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Infant Parent Mental Health Weekend: Bruce Perry


Bruce Perry came to speak to the Infant Parent Mental Health course last weekend. As usual, I was impressed by his discussion, and I agreed with him that his thinking has changed and grown more sophisticated and complex even from when I first met and was inspired by him a decade ago.

This time I was especially gripped by the notion of “dosing” the interventions that are aimed at growing the brain. I put that idea together with two other primary principles of Perry’s Neurosequential Model of Development – changing the environment to meet the developmental needs of the child, and repetitive, rhythmic patterned activity – to create the mnemonic, “RED”. Here is a summary of my thoughts after the weekend. These thoughts are directly relevant to the subjects of ADHD and Executive Function Disorder.

R: Perry frequently talks about the regulating function of repetitive rhythmic patterned behavior. This makes sense, since the body has many rhythms that are repeated over and over again mostly out of our awareness, creating micro patterns that then coordinate to create macro patterns, that help to organize and integrate our human body and mind. For example, we don’t usually pay attention to our heart rate or respiratory rate unless something is going wrong, such as the rapid heart rate associated with anxiety or panic. But our sense of well being emerges from among other things the signals these rhythms send us. An example of the coordination of these rhythms is the coordination of respiratory rate with walking. If walking at a comfortable pace, many people tend to take two strides for one inhalation and between two and three strides for one exhalation. Perry refers explicitly to walking as a regulatory activity, as well as dancing and drumming, and many other repetitive rhythmic patterned activities. In fact, music and dance often provide refined regulatory procedures that make one feel good – calm (“music soothes the savage beast”) or invigorated.

A child develops regulatory capacity through a process of mutual regulation with a caregiver (Cohn & Tronick, 1988, Tronick, 2005). This helps to explain why regulatory activities done with another person are often even more effective than done alone, for example, taking walk with another person. Even having a conversation with another person involves rich processes of turn taking that creates coordinated rhythms between the two people and also simultaneously within each individual (Beebe et al, 1992).

E: One of Perry’s key points is the importance of changing the environment to accommodate the child’s developmental needs for both regulation and for engagement.

From the point of view of regulation, that means more than adding regulatory activities to the child’s schedule. It also means evaluating the child’s capacity for processing sensory input to make sure that the noise, the visual stimulation, and the touch occurring in the child’s daily life is not overwhelming to the child. A crowded classroom or a disorganized routine can be modified to make life easier for a child with sensory sensitivities and that makes life easier for everyone in the family. Sometimes this is called a “sensory diet”.

From the point of view of engagement, this means that the child’s vulnerabilities must be engaged. As Perry says, “You can’t change any neural network unless you activate that neural network.” (Perry, 2015). Not surprisingly, children resist activities that require them to exercise functions that are hard for them, especially if their development is uneven and they do other things quite well. In that case they will tend to stick to what they do well and avoid what is hard. To help them grow, their caregivers must support them in attempting the difficult or uncomfortable task. For some children who are socially skilled but have a learning disability, this means practicing academic tasks that are difficult for them. For other children who have academic strengths but are stressed by interacting with other people, it means drawing them into social interactions, usually in play.

D: But how does one engage a child who is highly stressed by, for example, social interaction, such as very shy children or children on the autistic spectrum? Perry’s idea, which I find very useful, is that of dosing. By paying attention to the child’s cues, you can “read” the child’s intentions to “do something with you” or not. In the rather extreme case of an ASD child, you can’t just let him remain in a withdrawn position without attempting to make a connection; you often have to take the initiative yourself. I recommend small gestures that take place in short time intervals and are over quickly, and also that are of low to medium level of intensity (in noise, visual stimulation, affective tone, and arousal). After you have taken the initiative, you watch for the response. If the child seems not to respond you might try one more time. If the child pulls back further, you might wait. If the child looks a little interested, you might repeat the gesture.

