Pediatricians are in a unique position to promote healthy parent-child relationships, and competent, confident parenting.
Both the American Academy of Pediatrics (AAP) Guidelines for Health Supervision and the Bright Futures initiative stress the
need to achieve strong childhood development. It is strong parenting that guides this developmental process. You now give
to parents information about developmental milestones, changes in sleep patterns, setting limits and discipline, toilet training,
mental stimulation, and age-appropriate play that helps them adopt suitable expectations for their child's development. Beyond
information, parents need clear insight into the origins of their attitudes toward parenting to be able to deal effectively
with their child's behavior. This article offers a framework for giving parents the right start, beginning with an understanding
of their relationship with their parents, which portrays the deep reach of attachment in family life.
An icy plunge for new parents Adults who become parents are usually challenged by their new role, with its responsibilities and anxieties. New parents also
face previously unexplored values and attitudes that surface suddenly upon the birth of their baby, as well as new routines
and new problems that need an immediate answer. Such challenges often elicit a heightened emotional response, so that mundane
matters suddenly make for excessive worry (who among us hasn't heard from the parents of an infant who hasn't had a bowel
movement in two days?).
Other experiences quickly come, too, and add internal upset. The new mother is exhausted and feels—almost literally—consumed
by her constantly hungry infant. The new father is dismayed at his wife's physical and emotional unavailability as she keeps
her focus on the baby. Both must reset priorities of time, energy, and resources and balance home and work responsibilities.
Both become aware that even more challenging child-rearing tasks and risks lie ahead: How will I protect my child from my
own occasional frustrations, anger, and irritability? How can I avoid overindulging, yet set limits that are fair? How do
I provide appropriate praise yet correct unwanted behavior? How do I allow my child time and space for play, yet teach cooperation
and respect?
Clearly, enormous change has come into two people's lives.
You, Doctor, can help!
One way that you can help parents, of course, is to provide child-development information and child-rearing strategies. Another
is to guide them toward an understanding of their past—especially the relationship they had with their parents and how it
influences their patterns of behavior today. Self-understanding for parents comes through a long process, in which they review their upbringing on their own and with
their spouse or relatives, friends, and other parents and professionals.1 Counseling skills aren't usually taught during medical training, but many experienced pediatric clinicians know how important
these skills are in helping parents understand themselves and their long-term role.
Problems arise for parents when experiences, attitudes, and fears carried forward from their upbringing lead them to respond
inconsistently or behave inappropriately toward their child.2,3 When parents direct excessive anger, withdraw, use sarcasm and harsh criticism, or direct sharp orders toward their child,
they upset, confuse, and, ultimately, damage that child. Once parents know the origins of their attitudes, however, they can
learn to develop appropriate responses to their child. Reflection and self-exploration, inspired at opportune moments by your
involvement, are key to change.
A good place for a parent to begin is with stimulating questions, such as those in the Guide for Parents that has been posted
at www.contemporarypediatrics.com/contpeds/article/articleDetail.jsp?id=156681 and is adapted from the work of Siegel and Hartzell.1 At an office visit, you can raise an appropriate question to link the past to the present in a way that helps the parent
be more self-aware. The most important questions address parents' attitudes and values, especially as they relate to their
own childhood and the way in which they were raised. Example: Growing up in an overly strict or harsh family, or one that
lacks emotional warmth, may program a child to recreate the same family style when he (or she) becomes a parent. Research
shows, however, that parents who have taken care to review their upbringing, have considered which aspects were positive and
which were not, and have decided how they would like to raise their child are much less likely to repeat maladaptive patterns
learned from their parents.4
Examining the evidence Attachment theory and research offers a useful frame of reference for understanding intergenerational attachment, and can
be applied to promoting parental self-understanding as part of pediatric health supervision.5 The theory is that of English psychiatrist John Bowlby, who, in 1969, put it forward to explain the nature of a child's relationship
to his parents and what happens to an infant when he experiences significant separation from them or other primary attachment
figures.
Bowlby's research associate, Mary Ainsworth, later developed a research tool called the "infant strange situation" that assesses
the nature of the attachment of child to parents. Subsequent research has shown that, when parents can understand their attachment
to their parents, they can better see the effect those influences have on the attachment of their child to themselves as parents.6
Child attachment is of three types The central tenet of attachment theory is that a child who has a secure, confident basic connection to a caring adult has
been set free to explore the world with enthusiasm and to build healthy relationships. Research shows that, depending on patterns
of communication between parent and child, that child forms one of three different types of attachment to her parents. For
some, attachment is adaptive and healthy; for others, it is less so (see the table at the beginning of this article).
