Perseveration in Autistic Spectrum Disorder


Recently, I read an article sent by a colleague that had a catalytic effect on my thinking. The paper is entitled, “The need for a broader approach to emotion regulation research in autism” (Mazefsky, Palfrey, & Dahl, 2012).

This paper focuses on emotional reactivity and regulation in children on the autistic spectrum. The authors note that a more typical approach to studying emotion in ASD individuals is to explore their reaction to emotion in others or their difficulty recognizing their own emotions. However, those who have an ASD individual in their family or who work with ASD individuals know that emotional regulation is a major challenge. Often, frustration escalates, as a rigid imperative of expressed desire or need is repeated over and over in a pattern of perseveration. A child, such as one of my little patients, may plead, “choo choo train!” again and again, despite parental explanations that it isn’t possible to ride the choo choo train at that moment. Frequently, the perseveration ends in a meltdown.

The authors point out another crucial fact known to all families of ASD individuals. Too much negative emotion can adversely affect personal relationships, cognitive abilities such as attention and problem solving, and communication (p. 1). They suggest that individuals with ASD may have an exaggerated amygdala (part of the brain central to the stress response system) response when experiencing negative emotion, and a dampened response when perceiving or judging emotions in others (p. 2). Perseverating behavior is behavior in which the individual focuses intently and excessively on one thing and is unable to adaptively shift his focus of attention. Research on the perceptual processes in perseveration has shown that children with ASD can shift their attention perfectly well in a task involving continuous shifting of attention, but when they are allowed to get involved in an activity, they have difficulty shifting their attention to something else. The paper hypothesizes that increased and sustained amygdala reactivity in individuals with ASD interferes with their cognitive control. This sustained amygdala reactivity may be caused by decreased inhibition of the amygdala by the prefrontal cortex, the part of the brain that exercises judgment, among other things (p. 3).

Studies have shown that negative emotion can interfere with a child’s ability to control his behavior, particularly when his attention is focused on a salient emotional cue or when the motivational significance of the cue is enhanced (p, 4, citing Mischel & Baker, 1975; Prencipe & Zelazo, 2005); (Beck et al, 2011). Since the choo choo trains are motivationally significant to the child in my example, his cognitive flexibility is impaired and it is difficult for him to stop pleading for “choo choo train” and accept the alternatives his parents offer him.

The paper proposes a model called the Iterative Reprocessing Model to explain how strong emotional salience may interfere with executive functioning and cause emotional dysregulation (p. 4). According to this model, there is a bidirectional flow of information from a neural network beginning in the midbrain in the thalamus and amygdala and interacting with many areas of the prefrontal cortex (Zelazo & Cunningham, 2007). When this information reprocessing system works well, it supports regulation by amplifying or suppressing attention to certain stimuli. Negative emotion can affect this reprocessing, but in typically developing children the prefrontal cortex improves in its ability to function in this reprocessing system over time, even in emotionally salient situations (p. 4, citing Zelazo et al, 2010). Current theories of underdeveloped connectivity with the frontal cortex in ASD are consistent with the idea of this reprocessing activity being disrupted (p. 4, citing Schipul, Keller, and Just, 2011). In the case of the child with the perseveration on choo choo trains, we would hypothesize that his initial love of choo choo trains (their “emotional salience” for him) would have caused his amygdala to overreact, and the failure of inhibitory processes due to ineffective connectivity to the prefrontal cortex would sustain the negative affect state and indeed allow it to escalate.

Considering some of the clinical implications of this model, the article suggests that treatment of emotional responses in children with ASD could be improved by learning more about the neurobiological mechanisms involved. Current methods of treating these problematic emotional responses are often nonspecific, involving multiple psychotropic drugs, or have not been shown to generalize to long-term emotional stability (p. 5).

After reading this article, I wondered if joining the child in the emotional aspect of his perseverating behavior – even exaggerating that emotion in a pretend mode – might be an effective approach. In the dyadic work I am doing with an autistic child and his mother, she and I began to experiment with joining him in his plaintive cries for choo choo train. This was a change from our previous empathic remarks about how sad it was for him to not be able to have a ride of the train right now. Instead, assuming that we didn’t really know the exact meaning “choo choo train” had for him in that moment, we joined him in lamenting not having it, as if it were a legitimate and urgent desire. We were as repetitive and insistent as he in crying for a choo choo train, though we always waited for him to initiate the call.

My rationale, in addition to the hypotheses about the neurobiology of ASD proposed by the article, was informed by the principles of dynamic systems theory. A greater number of component parts of the system (now composed of the child, his mother, and I) in interaction had a better chance of finding a moment of meeting and disorganizing the current rigid organization of the system – his perseverating on choo choo trains. If that happened, there was a chance of a new, more complex organization to emerge. In fact, at one point, he murmured “airplane” instead of choo choo train. Picking up on the cue, his mother began to alternate cries for choo choo train with airplane, and a new pattern – slightly more complex – was created. Indeed, there was no meltdown in the session. Instead, there were moments of pleasure shared by all of us, and – though we do not know what next week will bring – even a feeling of hopefulness about change.

Mazefsky CA, Pelfrey KA, Dahl RE (2012). The need for  a broader approach to emotion regulation research in autism, Child dev Prospect, 6(1):92-97.

