Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. Through stories from my behavioral pediatrics practice (with details changed to protect privacy) I will show how contemporary research in child development can be applied to support parents in their efforts to facilitate their children’s healthy emotional development. I will address factors that converge to obstruct such support. These include limited access to quality mental health care, influences of a powerful health insurance industry and intensive marketing efforts by the pharmaceutical industry.

Wednesday, May 19, 2010

The "Transitional Space" and its Relevance to Pediatrics

When parents come to see me in my pediatric practice for a child's behavior problem and I begin to explore the parent's own life experiences, he or she may say in a resigned tone, "then its all my problem!"

D.W.Winnicott, pediatrician turned psychoanalyst and one of the main guiding influences on my work, is perhaps best known for his description of the "transitional object." A related idea, less well known, is of the transitional space. I have found this idea to be very helpful in locating where the "problem" is in response to such a reaction.

When my daughter was five months old, we bought her two soft puffalumps with a bell inside.(I knew to follow the advice I had been giving parents for years- get two so you can wash one) She and the toy, which, when she began to talk, she named "mousy," almost immediately became inseparable. When, at about age 2, she fell at the playground, she immediately cried out, "MOUSY!! Now 15 years old, the worn and tattered mousies sit on my daughter's bed and receive almost no attention, though I suspect she will take them to college.

Winnicott referred to the transitional object at the first "Not-Me possession." As a baby begins to become a separate person, but does not yet have the capacity to regulate himself in the face of difficult feelings, such as occur when separating at bedtime, he or she makes use of this highly valued object.

The "transitional object" is the physical form of the transitional space between a child and his parent. In this space a baby begins, with appropriate encouragement from his parent, to grow into a separate person.

So how is idea of the "transitional space" helpful in evaluating and treating "behavior problems?" Consider 18 month old Kevin, whose mother, Amy, brought him to see me because "he hits too much." The three of us sat on the floor. Kevin played while we spoke. When he became restless and threw a toy at his mother, she had a vivid memory of having been slapped across the face by her father as a child. She realized that she would retreat emotionally when Kevin hit her, even physically leaving the room when it happened at home. The "problem" was neither in Kevin nor in Amy but in the transitional space between them. His experience as a healthy toddler with normal aggressive feelings met her experience of trauma.

Kevin was certainly contributing his share to the problem. The hitting was getting worse, perhaps beyond the level of what might be considered "normal". He had a very persistent temperament and was repeatedly testing Amy, likely looking for help managing his feelings rather than the emotional abandonment he was experiencing.

By sitting on the floor as a threesome, we were able to be in this transitional space, which is easier to see when there are three people. Only then could we gain a true understanding of what was wrong and begin to know how to solve the problem. Addressing either Kevin's behavior alone, or Amy's history alone, would not offer this opportunity. Certainly giving advice about how to do a "time out" would have missed the point. Amy was an intelligent woman and had access to the myriad of parenting books and articles that explain how to set effective limits. Only when she was able to understand the meaning of his behavior, both for him and for her, was she able to respond appropriately. She knew what to do.

So when I listen to the story of a "difficult" child I think of the problem as being neither in the child nor in the parent. The location of the problem is in the relationship. We can come to understand it by being in the transitional space between these two very close yet separate people.

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