Persistent patterns of communication between parent and child strongly correlate with specific types of attachment behaviors
in that child. Responsive caregiving, or contingent communication, requires that a parent notice her child's signals (happy
vocalizing, crying, fussing), make the effort to know what the child means, and respond in a timely, effective manner—all
leading to secure attachment that promotes well-being in the child and is a source of resilience in the face of stress.7,8
Repeated experiences with less responsive caregiving (non-contingent communication), create insecure attachment that is categorized
as avoidant,ambivalent, or disorganized:
Avoidant The child's signals are rarely perceived or responded to in an effective manner; this might happen when a parent is emotionally
distant. Avoidant attachment predicts later difficulty relating to peers and the emergence of a poorly developed sense of
self.
Ambivalent or resistant The parent is inconsistently available for sensitive, or contingent, communication and is at times intrusive in his or her
interactions. Ambivalent attachment predicts a later level of uncertainty and anxiety in social situations. (A child whose
development has been marked by avoidant or ambivalent attachment can still function relatively well; she manages the best
she can because she has adapted in a fairly organized manner to life circumstances.)
Disorganized attachment This category is distinctive because it is associated with more problems in a child's emotional development. It occurs when
a parent repeatedly causes a state of fear in a child—by expressing excessive anger, withdrawing, or creating a setting in
which the child is offered no hope of comfort or safety or no relief from distress.
Parents who relate to a child through frightened or frightening behavior present that child with an insoluble problem: The
parent becomes a source of alarm—a scenario known as "fright without solution"9—and there is no organized, healthy way for the child to adapt to such repetitive negative experiences. The process often
leads to impeded self-comforting ability.
Disorganized attachment also leads to significant problems with social relationships and emotional regulation. Longitudinal
studies document that a child's early and repeatedly overwhelming experiences of alarm caused by the parent cause long-term
damage10: inability to adapt to stress because he cannot resolve his conflicted feelings and drives and, over time, disconnection
in the normal interweaving of thought, emotion, and memory (dissociation), especially in response to stress.11
All parents experience fatigue, hunger, and irritation at times, and occasionally "lose it" and bark at their child, or are
overly harsh. An abrupt shift to such behavior in a parent who is usually accessible and attuned to the child's needs creates
an upsetting and confusing situation. Normally, timely recovery and review of what happened comes from the parent and offsets
the occasional outburst ("Whew! I had such a long day at work, and I was so angry to see you'd left your snack dishes all
over the table. I hate it when I lose my temper like that."). When, on the other hand, a parent's behavior is extreme and
repetitive and no chance of repair or reconnection is offered, a child responds with a disorganized form of attachment. Disorganized
attachment is common in the setting of child abuse, but it can also occur in non-abusive homes (although many experts would
label this type of parenting behavior emotional abuse).
Attachment among adults: Four patterns of response
Research in the 1980s revealed how early attachment patterns persist in adulthood. Mary Main and colleagues devised an adult
attachment interview (AAI) that asked parents to write down their attachment-related memories from early childhood and relate
them to their life at the moment.12 Information elicited by the interview included which parent they felt closest to; what they did as a child for comfort when
they were upset, hurt, or ill; what they remember about separations from their parents; and whether they ever felt rejected
by their parents. They were asked to describe, among other factors, how they think their adult personality was affected by
these experiences and how their relationship with their parents changed over the course of time. Last, they were asked to
recall experiences—as a child and as an adult—of abuse by, or the death of, important figures.
Analysis of the AAI revealed four categories of adult response:
- free (autonomous)
- dismissive of early attachment
- preoccupied with early attachment
- disorganized
The research also showed a robust correlation—as high as 85% predictive—between an adult's assessment category and the attachment
classification of his or her children. Findings from the AAI for an expectant parent can even predict the kind of attachment
their child is likely to form with each of them!
Free (autonomous) These parents have clear insight into their past and successfully separated from their parents, yet are secure in their adult
relationship and attachment to them. They will likely raise children with secure attachments to them. A related group comprises parents with "earned security"; in the face of significant difficulty and insecure attachment
during their childhood, they have made sense of their family experiences and understand how those experiences affect their
own role as parents. A parent who has earned security can offer as secure an attachment to a child as a parent who has had
security of attachment from their own childhood.13
Dismissive of early attachment These adults have limited access to the details of their past or can make little sense of how their past influences the present.
