Keeping Your Child in Mind

It began after five o'clock on a day that Karen had been gone at her new job. Three months earlier, she had returned to work full time. Daniel, his mother, and his two-year-old sister Hailey had had a nice outing to the grocery store to shop for dinner. They had all agreed that they wanted hamburgers. Because the kids had been so well behaved, Karen offered to go to the store to get a special toy for Daniel to replace one that had recently broken. In his excitement, Daniel ran ahead in the parking lot. It was dark and Karen yelled to him to stay close, which he did. Unfortunately the store did not have the toy they were looking for, but Karen agreed to try a different store. They never made it to the second store. Once again, Daniel ran ahead, but this time he did not respond to his mother's call. Karen had to scream at him to stop running. "Mom was worried about you," I said. "It was dark and you could have been hurt." When they finally were back in the car and buckled in, Karen, feeling exhausted and overwhelmed, said she was not going to another store. Daniel then hit Hailey, who started to cry. I asked Daniel how he had felt at that moment. He was very clear. "I was sad." "Were you angry?" I asked. He looked at his mother. "Was I angry?" I said I wanted to know from him. "No," he said. "I was sad."

What had happened next didn't make sense. Karen felt at the end of her rope. Daniel and Hailey were both crying. Then Daniel had said, "I want soup." This statement had the unfortunate effect of taking the conflict to a whole new level. Daniel and his mother went head-to-head over the dinner choice, and the battle continued for the next two hours, ending with Karen still in a rage and Daniel alone in his room without dinner. "Why," I wondered aloud with them in my office, "would Daniel take a situation that was already pretty bad, and then make it so much worse?" None of us knew the answer. "I wonder," I said, "if the soup was Daniel's way of saying, 'I feel bad and I need to be comforted.'" I told them that I had this idea because Daniel had told us that he felt sad, not angry.

With this suggestion the conversation took a new direction, as Karen began to tell me about an episode of depression she had experienced six months earlier. She had been very irritable and short with her children, and she recalled Daniel asking, "Why is Mommy sad?" As she thought about it, Karen realized that Daniel's difficult behavior really started then, and got worse only when she returned to work full time, although she herself now felt better. "Perhaps," I wondered out loud, "it's taken Daniel longer than you to recover."

"Should I have let him have the soup?" Karen asked. "It's not about the soup," I replied. In my opinion, there was no "right answer." Either way could have been OK, and each choice had its pluses and minuses, as is true about most of the minuteto-minute decisions we make as parents. What was important, however, was to reflect upon the meaning of Daniel's difficult behavior, to label his feelings and talk about them. My hope was that by giving Karen an opportunity to tell her story, she would learn how to regulate her own distress in future "hot spots" when things began to unravel. If she, in turn, could help Daniel reflect on what was happening, he would learn to say not, "I want soup" but rather, "I feel sad that you're angry with me" or "I miss you when you're away."

My approach and the ideas behind it have grown out of the unique experience of working on the front lines with children and families in a busy small-town pediatric practice while simultaneously studying contemporary developmental theory and research as a scholar with the Berkshire Psychoanalytic Institute. This research has had direct application to my work and has helped me to help families in dramatic and meaningful ways. I see day after day that if a parent is given the space and time to think about her child's experience, it has a significant and immediate effect on the child's behavior. "Behavior problems" are actually symptoms of disruptions in relationships. My approach can be applied to a wide range of behavioral issues, including, but not limited to, excessive crying, sleep problems, and explosive behavior. As relationships are healed, behavior improves. As children learn to manage strong emotions, parents have an increased feeling of competence. A positive cycle of interaction is set in place. The rapidly moving train of development gets back on track.

Parents are inundated with books on how to solve behavior problems, as well as books on how to raise a child with any number of biological vulnerabilities: the "spirited child," the "shy child," the "explosive child," and the child with "sensory issues." The standard approach in these books is to offer some explanation of the child's behavior, followed by advice about how to handle a variety of challenging situations. These books provide strategies for managing temper tantrums, sibling conflict, or outings to the grocery store. The focus is on "what to do."