1. Beck DM, Schaefer C, Pang K, Carlson SK, Executive function in preschool children: Test-retest reliability, J Cogn Dev. 2011 Jan 1; 12(2): 169–193.
2. Mischel W, Baker N. (1975). Cognitive appraisals and transformations in delay behavior. Journal of Personality and Social Psychology. 1975; 31:254–261.
3. Prencipe A, Zelazo PD. Development of affective decision-making for self and other: Evidence for the integration of first- and third-person perspectives. Psychological Science. 2005; 16:501–505.
4. Zelazo, PD.; Cunningham, W (2007). Executive function: Mechanisms underlying emotion regulation. In: Gross, J., editor. Handbook of emotion regulation. Guilford; New York: 2007. p. 135-158.
5. Zelazo, PD.; Qu, L.; Kesek, AC. Hot executive function: Emotion and the development of cognitive control. In: Calkins, SD.; Bell, MA., editors. Child development at the intersection of emotion and cognition. American Psychological Association; Washington, DC: 2010. p. 97-111.

Avoiding Struggles: Strategizing


One of the biggest challenges a parent or other caregiver faces is avoiding struggles with the child. Struggles are a no-win situation. Many children, like junior lawyers, are great at arguing. Caregivers (CG) often cannot resist getting pulled into a lengthy argument, in which the child usually gets the upper hand. Although some parents tell me about their child’s arguing skills with pride, I know that parents letting children litigate is making a fool’s bargain.

The argument usually starts with the CG setting a limit. For example, the teenager comes home from school, drops his back pack on the floor, and lunges for the couch and the t.v. remote. The CG asks, “How much homework do you have tonight?” Child responds, “Not much. I did most of it in study hall.” The CG represses her skepticism and asks, “What about that English paper that is due Friday?” The child says, “Why are you always always acting like that? My teacher says that kids need to relax when they get home from school! I’ve had a hard day, and I need to chill a little bit before I do anything like homework!” CG: “I’m sorry. What was hard about your day?” Child: “None of your business. Don’t be so nosy. I wish you were like Jason’s parents. They leave him alone when he needs his space!”

One can empathize with the CG. By now she has three people aligned against her – her child, the teacher, and (maybe 4) Jason’s parents! Also, she hears the stress in his voice and she agrees that he needs time to relax. At the same time, she replays in her mind the past few weeks, when he has stayed up until midnight struggling with homework with diminishing returns, or given up, after “relaxing” in front of t.v. or texting with friends for hours after coming home from school. What should she do?

Before giving suggestions, let me point out that this problem most likely started long ago. It is a pattern that has old roots. Consider this situation. Preschool child is in a bad mood when she wakes up. First, she wants her red pants that are in the wash, and nothing else can satisfy her. Then she decides that she will make do with her silver Cinderella sandals, but it is 10 degrees outside and there is snow everywhere. Her mother has left for work and her father (CG) is trying to get her ready for school, where she has pronounced she is not going.He is thinking of a difficult client he has an appointment with first thing, and he is feeling stretched to the limit. Finally he gets his princess downstairs to the kitchen, and she demands coffee cake for breakfast, remembering the special treat they served to a guest the morning before. He thinks for a moment about what her mother will say if he gives in, but he says, “OK, coffee cake and then eggs (pointing to the eggs he has already prepared). She says “OK” but after the coffee cake, she touches the eggs with a fork and proclaims, “These are not the kind of eggs Mommy makes. I don’t want them.” Sound familiar?

The solution to both of these situations (and one does indeed follow the other) is strategy. When you are on the front lines of the battle, you can’t make strategy; you can only shoot or surrender. It is the generals who make strategy, and they don’t make strategy on the front lines but in the “war room”, protected and far away from the storm of battle. Strategy is also best made with at least two collaborators. They can bounce ideas off each other, balance each other’s extremes, recall data that the other has missed. They can make a plan. After they make a plan, they have to execute it, and then they have to practice it over and over again until it becomes a habit. When it is a habit, the old bad habit – the struggle pattern – starts to unravel and make way for the new pattern, a more secure and potentially collaborative one not just between generals but between generals and soldiers.

Let’s look at how strategy works in our two examples. With out teenager, CG says, “Well, I totally sympathize with you for needing to relax, but we agreed that there were no screens except computer for homework until homework is done. That lets you relax afterwards and get to bed in time for you to be rested. Can I get you a snack before you begin? I got you your favorite popcorn and a new vitamin drink of the kind you like.” If the child protests, the CG responds, “I’m so sorry, but you know that is what we (she and other CG) decided, and we all agreed that was best. I know it is hard.” Then she leaves the room. This last part is crucial, because if she stays, he may persuade her to give in or get into a struggle with him that takes up his homework time and drains her of all her emotional energy.

Now the preschooler: The CG says, “You know we said no coffee cake. You can have eggs or an energy bar in the car (he and his partner agreed on this beforehand). Which will it be? And, by the way, you can wear your Cinderella slippers in the car but your boots are going with you, and I am putting them in your cubby when we get there.” If she has a total meltdown, he can carry her to the car. CG’s of preschoolers, remember the example of the teenager when you feel tempted to give in. You can’t carry teenagers to the car, or anywhere. Start building healthy habits early. It is hard in the beginning, but it pays off.