Attachment of this type may occur when a parent has been raised in an emotionally spare or unexpressive family environment—one
that did not foster emotional sensitivity. It is characterized by insistence that he does not recall the details of early
or even later family life experiences and by marked denial that relationships are important or that they have had a significant
impact on his own development. Dismissive parents minimize the importance of attachment. Without self-reflection, they may disconnect emotionally from their child, which often leads to avoidant attachment.
Preoccupied with their own early attachment These parents have past issues that interfere with their response to questions on the AAI. Example: A father asked about
his relationship with his mother and his early memories responded that she always favored his brother—and that even last week
she was treating him "unfairly." Preoccupations with recurrent themes held over from one's own upbringing often impinge on
current functioning and may impair the capacity to have a warm, caring relationship with a child. When negotiating bedtime,
setting limits, or dealing with an autonomy-seeking toddler or adolescent, the parent's background can intrude on perceptions
of how to respond to the child's wants, and is likely to create ambivalent attachment of that child to that parent.
Disorganized with unresolved trauma or loss Parents who suffered a significant trauma or loss when they were growing up and that remains unresolved are more likely to
raise their child with disorganized attachment. Even well-intentioned parents in this category, who clearly love their child,
can behave in a way that is terrifying for that child. Unresolved, overwhelming experiences from the past intrude unpredictably
on a parent's state of mind, leaving her less attuned to a child's needs, less empathic, and less flexible and self-aware.14
A child can become severely stressed or even terrified when a parent is in a troubled state of mind. Example: A mother reacts
with extreme anxiety when her child has a minor illness. She becomes upset, indulges in outbursts at home, and makes frequent
telephone calls and repeated office visits to the pediatrician—despite clear information and reassurance. In her case, it
is revealed that her beloved grandparent died at home after a brief respiratory illness and that she witnessed depression
in her mother subsequently. Disorganized attachment in a child is often preventable, however, because unresolved trauma and
grief are treatable.
What you can do: "Light a candle of understanding"
Of course, you cannot be expected to categorize the attachment level of your patients and their parents. But a clear understanding
of attachment research provides a basis for staying alert to basic relationships you may witness between parent and child.
Such awareness may, through an appropriate question or prompting at an opportune time, help parents understand their relationship
to their own parents and how it affects the way they are raising their children.
A strong association exists between the results of the AAI and child attachment categories, yet controversy and unanswered
questions persist.15 A few clinicians criticize the validity of using attachment categories based on a brief, standardized laboratory assessment.
Although data do indicate that parents who can relate a useful, integrated, reliable narrative of their own attachment experiences
(even in the face of having experienced trauma or loss) have children who develop secure attachments to them, we want to be
clear that direct intervention data are not yet available to say whether an intervention that initiates parents' self-understanding
can lead directly to healthier interactions with their child.
Nevertheless, we believe that pediatricians can help parents with an ongoing process of self-understanding through reviewing
their childhood experiences and reconsidering their actions as parents. Furthermore, patterns of adult behavior can certainly
be altered to keep them from degenerating into maladaptive interactions with their child.
One of the most important contributions that you can make is to offer a handout of leading questions to parents (see the Guide
for Parents at www.contemporarypediatrics.com/contpeds/article/articleDetail.jsp?id=156681). This guide is organized so that parents have the opportunity to answer simple, straightforward questions designed to make
them think about their past and how it relates to their present. Once you are familiar with the questions, use them to elicit
insights from parents in your office when opportunity arises. General themes should cover love, nurturing, separation from
loved ones, care when distressed, times of feeling threatened, and experiences of loss. Related questions might include how
the parent was disciplined as a child and what the parent's relationship with siblings was like while growing up.
Because you are trusted, you can gently ask questions, even at the neonatal exam, to open the door to a continuing dialogue
over coming years. (That long, trusting relationship gives you an advantage over mental health professionals.) The questions
in the Guide for Parents invite them to recall and to rethink the emotional meanings of their past life in the context of
a new role as parent. Consider this brief, ongoing conversation one that varies by need and changes its intensity at different
stages of a child's development or the parents' life circumstances.
By bringing up memory-inducing questions with parents during the first year of their child's life, you can use the information
to further elicit their feelings and reflections when normal parent-child difficulties arise. The potential for promoting
timely, effective resolution before a parenting problem progresses is enormous.