The beauty of this notion of dosing is that it is coordinating intention with the child, and dosing is repetitive and has a rhythm to it. Together with the child you are creating patterns of ways of being together. So you are putting together regulation-enhancing activities with growth-stimulating activities. Another good thing about dosing is that it takes the emphasis off success or failure and places it on creating a balance. If the child indicates, “no”, then you don’t feel, “Oh, I lost him.” Instead, you think, “OK, that was a “no”; I will wait and try again. The “no” is part of what we are doing together. It is part of the back and forth.” And, of course, back and forth is a rhythm too.

How is this discussion related to ADHD and EFD? Both ADHD and EFD can be thought of as regulatory disorders (or difficulties on a dimension, if we use my preferred terminology). I will discuss this further in another blog posting.


Beebe, B., Jaffe, J. & Lachmann, F. (1992). A dyadic systems view of communication. In N. Skolnick & S. Warshaw (Eds.), Relational perspectives in psychoanalysis (pp. 61-81). Hillsdale, NJ: Analytic Press.
Cohn, J., & Tronick, E. (1988). Mother-infant face-to-face interaction: Influence is bi-directional and unrelated to periodic cycles in either partner’s behavior. Developmental Psychology, 24, 386-392.
Perry B (2006). The neurosequential model of therapeutics: Applying principles of neuroscience to clinical work with traumatized and maltreated children, In: Working with Traumatized Youth in child Welfare (N Webb, Ed). The Guilford Press, New York, pp. 27-52.
Perry B (2015). Presentation to the Infant Mental Health PGC Program, U Mass Boston, Feb. 25-26.
The Child Trauma Academy (2015). Overview of the neurosequential model of therapeutics, www.ChildTrauma.org
Tonick E (2007). The neurobehavioral and social-emotional development of infants and children, New York, WW Norton.







The second subject that my mothers’ group asked that we discuss is that of “habits”. When I use the word “habit”, I mean a pattern of behavior that is hard to break even when you try very hard. We usually refer to the patterns we want to break as “bad habits”, but of course there are good habits, too. I like to use the principles of nonlinear systems theory to understand the establishment and maintenance of habits. That is not as complicated as it might sound.

Nonlinear systems theory says that “organization”, or patterns, emerge from the interactions of the component parts of a system (von Bertalanffy, 1968). In a family system, this would mean that when family members (parents, children) interact with one another, they create particular ways of behaving (patterns of behavior) that include characteristics of the individuals involved, their home environment, and the time (of day, month, and year). For example, what Sander calls the infant’s first organization, the diurnal sleep cycle, is established through the repetition of small caregiving acts – nursing, burping, bathing, and changing – that the caregiver and infant experience together, as they are repeated in the same order each day over and over again (Sander, 2008). When the baby grows older, the family establishes bedtime routines that parents and children tend to follow every night. Of course these rituals change with the age of the child and the time of the year, so that during school vacations the patterns usually loosen. Whereas families can typically describe to you their bedtime routines, they are usually not aware of the powerful significance of routines in their lives until something happens – houseguests, illness, a family trip – that disrupts the routine. It is then that the family recognizes the role of these patterns in the coherence of family life.

There are two other dominant characteristics of habits. The first has to do with motivation, or intention. Why would anyone intend to establish a bad habit or be motivated to maintain it, you might ask. Well, there are actually many reasons, and not surprisingly, most of them are out of awareness. Some of them are “non-conscious” in that they were never represented in language or other symbols in the brain and most of the time never will be. They usually have to do with efforts to escape perceived threat and are generated by the central nervous system in parts of the brain below the cortex (thinking part of the brain), such as what we refer to as “fight or flight”. You may wonder how fight or flight could qualify as a habit since it doesn’t happen all the time. I would respond that in highly stressed families, individuals feel threatened much of the time, and they develop a “habit” of reacting with aggression or running away (the flight may be a form of withdrawing or tuning out). People make up reasons to explain to themselves why they are behaving that way. For example, “I have to get him to school!” or “I am too tired to deal with this right now.” Even more insidious, they make up stories to explain why the other person (these “habits” originate in relationships) is causing them to behave that way, for example, “He is a little monster!” (Fonagy et al, 2005). Continue reading