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. Author manuscript; available in PMC: 2015 Dec 1.
Published in final edited form as: J Clin Nurs. 2014 Apr 18;23(0):3490–3500. doi: 10.1111/jocn.12600

Parental reflective functioning: Analysis and promotion of the concept for pediatric nursing

Monica Roosa Ordway 1, Lois S Sadler 2, Jane Dixon 3, Arietta Slade 4
PMCID: PMC4201893  NIHMSID: NIHMS573598  PMID: 24750548

Abstract

Aim

To identify the definitional elements of parental reflective functioning (RF) and develop a framework for nurses to apply this concept in their clinical work with families. Background: In recent years, researchers have concluded that parental RF is a key mechanism in the development of child attachment security leading to lifelong mental and physical health benefits. Despite its clinical relevance, little has been published in the nursing literature on this concept.

Design

Concept analysis.

Methods

The Walker and Avant (2011) method of concept analysis and the Whittemore and Knafl (2005) method of integrative review were used. A search of the literature published from 1989 to 2013 was conducted using edited texts and online databases - Scopus, CINAHL, PubMed, and PsychInfo. Among the 85 sources, 31 empirical studies, 17 book chapters, 32 review papers, and 5 case studies were identified concerning parental RF.

Results

The concept of RF, defined as the capacity to envision the mental states of self and other, was first described in 1989 by Fonagy. Slade (2005) expanded the concept specifically for parents (i.e. parental RF). Results of this concept analysis describe seven defining attributes and five antecedent conditions. Consequences of parental RF are related to a child’s attachment early in life and behavior later in life. A model case is provided to contextualize the concept. To date, there are three measures for parental RF.

Conclusions

While parental RF has been predominately featured in psychology and parenting interventions, the potential consequences of secure attachment and longer term children’s behavioral outcomes suggest that the concept has global implications for pediatric nurses and primary health care clinicians.

Relevance to clinical practice

Parental RF offers exciting and promising opportunities for pediatric health and new approaches for those who provide pediatric health care.

Keywords: parenting, concept, nurse-patient relationship, parental guidance, reflection

Introduction

Over the past decade, a growing number of research reports in developmental and clinical psychology have explored the notion that an individual’s capacity for reflective functioning (RF) is integral to the development of emotional self-regulation and early social relationships (Fonagy & Target, 1997; Slade, 2002, 2005). Early work describing RF referred to an adult’s capacity to envision his or her own mental states (defined as thoughts, feelings, intentions, desires, and beliefs) and the mental states of his or her parents (Fonagy, Gergely, Jurist, & Target, 2002). Subsequently, researchers expanded this work to specifically address the ability of parents to keep their child’s mental states in mind. This relationship-specific concept can be reliably assessed using a range of parental interviews (Slade, 2005). The aim of this paper is to review the literature on the concept of parental RF, currently published predominately in the psychology literature, and expand the concept for application to nursing. The Walker and Avant (2011) eight-step method is commonly used when a concept requires further development and this approach fits the purpose of expanding the concept of parental RF to nursing. Due to the diverse methodologies used in studies published on parental RF, the use of the integrative review method by Whittemore and Knafl (2005) was combined with the Walker and Avant (2011) method to provide a comprehensive understanding of the concept of parental RF.

Background

Researchers suggest that parental RF may enable parents to regulate the negative, intense emotions triggered by normal parent-child stresses (e.g. separation, tantrums, and aggression) (Schechter et al., 2005). Furthermore, there is a strong connection between parental RF and the child’s attachment organization, which develops over the course of the first year of life (Fonagy, 2001). Attachment is defined as an enduring emotional bond indicated by such child behaviors as seeking proximity to an attachment figure particularly during times of dysregulation resulting from fear or distress (Bowlby, 1969). The goal of the child is to develop a sense of security, safety, and protection. Attachment may be categorized as secure or insecure. In the absence of secure attachment, a child may be incapable of developing a full understanding of the minds of others (Fonagy, 2001). Slade, Grienenberger, Bernbach, Levy, & Locker (2005) found that parental RF was strongly correlated with infant attachment security; in addition, they found that maternal RF mediates the relationship between adult attachment (in the mother) and infant attachment. Specifically, the mother’s capacity to acknowledge and be curious about the mind of her child is the pathway through which her own attachment organization affects the child’s development of self and sense of belonging (Grienenberger, Kelly, & Slade, 2005; Slade, Grienenberger, Bernbach, Levy, & Locker, 2005).