If, during a visit, parents bring up concerns about intense emotions (anxiety, anger, sadness) or impulsive reactions, try
to identify themes that cause such reactions ("What are you doing with your child that might cause such overwhelming feelings?").
By identifying a theme that acts as a trigger, you prompt the parent to reflect on that theme at a later time.
Asking leading questions needs to be accompanied by allowing some time to listen to the parent's responses. You may rightly
fear opening a Pandora's box or drowning in a sea of information after asking a sensitive question. Remember: It isn't necessary
for you to listen indefinitely or hear the whole story, or to respond with explanations or immediate advice. The appropriate
"referral" is to spouse, friends, or select family members. You can say something like, "It sounds like you have many memories
and feelings. I encourage you to talk to your spouse [or sister or brother or friends, etc.] to give you insight into what
you want and don't want to do as a parent."
Issues uncovered can be explored in greater depth away from the office. A circle of friends or family can be remarkably helpful,
focusing insights and helping make sense of a parent's personal history through supportive, empathic, emotionally directed
conversation. Should problems surface and continue to bother the parent, you can recommend a therapist for further guidance.
Science and clinical experience tell us that parents' self-understanding greatly enhances their ability to be good parents
and to foster the best possible development in their child. You can safely advise parents: It is never too late to begin the
lifelong process of understanding one's self and deepening the emotional bond with one's children. Your role remains only
to raise issues and support the process.
Remember: Cultures differ and families are diverse
The base of evidence that links the AAI and categories of child-attachment is generally founded on studies of middle-class,
high-risk populations in the United States, Western Europe, and Israel.16 Can the association be generalized to other populations and different cultures? We do not know. Instead, our approach encourages
cultural competency: Ask parents about their upbringing but be mindful that another culture may be exerting its influence. As you gather nuggets
about parents' relationships and feelings carried forward from childhood, you may also learn about cultural variables that
differ from what is seen in mainstream Western culture.
The best approach to cultural competency is to learn about the history of parents and patients in the broad context of extended
family and culture. Ideally, cultural competency extends beyond learning facts about another culture when trying to understand
people; it should also reveal cultural differences in, and attitudes about, child-rearing within a specific family.
An important caveat: Suspend value judgments about child-rearing practices in different cultures. Example: Many cultures emphasize
interdependence, and a family style of this kind contrasts sharply to the independence fostered in traditional middle-class
American society. Societies that value interdependence emphasize dependency, especially with their children. Mothers from
some cultures often feed their child until 3, or even 7, years old—a sharp contrast to the practice of middle-class mothers
in the United States, who often encourage a child to feed himself at 1 year of age.
You may find yourself in conflict with mothers and fathers about child-rearing practices unless you understand and take into
account cultural differences. But you are in the ideal situation—frequent, brief meetings in your office—to mention cultural
differences and ask parents to compare child-rearing in the United States with practices where they were raised. By being
observant and open, you can monitor the parents' approach and help them decide if they want to retain their cultural practices
or begin acculturation.
Summing up The basic task of parenting is always to help the child balance a need for healthy closeness with a healthy drive to explore
the world outside. Usually, parents find it easier to support one side of that equation. Imbalance results when a parent is
comfortable with the child's intimate closeness and healthy dependence but finds it difficult to encourage the child to be
independent. Alternatively, a parent may be less available for normal closeness or affection and, instead, is better at encouraging
the child's independence and initiative.
Parents need to know about themselves to raise a child well. The following signposts should be kept in mind:
- Self-understanding and making sense of one's life calls for reviewing, recollecting, and rethinking. The process is sometimes uncomfortable but essential for self-understanding. Parental self-understanding in the face of a
difficult childhood history is key to breaking regrettable patterns that lead to insecure attachment across generations.
- Emotional communication between parent and child is a sensitive interchange in which the parent shares and deepens the child's
positive emotions and shares and soothes negative ones. The reciprocal connection and responses of a parent to a child are at the heart of secure attachment.
- Parents who are emotionally unavailable or inconsistently available to their child—including in nonverbal interactions—may
create an emotionally sterile or confusing home environment, which can lead to an avoidant attachment in the child. Without a strong model of warm and supportive communication, a child is poorly equipped to form friendships and love relationships.
Such a child may appear "strong" or "independent" but is, in fact, as detached and distant as his parents.