Helping Your Child Learn Self Regulation: The “3 R’s”

IMG_boysinarow What is regulation? Regulation refers to the integration of the various functions of the body and mind in order to achieve a sense of wellbeing. Regulatory processes are organized into rhythms. 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. Walking is a self-regulating 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, beginning in infancy (Tronick, 2007). 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 (or a dog). Even having a conversation with another person involves rich processes of turn taking that create coordinated rhythms between the two people and also within each individual. The capacities for mutual regulation are developed over time, and some children develop them more easily and earlier than others. That is because some children are born with better functioning capacities for self-regulation and coordinating with others than other children, and because some caregiving environments are better “regulators” for children than others. Mutual regulation is intimately tied to self-regulation, so that if someone is not good at mutual regulation, he is also not so good at self-regulation.

In order to better understand regulatory processes, it is important to understand something about brain development. No one describes the connection between brain development and stress regulation than Bruce Perry. Perry explains, 1. The brain develops sequentially from the brainstem to the cortex; in the first year of life, the cerebral cortex is not yet “on line”, and the lower and mid brain are what the infant makes use of to make sense of his world. 2. The brain is use dependent – “use it or lose it”, “Neurons that fire together, wire together.” 3. The stress response systems originate in the lower parts of the brain and help regulate and organize higher parts of the brain – or if poorly organized or poorly regulated themselves, they dysregulate or disorganize higher parts of the brain.

Interventions that support regulation can target various parts of the brain. Thinking through a challenge (“Use your words!”) targets the cerebral cortex that is involved in functions of language and thinking. Thinking things through or “understanding” is highly regulating. However, if an individual is stressed, or if certain of his thinking functions are not well developed due to an inherited learning challenge or immaturity, intervening at these higher-level brain functions will be insufficient.

In fact, all of us from time to time need more basic regulatory means than “thinking things through”, at least to settle ourselves enough to actually do the thinking. We benefit from building up our stress regulatory system in the lower part of our brain. How do you do that? We do that through – Rhythmic, repetitive, patterned activity.  3 R’s – rhythm, repetition, relaxation. Walking; dancing; meditation; rhythmic music; drumming.  Although dancing and making or listening to rhythmic music is highly regulating, most of us do not have the habit of doing this regularly. However, taking a walk is easy to do. It may have the added advantage of taking you physically away from a stressful situation.

There is another set of 3 R’s – routine, ritual, rendering (articulating). Daily routines and rituals (the parents’ best friends); rendering means articulating transitions – creating multiple steps to organize the transitional space (first we get out of bed, then we go to the bathroom, then we brush out teeth, then we wash our face, then ….). For more information on routines, follow the tag “routines” on the blog.


Tronick E (2007). The Neurobehavioral and Social-Emotional Development of Infants and Children, Norton.

Second Posting on Lynne Murray at IPMH


Part II of Lynne Murray at IPMH

Cognitive Development: IQ and School Achievement

The overall findings for poor outcome in cognitive development in Murray’s Cambridge longitudinal study and other recent studies show that PND is associated with a significant risk for poor outcome, but mainly in the context of high risk (families with multiple risk factors such as poverty and social disadvantage), persistent depression, and possibly being a male child.

What are the maternal behaviors that are associated with poor outcome in PND? Multiple studies suggest general reduced responsiveness (Murray et al, 1993, Milgrom et al, 2004), lack of contingency and learning (Tronick & Weinberg, 1997), and modulation of input to sustain attention (Kaplan et al, 2011).

What do these behaviors look like and how do they exert a negative effect?

It is not hard to imagine that depressed mothers would have a generally reduced responsiveness to their children. However, in the newborn period the child is particularly sensitive to communications – particularly emotional communication – from the caregiver, so that reduced responsiveness exerts a powerful influence at this time in life. Nothing demonstrates this fact more than Tronick’s still face experiment. We have described this research in earlier blog postings. In essence, the mother is instructed to play with her baby in a face-to-face situation with the baby in a baby seat and the mother facing him or her. At a signal, the mother is supposed to assume a nonresponsive pose and hold it (for 1-2 min) until another signal alerts her to resume playing. The infant’s response is powerful. She will usually begin with various bids for the mother’s attention – gazing at the mother, giving her an inviting facial expression, smiling, gesturing, or vocalizing. When persistent bids for connection are unsuccessful, the infant looks increasingly distressed, attempts to self-soothe in various ways, and finally may become acutely dysregulated; some infants even lose postural tone and slump down in their seats.
This experiment does not actually simulate the situation with a depressed mother, but corresponds in terms of the reduction in general responsiveness.

Depressed mothers tend to fall into two different patterns (although these are rough generalizations). Some tend to primarily withdraw, and others tend to be intrusive and controlling (Tronick & Weinberg, 1997). The particular style a depressed mother takes will depend at least in part on her own history of caregiving experiences with her own mother and on her personality style. Both of these problem patterns interfere with the way a mother a mother wants to be with her infant. What are some ways that the PND mother can correct some problem patterns and give her baby what she wants to give him or her?

