weekend Dr. Tronick, who is perhaps best known for developing the still face paradigm, talked to us about his mutual regulation model. In a paper we read for that weekend, Dr. Tronick writes:

The MRM(mutual regulation model) stipulates that caregivers/mothers and infants/children are linked subsystems of a dyadic system and each component, infant and caregiver/mother, regulate disorganization and its costs by a bidirectional process of behavioral signaling and receiving.

The still face paradigm, in which a mother interacts face to face with her infant as she usually would, then for a two minute period presents a completely still face, followed by a reunion episode of resumed face to face interaction, in Dr. Tronick's words "demonstrates the costliness of an experimental disruption of the mutual regulatory process...as it serves as a model for the stress inherent in normal interactions." Dr. Tronick's model is compelling and very complex. I admit that while I was fascinated, I had a difficult time connecting this construct with the daily interactions I have with children and families in my office.That is until my "aha" moment.

Another leading researcher in the field, Arietta Slade, has written extensively about what is referred to as parental reflective functioning. This is also described as "holding a child's mind in mind."It essentially refers to a parent's capacity to reflect on the meaning of her child's behavior, to consider motivations and intentions, rather than responding to simply the behavior itself. Slade, along with other researchers, has shown how enhancing a parent's capacity for reflective functioning is associated with many positive outcomes for a child's emotional development, including flexibility, cognitive resourcesfulness and the ability to manage complex social situations. I have been heavily influence by her work in my practice, and the concept of holding a child in mind is the central theme of my new book, Keeping Your Child in Mind: Overcoming Defiance, Tantrums and other Everyday Problems by Seeing the World Through Your Child's Eyes, now available on Amazon, in bookstores August 30th.

In this "aha" moment, I suddenly understood that when things go well in my office, as exemplified by the remarkable change that occurred between David and Anne, it is not only because a parent increases her capacity for reflective functioning. Supporting her in her efforts to her to reflect upon the meaning of her child's behavior is simply the point of entry. Once the child feels understood, or held in mind, he becomes calm. As I describe in my book, it is likely that this change is on a neurobiological basis, occurring at the level of the structures of the brain that produce stress hormones. When a child is calm, a mother begins to feel better about herself. In fact, often a child's out of control behavior itself produces a feeling of shame in a parent. When parent and child are more in control, this sense of shame decreases. In turn, when a parent feels less shame, and less stress, she can think more clearly. She is better able to reflect on the meaning of her child's behavior. In turn a child feels even more calm and in control. Voila! Mutual Regulation! This is where we aim to be.

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