In my work with families, I focus not on "what to do" but rather on "how to be" with your child. Guided by the most current research in child development, together with more than twenty years' experience practicing pediatrics, I focus on this one basic point. What a child needs most is to have you recognize and empathize with his experience and help him to contain strong emotions. Whatever quirks and vulnerabilities he may have, they rarely suggest that something is "wrong with him." Rather, they are a unique set of challenges that he must learn to cope with and even perhaps use as an asset as he grows and develops.

Consider Ella, who as a young child was very sensitive to sensory input and overwhelmed by loud noises. She would get agitated and have meltdowns at the most inopportune times. Once when she was three, she exploded at a children's concert where all the other children were quietly sitting on their mothers' laps. At that particular moment, her mother, Beth, might have felt any number of very distressing things, from "what's wrong with my child?" to "I'm a bad parent." She might have yelled at her, or left in a rage, overwhelmed by a sense of shame and failure.

Instead, Beth took Ella to a coat closet next to the auditorium, where she was close enough to hear yet not be overwhelmed. She held Ella on her lap and talked to her about how loud noises were hard for her without conveying a sense that she had been "bad." In doing so she gave Ella the security and the language she needed to think about what was happening to her. In time she might recognize her sensitivities and come to master her distress. Indeed, by age eleven Ella had learned to play several instruments and loved to sing and dance on stage. It is quite possible that her extreme sensitivity to various kinds of noise, which as a young child was such a challenge for her, now manifests itself as a talent for musical endeavors.

What does it mean to hold a child in mind? Imagine this scene, some variation of which has occurred in almost every household with a toddler. Peter sits in his booster seat at the dinner table and insists on drinking from his favorite red sippy cup. But you realize that you left it at the playground that day, so you give him the blue one. He throws it on the floor and starts to scream. How do you turn this moment into one in which he learns to manage his feelings of frustration, rather than one in which he disintegrates into an all-out tantrum and you yell at him and feel like a bad parent?

Holding a child in mind can be understood narrowly as an ability to think about your child's behavior in terms of his underlying feelings and motivations. But on a broader level, it is a crucial human skill with long-term effects. Parents who develop this skill are helping a growing child regulate intense emotions. If your child could give words to his experience, he might say, "When you think about me, I learn to understand myself."

Holding your child in mind is sometimes more than a metaphor. Here is a case in point. It was close to 3:00 AM, and Christine's body ached with fatigue. But she was instantly awake when she heard six-week-old Henry stir in his crib. She nursed him in the quiet, dark room, hoping with all her heart that this time he would just settle back down and she could return to her warm bed. But this was not to be. After nursing, Henry began to fuss. Even a good burp did not quiet him. His fussing soon escalated to an all-out cry. Christine held his wriggling body wrapped tightly in a soft flannel blanket. She rocked back and forth, feeling his body begin to relax, only to again be gripped by another round of screaming. She knew from experience that this might take a while. Part of her was screaming, too. "I can't do this anymore! You have to go to sleep!!" But she kept these thoughts under control, knowing that her frustration only prolonged things. And sure enough, eventually the quiet periods lengthened. The wriggling became occasional squirms. She kept rocking, holding him tight in her arms. She sang a song to herself to calm her ragged nerves. Finally that magic moment arrived. She felt him become heavy in her arms as his whole body relaxed. All was quiet. He was asleep. Christine gently returned him to his crib and went back to bed.

The image of Christine physically holding Henry is helpful in trying to grasp the more abstract concept of holding a child in mind. In this physical act one can see the four key elements. First of all, Christine knew that babies of Henry's age may cry for all kinds of reasons; his crying did not necessarily mean that there was something wrong. Thus she understood his behavior in terms of his stage of development. Christine also empathized with the feelings her child was having. She sensed that Henry needed her to be with him, that her presence alone was helpful to him. Third, by literally containing Henry's feelings with her body she was able to help him regulate himself in the face of a difficult experience. She managed to do all of this without being overwhelmed by her own feelings or shutting down emotionally. Christine had had thoughts that she was a bad mother because she couldn't make him stop crying. Her fatigue threatened to overwhelm her and lead her to give up. But she did not shut down. She did not let her distress get in the way of being with Henry.