The first step is to find a supportive family member, friend, or therapist. This is important not only to combat depressive thoughts that pull the mother down further into unhappiness – such as, “I am a failure”, “I can’t do anything right” – but also to gain assistance in reading the baby’s cues. A mother who feels like a failure may easily misinterpret her infant’s gaze aversion as a rejection of her, rather than the communication, “I need a break; I will be right back.” Videotapes of mother and infant interacting can be particularly helpful. Often the videotape will reveal missed opportunities for positive engagement, when for example, the infant is gazing at the mother’s face and she is looking away. After viewing the videotape with a friend or therapist, the mother is more likely to be on the lookout for her baby’s invitations to “be together”. It is important to note that whereas medication may relieve the mother’s depressive symptoms, it does not seem to change problematic interactional patterns in PND mothers. In addition, therapy with the mother alone does not seem to be as effective as therapy that includes mother and infant together. In my opinion, videotape intervention therapy is the most effective for PND of all the alternatives.

Beebe B, jaffe J, Markese S, Buck K, Chen H, Cohen P, Bahrick L, Andress H, Feldstein S (2010). The origins of 12-month attachment: A microanalysis of 4-month mother-infant interaction, Attach Hum Dev. 12(0):3-141.

Kaplan PS, Danko CM, Diaz A, Kalinka CJ (2011). An associative learning deficit in 1-year old infants of depressed mothers: Role of depression in duration, Infant Behavior and Development, 34(1):35-44.

Milgrom J, Westley D, Gemmill AW (2004). The mediating role of maternal responsiveness in some longer-term effects of postnatal depression on infant development. Infant Behavior & Development, 27:443-454.

Murray L, Kempton C, Woolgar M, Hooper R (1993). Depressed mothers’ speech to their infants and its relations to infant gender and cognitive development, Journal of Child Psychology and Psychiatry 34(7):1083-1101.

Tronick EZ & Weinberg MK (1997). Depressed mothers and infants: Failure to form dyadic states of consciousness. In L Murray and PJ Cooper (Eds.), Postpartum depression and child development (pp. 54-81). New York: Guilford Press.

IPMH lectures by Lynne Murray: Postnatal Depression


The IPMH group had a wonderful weekend with Lynne Murray. Lynne talked about the effects of postnatal depression in the mother on the developing child, and the effects of maternal anxiety on the developing child. I will discuss postpartum depression in this blog and anxiety in a subsequent posting.

Postpartum depression (or postnatal depression – PND):

Depression can be defined as a pervasive low mood, loss of interest, and feelings of guilt or even the wish to die, and usually includes neuro-biological features such as sleep or appetite disturbance, loss of concentration, retardation or agitation, and excessive fatigue. The point prevalence of depression in childbearing years (the proportion of women in child-bearing years that has depression at a specific point in time) is more than 8%. The prevalence of women with depression 3 months postpartum ranges from 13% in high-income countries (Gavin et al, 2005, Pearlstein et al, 2009) to 20% in low-income countries (Fisher, 2012, Pearlstein et al, 2009). Most women with postpartum depression recover within 6 months, but a significant proportion (30%) continue to be depressed after one year (Goodman et al, 2004). The impact of a mother’s postpartum depression on her developing infant derives from the fact that this condition occurs at a time of an infant’s maximum dependency on his mother (I will refer to the infant using the masculine pronoun to distinguish the infant from pronouns indicating the mother.) and at a time when the infant is most sensitive to his mother’s cues and will be most strongly influenced by them.

Nature has encouraged the process of mutual communication between babies and adults by giving baby faces features that adults find irresistible and by making babies prefer human faces to other visual images. In fact, an adult has specific brain responses to gazing at a baby (especially a mother to her own baby) that are similar to those when gazing at her romantic partner. There is also a rise in the “love hormone”, oxytocin. Gazing at a baby sets off specific behaviors such as a stereotyped greeting (raised eyebrows, open mouth, smile) and changes in the voice (high pitch, simple phrases, melodic pitch). Correspondingly, the infant will gaze longer at an image with the configuration of a human face (schematic eyes, nose, mouth) than at a blank face shape or one with scrambled internal features. Newborns also prefer faces with eyes open and with a gaze directed at them than eyes closed or averted gaze (A Batki et al, 2000, Farroni et al, 2002). The famous studies of Meltzoff and Moore showing that newborns can imitate an adult sticking out his tongue or opening his mouth wide demonstrate the amazing capacity the infant has for “cross-modal” responsibility. In other words, the infant can perceive the visual image of the adult making these movements and respond by making a facial action that mirrors that of the adult through an “active intermodal mapping” ( Meltzoff & Moore, 1989, p. 961). You can imagine that this ability in the newborn prepares the infant to be able to connect with the adult caregiver in a remarkable way. Not only that, but newborns also prefer their mother’s face, voice, and smell, rather than someone else’s. All these preferences prepare the infant to make a connection to his particular caregiver.

However, postpartum can intrude into the caregiving relationship just at this sensitive time when the infant is ready for a special connection and needs it for his healthy development. Colwyn Trevarthen calls the back and forth gaze, gestural, and vocal exchange of the caregiver and infant in the first few months as “proto-conversation” (Trevarthen, 1978). This important communication between mother and infant can be interfered with when the mother is depressed. Mothers with postnatal depression tend to show general insensitivity to their infants’ cues with two main patterns of response – either remote and disengaged or hostile and intrusive. In both cases the infants are likely to avoid contact with their mothers and become distressed. In low risk samples, the PND mothers are less sensitive but the disturbance is subtler, with problems occurring more often with boy babies than with girls.