- Unexamined issues from their own childhood influence or preoccupy parents' thoughts and interfere with the evolving relationship
with their child. Parents' negative memories or experiences, and their defenses against feelings of anger or dependency, can keep them from
an accurate perception of their child's signals. A preoccupied parent's responses certainly affect the child, and can cause
him to be anxious, irritable, clingy, and frightened about separation from the parent—and make him less interested in exploring
the outside world.
- Parents who have unresolved serious trauma or loss, or established patterns of interacting with their child in a way that
causes the child to feel intense fear or alarm, may cause the child to develop disorganized attachment to them. A history of trauma or loss—when resolved—does not cause any form of insecure attachment. To become more capable parents,
parents should understand the effect that past experience has on current practice through the support and guidance of the
pediatrician.
We know that how adults behave as parents is a direct reflection of their experience of childhood. It is not simply what happened to them as a child: It is how well they understand the impact of their past on their present and have emotionally resolved the traumatic and loss aspects of those events in
their life. When parents have that understanding, they are—no question—able to forge the emotionally sensitive, strong relationship
between parent and offspring that a child needs to thrive.
An artful, wise pediatrician goes beyond giving advice: She uses strategies and techniques to help parents initiate introspection
and continue on the path to self-understanding. Ask a question, listen, and suggest themes for exploration: All these make
for a strong beginning.
DR. BARRY ZUCKERMAN is professor and chairman, department of pediatrics, Boston University School of Medicine, and chief of
pediatrics at Boston Medical Center
DR. PAMELA ZUCKERMAN is in private practice in Brookline, Mass., and is associate clinical professor of pediatrics at Boston
University School of Medicine.
DR. SIEGEL is associate clinical professor in the department of psychiatry at the University of California, Los Angeles.
References 1. Siegel DJ, Hartzell M: Parenting from the Inside Out: How a Deeper Self-understanding Can Help You Raise Children Who Thrive. New York, N.Y., Penguin Putnam, 2003
2. van Ijzendoorn MH: Adult attachment representations, parental responsiveness, and infant attachment: A meta-analysis on
the predictive validity of the adult attachment interview. Psychol Bull 1995;117:387
3. Dozier M, Stovall KC, Albus KE, et al: Attachment for infants in foster care: The role of caregiver state of mind. Child Dev 2001;72:1467
4. Hesse E: The adult attachment interview: Historical and current perspectives, in Cassidy J, Shaver PR (eds): Handbook of Attachment: Theory, Research, and Clinical Applications. New York, N.Y., Guilford Press, 1999, pp 395-433
5. Cassidy J, Shaver PR (eds): Handbook of Attachment: Theory, Research, and Clinical Applications. New York, N.Y., Guilford Press, 1999
6. Hesse E, Main M, Yost-Abrams K, et al: Unresolved states regarding loss or abuse have "second generation" effects: Disorganization,
role-inversion, and frightening ideation in the off-spring of traumatized, non-maltreated parents, in Solomon M, Siegel DJ
(eds): Healing Trauma: Attachment, Mind, Body, and Brain. New York, N.Y., W. W. Norton, 2003
7. Siegel DJ: Toward an interpersonal neurobiology of the developing mind: Attachment, 'mindsight' and neural integration.