Although research on RF has been predominantly conducted and reported in the field of psychology, it is a concept that offers rich potential for application in nursing research and clinical practice as a model of care within pediatric healthcare settings. Parents commonly seek assistance from nurses and primary care providers for help with their children’s behavior. They will often ask the question “what should I do?” and hope for concrete instruction from the clinician. Assisting parents in developing the capacity to consider their children’s mental states in relation to their behavior will help to increase parents’ understanding of their children’s thoughts, feelings and intentions underlying the behavior in question. Reflecting on their children’s behavior in this positive social-emotional manner provides a framework that can help parents learn that if they approach child rearing issues by trying to think about and understand their child’s mental states, then the question of what to do will become more clear (Slade, 2008).

Methods

The aim of this concept analysis was to identify the definitional elements of parental RF through an analysis of the history, attributes, measurement, and current research related to parental RF. The approach combined the Walker and Avant (2011) method of concept analysis and the Whittemore and Knafl (2005) method of integrative review to help define and further develop the concept as applied to nursing. The review and development of the concept focused on an application of the concept specifically to parents (Fawcett, 2012). A literature review was conducted from 1989–2013 using various search strategies. An online literature search used the keywords “reflective functioning” or mentalization (a term often used synonymously to RF), and parent, mother, or father, from the online databases, SCOPUS, CINAHL, PubMed, and PsychInfo. The literature search was limited to articles and reviews printed in the English language. The result yielded 133 articles and book chapters. Notably, only two of the citations were found in the nursing literature. Among the 133 citations, the review excluded dissertations and citations that did not involve a discussion of the parent-child relationship with respect to RF or mentalization. The final dataset included 85 source citations. The primary author researched three measurement instruments through personal communication with the instrument developers and review of the associated scoring manuals.

Combining the Walker and Avant (2011) with the Whittemore and Knafl (2005) method of concept analysis, the focus of this review was to understand how the concept of RF (with specific focus on parents) is defined in the predominately psychology-based literature, and to apply the definition of the concept for nursing practice. Analysis began with a summary of each source identified in the literature search. Data were extracted from primary sources with the following criteria: sample, type of report (empirical, theoretical/review, case study, or manual), and reference to the concept of parental reflective functioning. Among the 85 sources, 31 empirical studies, 17 book chapters from 13 books, 32 review papers, and 5 case studies were analyzed. Following Whittemore and Knafl (2005) the integrative review began with problem identification, literature search, data evaluation, and data presentation. The content analysis included data evaluation which led to the development of categories based upon the concept analysis method of Walker and Avant: attributes of parental RF, antecedents to the development of parental RF, consequences of parental RF, and measurement and research involving parental RF. Data were displayed in a table for comparison across the various primary sources. There was an iterative process involved in comparing the categories among the sources. This process of data visualization and comparison described by Whittemore and Knafl (2005) was particularly useful in discerning between the antecedents and attributes of the concept of parental RF as described in the Walker and Avant (2011) method. For example, the review articles were most useful in identifying the antecedents of parental RF while the empirical studies and instrument manuals (see Slade, Bernbach, Grienenberger, Levy, & Locker, 2005; Slade, Patterson, & Miller, 2007) provided more data on the defining elements/attributes of the concept. The last phase in the data analysis was to draw conclusions and verify congruency among the primary sources. The presentation includes a description of the results and a model case of the concept as suggested by the Walker & Avant (2011).

Results

Origin of the Concept

RF is thought to be a manifestation of mentalization, which refers to an imaginative capacity that allows one (explicitly and/or implicitly) to envision the mental states of the self and others. Mentalization theory (of which RF research is a part) grew out of attachment theory, cognitive psychology and psychoanalytic theory (Fonagy et al., 2002). Mentalization is said to be “the most fundamental common factor among psychotherapeutic treatments” (p. 1) and much of the theory came from the joint effort of psychiatrists and psychologists to address the complicated needs of patients with personality disorders (Allen et al., 2008). The concept of parental RF first appeared in the literature in the early 1990s when researchers, interested in understanding the intergenerational transmission of attachment patterns, began to examine the parental capacities that might lead to an infant’s secure attachment (Fonagy, Steele, Steele, Moran, & Higgitt, 1991). Fonagy and his colleagues proposed that RF allows a parent to hold a child’s affect in mind, anticipate their physical and emotional needs, adapt to these needs, and help their child to regulate themselves, and thus create the context for security (or, conversely, insecurity). Slade (2005) formally introduced the concept of parental RF to include the parent’s capacity to mentalize about self and child.