In fact, after the mother’s recovery from depression, there tend to be persistent difficulties in the interaction between mother and infant (Martins & Gaffan, 2000, Murray et al, 1996). It is important to recognize that different parenting practices are associated with different patterns of child development; weaknesses in one area do not always predict weaknesses in another. Murray has documented different parenting practices associated with cognitive development and achievements (IQ), behavioral regulation problems in childhood, and depressive disorder in adolescence. I will discuss these three areas of child development and the effects of PND in several subsequent blog postings. I will emphasize the potential for mothers with PND to modify their behavior towards their infants in order to possibly mediate these effects.


Batki A, Baron-Cohen S, Wheelwright S, Connellan J, Ahluwalia J (2000). Is there an innate gaze module? Evidence from human neonates, Infant Behavior & Development, 23:223-229.

Farroni T, Csibra G, Simion F, Johnson M, Eye contact detection in humans from birth, Proceedings of the National Academy of Sciences, 99:9602-9605.

Fisher J, Mello M, Patel V, Rahman A, Tran T, Holton S, Holmes W (2012). Prevalence and determinants of common perinatal mental disorders in women in low-and lower-middle-income countries: A systematic review. Bulletin of the World Health Organization, 90:139-149.

Gavin N, Gaynes B, Lohr K, Meltzer-Brody S, Gartlehner G, Swinson T (2005). Perinatal depression: A systematic review of prevalence and incidence, Obstetrics & Gynecology, 106:1071-1083.

Goodman J (2004). Postpartum depression beyond the early postpartum period, Journal of Obstetric, Gynecologic & Neonatal Nursing, 33:410-420.

Martins C, Gaffan EA (2000). Effects of early maternal depression on patterns of infant-mother attachment: a meta-analytic investigation, J Child Psychol Psychiatry 41(6):737-746.

Murray L, Fiori-Cowley A, Hooper R, Cooper C (1996). The impact of postnatal depression and associated adversity on early mother-infant interactions and later infant outcome, Child Development 67(5):2512-2526.

Pearlstein T, Howard M, Salisbury A, Zlotnik C (2009). Postpartum depression, American Journal of Obstetrics & Gynecology, 4:357-364.

Trevarthen C & Hubley P (1978). Secondary intersubjectivity: confidence, confiding and acts of meaning in the first year. In A. Lock (Ed.) Action, gesture and symbol: The emergence of language, London: Academic Press (pp. 183-229).

Peter Fonagy on Metallization

IMG_6816 - Version 2

Peter Fonagy and his colleagues have introduced and elaborated the concept of metallization. Metallization includes the developmental capacity to reflect on one’s inner life and to imagine the inner life of another person. It is central to important other capacities such as the capacity of empathy and self control. The relationship between empathy and metallization is easy to understand in that you have to be able to imagine what another person is thinking and feeling in order to empathize with him. Self control, on the other hand, takes more explanation. As the child develops the capacity to reflect on what is going on inside of himself, he begins to be able to make sense of the motivations for his actions and also for the consequences of his actions on others. He sees a playmate cry when he pushes him or when he grabs a toy away from her. With the help of an adult caregiver, he realizes that his action caused distress to the other child. Then he starts to make a connection between his inner desire to have the toy or his anger at the other child and his action of pushing or grabbing. He also realizes that if he wants to play with the other child, he will have to control his impulse to push or to grab. All of this cognitive and emotional activity is scaffolded by the caregiving relationship and grows into a competency for self reflection and also for self control. Fonagy and his group call this competency metallization.

All individuals, including adults, lose their capacity for mentalizing when they are highly stressed. The individual’s ability to mentalize therefore depends both on the robustness and flexibility of their developmental competency and also on the stress in their lives.

Metallization distinguishes humans from other apes. Animals are very poor at recognizing whether an act of a conspecific is due to serendipity or is rooted in intention, wish, belief, or desire. The capacity to recognize these intention, wishes, desires, and beliefs of the other person is sometimes called “metallization”. It has been argued to account for the major difference between humans and other apes.” (Fonagy, 2014). (Peter says that dogs can mentalize humans but not other dogs. That could explain a lot!)

We all depend on one another to know ourselves. A working definition of mentalization is that of a form of imaginative mental activity, perceiving and interpreting human behavior. Mentalizing is the capacity to see ourselves from the outside and to see others from the inside. It has to do with seeing oneself as an agent, as an intentional being and also seeing others as intentional beings. The capacity to mentalize allows us to create a narrative continuity over time. Mentalization is an integrative framework.

The Development of Mentalization: The newborn has a social brain. She detects and prefers social agents, gazing longer at faces with open eyes and to direct versus averted gaze, showing greater activation of the anterior temporal cortex to voices versus non-voices, and differential activation of the orbitofrontal cortex and insula to happy versus sad voices. The newborn is prepared for mimicry by the mirror neuron systems in the prefrontal and parietal regions, and oxytocin and vasopressin mediate mutuality in the infant-caregiver relationship. In fact, administering oxytocin in the nose makes adults better at reading the expression of others’ intentions.