In my office we see dramatic effects when children feel understood and contained in this way. "She hits him for no reason! We send her to her room, but she just does it again. What can we do to make her stop?" Seven-year-old Amy was in my office with her parents, Lori and Rich, and her three-year-old brother Max. I cringed inside at this all-too-familiar scene of parents asking me to fix their child's "problem behavior." Amy quietly drew pictures at a small table. Her brother played with LEGOS in the corner of the room. "What were you doing?" I asked Amy, referring to the most recent incident of conflict. She began to describe her attempt to enlist her brother's help in tying a rope to a chair to play jump rope. Her mother interrupted. "She just explodes! She pinched him and I sent her to her room." "Let's slow down," I said. I wanted to know what everyone had been doing and feeling leading up to this moment of disruption. As we focused on the details, many things emerged. Lori was overwhelmed by the responsibilities of running the household and acknowledged having little time to think about Amy, particularly since Max was born. Rich spoke of taking many outings with Max and realized that these outings often did not include Amy. "Perhaps she misses me," he said.

As Lori and Rich talked about themselves and how their lives had changed since they had had kids, everyone seemed to calm down. Max began to explore freely all the toys in the room. Amy drew an elaborate picture of a girl on a horse. When I commented on it, Lori began to describe Amy's creativity, telling me that Amy loved to read and to write her own stories. I felt that some of her rage that had been directed at Amy had dissipated. It occurred to Lori that if Amy had more opportunities to use her creativity, she might not get in so much trouble with her brother. "Maybe she's bored," Lori said. Amy then told us how she wanted to jump rope but that her brother didn't "get" what she was explaining to him.

"Amy is very bright, and also very angry," I observed. "She becomes so overwhelmed by her anger that she can't contain it. It is important that Amy knows that hurting is never OK, but that the angry feelings are OK." We all agreed that being sent to her room for an indefinite period, accompanied by yelling and repeated reprimands, did not help her to calm down. The "time-out" for hitting needed to have a definite structure, with a time limit, preferably a location different from her room, and a clear beginning and end. In addition, Lori and Rich needed to convey a sense that Amy's feelings were understood.

The three of us were engaged in conversation when we noticed that Amy had moved over to the dollhouse and sat beside her brother on the floor. They were playing together. Max handed the dolls to Amy and she placed them on the tiny chairs. They were quiet and cooperative side by side. Mom and Dad stopped talking and watched in awe. "We have never seen this." After allowing some time to let the moment sink in, I said, "They seem to like when you think about them in this way. It makes them feel calm." Our fifty-minute visit was at an end. I acknowledged that we did not have all the answers, and there was still a lot of work to do. But now the family knew what was possible and what to reach for.

As I elaborate upon in later chapters, holding a child in mind may be made more complex by factors that are particular to your child or to you. Among them are your child's biological vulnerabilities, the qualities he was born with, some of which he may have inherited from one or both parents. For example, as we shall see in chapter three, some children, from the moment they are born, have difficulty with what is referred to as "state regulation." They do not easily make the transition from being awake to being asleep and may need to cry intensely to get from one state to another. Others may have extreme sensitivity to sensory input. One infant I took care of would cry when the dishwasher changed cycles.

Further complexity can be added by the relationships in the family, primarily the relationship between two parents. Parents may find it easier to focus on their child's behavior than to face seemingly overwhelming conflict in their marriage. Yet children absorb this conflict and reflect it in their behavior. When you don't feel supported by your spouse, or when parents are not together, handling challenging behavior can be very difficult.

Then there is your own history, particularly relationships with the family you grew up in. When parents associate a child's behavior with difficult episodes in their own childhood, they may become overwhelmed by the fear that their child will suffer as they did. This can make them unable to think clearly just at the moments when their child most needs them. Each of these three components—a child's biology, family relationships, and a parent's history—contribute to any individual "behavior problem."