Infant Ment Health Jour 2001;22:67
8. Sroufe LA: Psychopathology as an outcome of development. Dev Psychopathol 1997;9:251
9. Main M, Hesse E: Parents' unresolved traumatic experiences are related to infant disorganized attachment status: Is frightened
or frightening parental behavior the linking mechanism? in Greenberg MT, Cicchetti M, Cummings EM (eds): Attachment in the Preschool Years: Theory, Research, and Intervention. Chicago, Ill., University of Chicago Press, 1990. pp 161-184
10. Lyons-Ruth K, Jacobvitz D: Attachment disorganization: Unresolved loss, relational violence, and lapses in behavioral
and attentional strategies, in Cassidy J, Shaver PR (eds): Handbook of Attachment: Theory, Research and Clinical Applications. New York, N.Y., Guilford Press,1999, pp 520-545
11. Carlson EA: A prospective longitudinal study of disorganized/disoriented attachment. Child Dev 1998;69:1107
12. Main M: Attachment: Overview, with implications for clinical work, in Goldberg S, Muir R, Kerr J (eds): Attachment Theory: Social, Developmental, and Clinical Perspectives. Hillsdale, N.J., Analytic Press, 1995
13. Roisman G, Padron E, Sroufe LA, et al: Earned-secure attachment status in retrospect and prospect. Child Dev 2002;73:1204
14. Siegel DJ: The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are. New York, N.Y, Guilford Press, 2000
15. Rutter M: Attachment reconsidered: Conceptual considerations, empirical findings, and policy implications, in Shonkoff
JP, Meisels SJ (eds): Handbook of Early Childhood Intervention. New York, N.Y., Cambridge University Press, 2000, pp 65-82
16. van Ijzendoorn MH, Sagi A: Cross-cultural patterns of attachment: Universal and contextual dimensions, in Cassidy J, Shaver
PR (eds): Handbook of Attachment: Theory, Research, and Clinical Applications. New York, N.Y., Guilford Press, 1999
Key PointsBetter parenting: Your intervention may make it happen - You can help parents understand feelings and behaviors about parenting by asking them appropriate questions at key times
- Handout for parents that contains questions that focus memories of how family life was when they were growing up can help
them understand how they have adopted their own style of parenting
- Parents who can, or are helped to, recall and interpret their own childhood and how it can affect parenting style become stronger,
more flexible, understanding parents
- Attachment styles of avoidance, ambivalence, and disorganization between parent and child can greatly affect a child's sense
of himself and of having a secure place in the world
- Parents mainly use four basic patterns of response—autonomous, dismissive, preoccupied, and disorganized—when dealing with
their child
GUIDE FOR PARENTSAsk yourself about your childhood—and make yourself a stronger parent
Here is a quiz about your childhood experiences to help you understand yourself
better. Why do this? By looking into the past, you’ll shed light on your relationship
with your child now, and open the door to being a better parent.
This is not a short-term exercise. You can ask yourself these questions over the course of many years. And, during a number
of office visits, you can also briefly discuss your answers and observations with your child’s pediatrician as to how they
relate to raising a healthy, well-adjusted child. Your parents, brothers, sisters, friends, and spouse can also help you rediscover
yourself; consider asking them about your childhood, too.
REMEMBRANCE
- What was it like growing up?
- What kind of people did you have in your family?
- What was your parents’ philosophy of raising children?
- What did you like about your childhood? What didn’t you like?
- Do you plan to raise your child the way your parents raised you?
RELATIONSHIP- Did you get along well with your parents?
- What changes in that relationship occurred during your youth, and until now?
- How did your relationship with your mother differ from your relationship with your
father? How were they similar?
- Describe three characteristics of your childhood relationship to each of your parents. Why
did you choose these adjectives?
- Are there ways in which you try to be like, or not like, each of your parents?
SEPARATION- Do you recall your earliest separation from your parents? How did it feel?
- Was there ever prolonged separation from your parents?
- Have you ever been separated from your child?
DISCIPLINE- How did your parents discipline you? What impact did that have on your childhood?
- Do you think that discipline shapes your role as a parent?
TRAUMA- Did you ever feel rejected or threatened by your parents?
- Were there other overwhelming or traumatizing experiences in your life? During
childhood? Beyond?
- Do any of these experiences still feel very much alive?
- Do they continue to influence your life?
LOSS- Did anyone significant in your life die during your childhood? Later in life?
- What was that like for you at the time?
- How does that loss affect you now?
BONDS- How did your parents communicate with you when you were happy or excited?
- Did they join you in your enthusiasm?
- What happened when you were distressed or unhappy as a child?
- Did your father and mother respond differently to you during these emotional times? How?
- How do you communicate with your child now?
EXTENSIONS- Did anyone else besides your parents take care of you during your childhood?
- What was that relationship like for you? What happened to those people?
- What is it like for you when you let others take care of your child?
REFUGE- Were there positive relationships inside, or outside, your home that you could depend on
during difficult times during your childhood?
- How do you feel those connections benefited you then?
- How might they help you now?
IMPRESSIONS- How have your childhood experiences influenced your relationships with others as an
adult?
- How has your own childhood shaped the way you relate to your children?
Adapted with permission from Siegel DJ, Hartzell M: Parenting From the Inside Out: How a Deeper Self-Understanding Can Help
You Raise Children Who Thrive. New York, N.Y., Penguin Putnam, 2003.
This guide may be photocopied and distributed without permission to give to your patients and their parents. Reproduction
for any other purpose requires express permission of the publisher, Advanstar Medical Economics Healthcare Communications.
2005
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