The Reward Circuits Are More Active in Secure Mothers: The oxytocin levels of mothers whose AAI’s (Adult Attachment Inventory) were read as secure before the birth of their child, went up when they interacted with their children. By contrast, in the case of mothers with “insecure” AAI’s, the oxytocin levels went down. Later on, the pituitary, the part of the brain that generates oxytocin, released more oxytocin in secure mothers. Also, the mesocorticolimbic areas were more active for secure mothers when looking at their babies smiling. All this suggests that the reward circuits are more active in secure moms. Fonagy suggests that this is because when the baby is crying, secure moms have an elevation of activity in the Ventral Striatum, whereas insecure moms do not. Rather, insecure moms have activation in insula (negative memories). Looking at their baby when he is sad makes her sad. You could argue that the absence of oxytocin in insecure moms gives them difficulty mirroring their awareness that it is the baby’s sadness and not theirs. That would make it harder for the baby to manage his sad affect.

Provisional Model for the Developmental Roots of Mentalization : The “secure” mother generates increased oxytocin when interacting with her baby, in association with a more mentalizing (marked-contingent) maternal response to the baby’s distress. The baby perceives the mother’s empathy, while at the same time appreciating that she herself is OK and available to comfort him. This improves the baby’s regulatory state. The evolving capacity of the baby to perceive his mother as having a different mental state from his own is consistent with the development of mentalization and the infant’s resilience. On the other hand, if the mother herself is insecure and generates a reduced level of oxytocin, she makes a “non-mentalizing response” to her infant, reacting not only with her own distress but with an escalating distress response that communicates helplessness. This is not comforting to the infant and may increase his sense of helplessness and fear. He is at risk of not developing the capacity to discriminate between what is in his mind and what is in his partner’s mind, which makes him more vulnerable.

Fonagy referred to a paper in which the maternal oxytocin response predicts mother-infant gaze: in the case of the antenatally secure mother with high oxytocin, the mother looks longer at her infant, especially in the recovery phase of the still face experiment, and there is more imitation of the infant’s intention (Kim, Fonay & Strathearn in press). This is interpreted as the mother’s capacity to tolerate the infant’s distress and is therefore emotionally available to the infant.

Numerous studies reveal the development of an important group of social capacities related to reciprocity, the sharing of mental states, self-awareness, and identification. Joint attention is usually achieved at 9-12 mos. This capacity involves the medial prefrontal cortex and posterior temporal sulcus and is incredibly important. In order for humans to have culture, a shared sense of where they are, they have to develop the idea that when they are looking at the same thing as others in their culture, they are thinking the same thing.

Studies suggest early emergence of the capacities for empathy and mentalizing. In the Baby and Smurf test, the baby’s capacity to put himself in the place of the smurf who has lost its ball is tested. The baby’s sensitivity to the smurf’s situation (the baby saw where the ball went but the smurf did not) is measured in terms of looking time. The baby at 7 months is capable of considering what the smurf believes about the status of the ball (AM Kovacs et al, Science 2011; 330:1830-1834). At 9 months, babies have a sense of fairness, as they demonstrate in an experiment in which of two giraffes one giraffe gets two toys and the other gets only one. Interestingly, it is relative deprivation, not absolute deprivation that predicts outcome. How well we are doing in relation to others around us has a profound influence on outcome.

The Romanian orphanage (orphanages in which the children were essentially deprived of a responsive caregiving relationship) studies show that the age beyond which the influences of deprivation cannot be repaired is between 6-18 mos. Children who were placed in these orphanages at birth and stayed for longer than 6-18 months demonstrated atypical development: signs of autism – reduced imitation, lessened response to name, lower social interest and social smiling, atypical eye contact. On the other hand, deprivation before 6 months (in cases in which the child was placed in a family at 6 months) has surprisingly little consequences.

More About Culture: A Pre K Classroom


First of all, I want to give credit in this blog posting to one of my colleagues on this trip, Alayne Stieglitz. Alayne has a background in education of young children and was an astute observer, helping us recognize patterns we might not have seen without her help.

We observed a pre-K classroom of 3 ½-year olds in South India. There were 30 children and one teacher. The teacher was completely in control of the class. Substituting for another teacher who was out that day, she was not new to the school; ordinarily, she taught a third standard class. Although this teacher was not their regular teacher, the students seemed familiar with her cues, which seemed to be “the way they do things” in that school.In a classroom, subtle cues especially, are usually explained verbally and then practiced multiple times until the children recognize them and can use them to get organized. We imagined that was what we were seeing here. In a parent-child relationship that process begins in infancy, and it is likely that most of the cues have originated in nonverbal communications that later gain verbal meaning.

The children started the day outside, with free play. Inside, older children from other classes helped set up classroom. Inside the classroom, the children sat on individual mats in a semicircle facing the board, with their backpacks arranged neatly in front of them and began the class with a meditation. Then they were ready to begin.

The teacher used a number of different ways to help the children make transitions: (1) First, she asked them to line up to come inside. That activity is spatially organizing and potentially rhythmic; as all the children file in together, it is likely that they will coordinate their pace. (2) She asked them all to sit on their mat in a cross-legged position and place their backpack in front of them; that also organized the children in space and included repetition on a theme – sit in the right position in the right place and orient another identifying part of you – your backpack – in front of you. (3) Then there was the meditation; meditation is highly organizing, calming the body and emotions and lowering stress. The multiple steps involved in settling down to begin the lesson would be expected to facilitate the transition by establishing a 1, 2, 3 4 rhythm – first (1) get in a line to come inside; then, (2) get out mat, and (3) place your backpack on floor in front of the mat; then (4) sit down in the right position. Sometimes, when a child was not in place on his mat on the floor, she would reposition his backpack, which seemed to be a cue for him to take his place. (5) The teacher also used counting to go from one activity to the next.