John Bowlby, a British psychoanalyst and contemporary of Winnicott's, observed the devastating effects of separating mother and child. He described the way a child keeps close to his mother in times of stress and fear as "attachment" behavior. Greatly influenced by Darwin, Bowlby postulated that this attachment relationship was essential to the survival of the species. The subsequent forty years of attachment research have clearly demonstrated the wisdom of Winnicott and Bowlby's conclusions. When a parent is fully emotionally available, a child feels free to explore the world with the knowledge that in the face of fear or danger, the caregiver will respond appropriately. On the other hand, if the caregiver is inconsistently available or emotionally removed, as occurs with depression, the child may show insecure attachment. He may be alternately clingy and aggressive in the face of an unreliable or unpredictable caregiver. Furthermore, this research has shown that the quality of a child's attachment to a parent is very closely related to a parent's attachment to her own parents. When an adult describes her relationships to her parents in a way that suggests she is preoccupied or unresolved in some way about those relationships, her child is likely to have an insecure attachment relationship with her.

Emotional availability and holding a child in mind are very closely connected. Peter Fonagy, PhD, a psychoanalyst and chief executive of the Anna Freud Centre in London, and his colleagues found a clear connection between "reflective functioning"—a term Fonagy uses for holding a child in mind—and secure attachment. Parents' ability to think about a child's experience from the child's perspective, to empathize with his feelings, and to contain and help him regulate his emotions without becoming overwhelmed themselves or shutting down is clearly associated with the quality of a child's attachment. Perhaps most important, longitudinal studies spanning more than twenty-five years have demonstrated that when children have secure attachment relationships in early childhood, they are likely to grow up with the ability to handle difficult emotions, think resourcefully, and adapt to complex social situations.

The field known as "behavioral genetics" adds another dimension to these findings. It examines the way in which the environment, specifically early life experience, helps determine how genes are expressed, or turned on and off. The way in which individual genes are expressed in turn determines individual differences in behavior and development. For example, a person born with a genetic trait associated with anxiety may have a large physiological stress response in unfamiliar situations. But if he grows up in an environment that supports him in his efforts to manage these anxious feelings, he may develop the capacity to be comfortable in new situations even in the face of this inherited trait.

Finally, there is a huge explosion of knowledge about the neurobiological basis of emotional regulation, which points to the critical role of the right brain. Even in adults, these structures can be altered in the setting of caring, responsive relationships, such as occur in psychotherapy. Similarly, when parents change the way they relate to their children at times of stress, these critical right brain structures that regulate emotion can change.

Let's start with guilt. Any parent will tell you that a hefty dose of guilt comes with the job. Where does this guilt come from? It is triggered in large part by the natural but usually unspoken mixed feelings that parents have toward their children. Hundreds of parents, in the privacy and safety of my office, have described being startled by the intensity of rage they feel toward their young child for whom they also feel powerful love. A mother may even confess her disappointment that a difficult child who cries all the time is not the child she dreamed of when she was pregnant.

Children express similar intense feelings. A wise toddler on a popular YouTube video tells his mother from his high chair, "I love you, but I don't like you." And, like the mother who wishes for a different child, he says "I only like you when you give me cookies." Although these experiences can be devastating in the heat of the moment, most parents accept these normal, healthy expressions of frustration and anger. Strong opposing feelings are a part of any passionate relationship.

However, when a parent feels these ambivalent feelings but does not acknowledge and accept them as she does her child's emotions, when a parent believes these feelings are "wrong" or "bad," guilt soon follows. The trip from guilt to blame is a short one. If parents feel guilty simply for having feelings, any suggestion that their actions might affect their child's growth and development will naturally be heard as blaming them when things go wrong. If they feel guilty, they easily assume blame. This kind of guilt can be debilitating. Yet if we acknowledge and accept these mixed feelings in ourselves, rather than being paralyzed by guilt, we can turn this whole idea on its head. Guilt can actually become a thing of value if we realize that "I'm guilty" can also mean "I'm responsible." And "I'm responsible" also means "I can help."

Winnicott summed up these ideas in the following way: "I think on the whole if you could choose your parents . . . we would rather have a mother who felt a sense of guilt—at any rate who felt responsible, and felt that if things went wrong it was probably her fault—we'd rather have that than a mother who immediately turned to an outside thing to explain everything . . . and didn't take responsibility for anything."

Guilt and blame