It is important to note that none of the children seemed overly constrained. There were little disruptions to the routine, most of which were smoothed out quickly without the teacher’s attention. Mostly, however, the children seemed relaxed and comfortable – knowing their routine and on familiar ground. After the meditation, they continued with chanting and prayers. Again, this activity offered more than the verbal content of the prayers; it offered the regulatory support of rhythm. Continue reading

Culture – What Can Caregivers in Our Culture Learn from Caregivers in Other Cultures?


I am convinced that you can’t fight culture. Whereas we in the US have multiple subcultures, there is a general culture that values multi-tasking, technology use, and lack of downtime. The consequence seems to be a relative lack of tolerance for ambiguity and spontaneity, both of which are often associated with creativity. That is not to say that there are not creative individuals in our society nor that there is no creative activity, but it seems to me likely that one has to step out of the typical mind set and pattern of activity of contemporary American life to be truly creative. I accept the misconceptions that underlie idealization and the romanticization of other cultures, particularly those of developing cultures closer to their ethnic roots. However, I cannot be blind to the advantages I see here at the orphanage and school in South India and in the orphanage in El Salvador where I am a regular guest.

Two apparent advantages are – at least in the case of the younger children – plenty of down time, and few toys, especially tech toys. In the evening last night, the gentleness of the temperature matched the tempo of the activity of the courtyard of the boys’ residence. Boys of different ages were playing in two main groups. One group was playing with a volleyball. Two older boys, one of whom had just graduated college, were playing ball together with obvious enjoyment. About 6 much younger boys were trying to capture the ball, while also imitating the older boys’ athletic moves. Sometimes the older boys would allow them to take the ball, and there would be a playful skirmish between the younger and older boys that looked more like a soccer game than the original volleyball. Other times, the older boys continued to play together without much attention to their younger followers, who watched them closely, while also running around. How much learning was going on in that admiring observation, and how much healthy physical activity and enjoyment! There was no conflict among the boys that I could see.

The other group of boys was playing with stiff slender stems of a plant that they used as arrows. They fixed a small rubber band to the rough end of the stick and pulled it with their fingers while pointing the stick upwards. When they released the rubber band, the stick soared into the air. After a while they identified a tantalizing target – a huge jackfruit hanging low on a tree. As the arrows hit the target again and again a milky substance started to seep mysteriously from the fruit. Here also, there was no real conflict. No adults were constraining their activity, telling them what to do or what not to do. No one cared that the fruit of the tree was being injured – it wasn’t as if a precious garden tree or a piece of furniture in the family home was being harmed. The children were free to play unencumbered. How many of the limits we place on children are dictated by the environment in which we expect them to play?

The comfort of the boys in the courtyard was mirrored by the children in the kindergarten classroom. Thirty two children were sitting on small mats on the floor, overseen by one teacher. The teacher, a superb teacher I had known from earlier visits, was calling on the children one at a time to come to the front and create a story out of a picture with four panels of images. This is a rather sophisticated task, requiring them to create a coherent narrative out of the pictures, and the children were doing a good job. At least as impressive was the attentiveness of the other children while the narrating child was at work. Every once in a while one child would start to cause a minor disruption. The teacher did not call the child’s name from a distance. Without speaking at all at first, she moved to his or her side and put her hands gently on their shoulders, moving them back into position. Is there any way we can transport this into our culture?

“Come here right now!”: The Iceberg Effect and More About Transitions


I find myself talking about transitions to the parents I see perhaps more than anything else. A parent will say, for example, “When I call her to come to dinner and finally say, ‘Kate, I need you to come here right now!’ I will either get a nasty response or none at all. If she does respond it will take 10 minutes and more nagging before she comes! Why does it have to be that way?!” the beleaguered mother will ask. These parents are good parents of good children. Most of the children whose parents consult me have major or minor neurodevelopmental problems, ranging from autism to ADHD or the kind of organizational problem commonly called “executive function disorder”. All of these problems involve difficulty making transitions. The good mother who is explaining that her daughter does not come when she calls is looking at the top of an iceberg. She sees a little mound of snow or ice. It is a simple, reasonable request. Why can’t her daughter make a “normal” response? However, beneath the water is a huge iceberg of patterned behavior and the meanings associated with it that has been built up over the child’s life.

Let’s analyze the mother’s “simple request” to “come now”. First of all, she is requiring that the child take in the auditory command. This is harder for some children who have ADHD or who have what is called “auditory processing problems” than for others. The mother might not know that Kate has auditory processing problems or if she did hear that from a tester, she may not have entirely understood what it meant. Or even if she did understand what it meant when the tester was explaining it to her, it is hard to keep in mind during the course of family life.

Second, the mother’s command requires Kate to shift her attention from whatever she was doing at the moment to what her mother is telling her. That shift in attention can be much more difficult that you would think. It involves taking apart the current organizational state of the child – her attention, narrative (the story of what she is doing), and her motor activity. It requires Kate to change her postural position and her physiological state of excitement or of comfort, and prepare for something else. Usually, these shifts in our state of being take place out of awareness. We have an intention to change, and it all happens – we stop reading, get up, and walk to the kitchen to start cooking dinner. We don’t realize that all these small changes of everyday life take energy. Other transitions – sleep to wake, home to school, bedroom to bathroom, bedroom to kitchen table, pajamas to school clothes or even worse, snow pants, also take energy. For some children it requires more energy than for others.

In addition to all those shifts, there is the relational and symbolic meaning associated with the transition. For Kate’s mother it may mean, “Oh, dear. I shouldn’t have taken so long reading that paper. I need to get dinner started!” That may be slightly annoying, but no big deal. For Kate, her mother’s calling her may have a very different meaning. That may be something like, “She is bothering me again, just when I got comfortable watching t.v. I had a really hard day at school and Susie was mean to me, and Mom just can’t give me a break. Why is she always making me do things and not Freddie (little brother)!” I am not suggesting that these coherent sentences appeared in Kate’s mind, but that her mother’s reasonable request may feel entirely unreasonable to her, and this meaning comes together with all the other transitional demands – that she shift her attention, her body, get stirred up inside instead of comfortable, etc.

There are two general antidotes for the stress of transitions. One is routine and the other is what I call “herd mentality”. Herd mentality is more available to teachers than to parents of children in small nuclear families. I first noticed it at the orphanage in El Salvador when the little children – most of whom had suffered early neglect and abuse and therefor could be expected from a neurodevelopmental point of view to have difficulty with transitions – all seemed to manage transitions relatively well. I came to think that it was because they all did the transitions together. When it is time to come to dinner and all the other kids start heading in the direction of the dining hall, the stragglers seemed to notice the general movement and catch up, as if noticing that they didn’t want to be left alone. There is another factor – those children didn’t have the hypnotizing effect of video games or other screens to interfere with the process of the transition.

In addition to the herd mentality, there is the importance of routine. What I tell parents is that routine is their best friend. That is because a routine has momentum. The teacher of the children in the preK classroom in the photo above is using routine, herd mentality, and the rhythm of dance, to facilitate a transition. Once you have established a routine the child does not have to move into that state of limbo, an extended disorganized state, with all the stress that entails. (Remember that stress can be expressed as irritability or aggression!) Instead, although the child may not want to interrupt what she is doing to come to the table, it is easier for her to do it. Kate’s mother’s command does not “come out of the blue”. Dinner is at the same time every night, more or less. Kate’s mother has given her a warning five minutes ago, just as she always does. She may even have gone into the family room to join Kate temporarily in her present state (“That looks like a good program! How about if we record it so that you can finish it later!”) and then used her own body to generate a rhythm in the direction of the kitchen. She may also have initiated a conversation about something that interests Kate – “Remember that girl, Karen, who moved out of the school? I just heard that she was moving back!” All these things help establish a routine. Once the routine is established, it makes everything easier.


Peter Fonagy Lecture at IPMH I: Mentalization Based Therapy

MBT (Mentalization Based Therapy) focuses on how the person feels now, rather than on the past. Imagine yourself talking to a client. Try to think about how you would think about the situation the person is describing. When the other person isn’t making sense, it is because he is not bearing in mind the person he is talking to – you. That means he isn’t “mentalizing”.

The therapist makes “simple sound-bite” interventions that are affect-oriented (related to love, desire, hurt, catastrophe, excitement), and focus on the patient’s mind, not on his behavior, nor on his past. MBT relates to a current event or activity, and identifies non-mentalizing as getting in the way of the patient’s stated goals.

Technically, the therapist in MBT notes breaks in the patient’s mentalizing – when the patient starts to talk as if the world is against him and he is the helpless victim, for example – and rewinds the conversation to the moment before the patient stops mentalizing. Suppose the patient is explaining a disagreement with her boss and then says that her boss treats her the way all men treat her, in fact the way you, the therapist, is treating her right now – by not ‘hearing’ her! In fact, she should leave right now since she is just wasting her time in this therapy!” You might then go back to what the boss said to her that morning and explore how it feels the same as what is going on now between you. How is she feeling ‘not heard’ by you? You accept responsibility for contributing in some way you do not yet understand, for generating this terrible feeling in the patient.

In MBT the mind of the patient becomes the focus of the treatment. Your job as therapist is to help the patient learn about the complexities of his thoughts and feelings about himself and others, how that relates to his responses, plus how “errors” in his understanding of himself can lead to actions that cause problems for him. It is not your job to tell the patient how he feels, what he thinks, how he should behave, or what the underlying reasons are. Instead, you are helping him build new competencies for maintaining a self-reflective mind even under the stress of intense affect. Peter recommends adopting a “not knowing” stance, conveying to the patient a sense that mental states are opaque.

In the therapy, the therapist first of all helps the patient become better regulated. That sounds familiar, doesn’t it? You want to lower arousal as much as possible. Then you validate the patient’s perceptions. Finally, you begin the painstaking work of trying to get the patient to see the situation from another person’s point of view – that is “mentalizing”. Suppose the patient says, “I am just a bad mother.” That is not mentalizing. You stay with what she is saying right here, recognize the self critical feelings are flooding back, and do not turn your attention to the past. If she is not mentalizing when she tells you about herself as a mother, go to another subject and help her regain her more mature perspective, then return to her distress as a mother.

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