Bowlby (1969) states that children are not born knowing how to behave. The tools needed by children to understand their lives are developed through learning, specifically learning by observing and imitating mothers or primary caregivers. Winnicott (1971) also believed that a child’s early learning comes from the mother and suggested that, for a baby, “the precursor to the mirror is the mother’s face” (p. 149). The roots of RF originate in the child’s earliest relationships, in which their thoughts and feelings are held in mind by the parent and thus made real and manageable within the framework of the interaction. In this way, the attachment relationship provides the context for the development of the capacity to mentalize. Fonagy et al. (1995) suggest that secure parents are better able to help their children regulate their affect and thus secure parents foster their children’s security. This secure base is thought to provide the foundation for the development of children’s own RF and subsequently their capacity for the development of secure relationships with others; it is in this way that RF is transmitted intergenerationally (Fonagy et al., 1995).

Uses of the Concept

The application of parental RF is predominantly found in programs aimed at helping parents become more sensitive and attuned parents. These programs began in the early 2000’s - about a decade after the introduction of the concept of reflective functioning. A review of programs utilizing the concept of parental RF resulted in the following list: Minding the Baby® (Ordway et al., 2014; Sadler et al., 2013; Slade, Sadler, & Mayes, 2005), Mindful Parenting (Reynolds, 2003), the Mothers and Toddlers Program (Suchman et al., 2010), Short-term Mentalizing and Relational Therapy (SMART) (Fearon et al., 2006), Reflective Parenting Program (Grienenberger, Denham, & Reynolds, in press), and New Beginnings (Baradon, Fonagy, Bland, Lenard, & Sleed, 2008) (Table 1). The foundation of these parenting intervention programs is the belief that enhancing parents’ capacity for RF as a way of understanding their children’s mental states, aids in developing healthy parent-child relationships throughout the developmental trajectory of their relationships. Among the six identified programs, three have been evaluated empirically.

Table 1.

Parenting Programs using Parental RF

Parenting Program Child’s age Location/Setting Research/Evaluation Goals Length of Program
Minding the Baby (Ordway et al., 2014; Sadler et al., 2006; Sadler et al., 2013; Slade, Sadler, et al., 2005) Prenatal-2 years old Home visitation in New Haven, CT Research

  • Enhance mothers’ parental RF

  • Promote secure infant attachment

  • Improve maternal health and life course outcomes

  • Positively influence the health as well as emotional and physical development of the baby

  • Weekly home visits to coach new mothers to mentalize and reflect on their babies as their provide routine daily care and nurturing

 27 months
Mindful Parenting (Reynolds, 2003) Infants grouped by age (no more than 4 months apart) 3 months – 3 years Evaluation

  • Slow down and observe their child for 20 minutes

  • Reflect and discuss observations and the emotional experience with the group

  • Flexible responsiveness

 8+weeks
Mothers and Toddlers Program (Suchman et al., 2010) Birth to 36 months children of drug abusing mothers Substance abuse clinic New Haven, CT Research

  • Enhance maternal ‘reflective functioning’

  • Encourage a balanced psychological representations of the child

  • Increase knowledge of the child’s developmental capacities

  • Indirectly target maternal and child behavior and maternal psychosocial adjustment

 12 weeks
SMART (Fearon et al., 2006) Children and adolescent England Evaluation

  • Address the processes that limit children and families in their reflective capacities

  • Teach parents the “curious stance”

 6 weeks
Reflective Parenting Program (Grienenberger et al., in press) 2–6 years old Southern California Group session workshops for parents and professional training programs Research

  • Better understand their children’s mental states that influence and motivate their behaviors

  • Increase communication skills with their children

  • Improve their capacity to regulate their children’s emotions

  • Gain control and understanding over difficult parent-child interactions

  • Support healthy parent-child attachment

 10 weeks for parenting program; Professional programs vary
New Beginnings (Baradon et al., 2008) Infants of incarcerated mothers Prisons in England Research

  • Work directly with the baby’s attachment needs

  • Mirror emotional states of the baby

  • Verbalize experience and anxieties that are seen or assumed in the baby

  • Create intersubjective connectedness through play

 8–2 hour sessions over four consecutive weeks
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Minding the Baby® (MTB) has been in place since 2002 and pilot findings have begun to demonstrate positive outcomes in maternal RF, parent-child relationships, infant attachment, and maternal life-course outcomes among young first-time mothers who struggle with poverty, histories of trauma, and few social supports (Sadler, Slade, & Mayes, 2006; Sadler et al., 2013; Slade, Sadler, et al., 2005). In this study, the highest risk mothers (those with less education and the lowest levels of RF at intake) showed a significant increase in RF over the course of the intervention. In a recent follow-up study, mothers who participated in the MTB program reported significantly fewer behavior problems in their children 1–3 years post-intervention (Ordway et al., 2014). In England, researchers conducting the New Beginnings cluster randomized trial have reported that parental RF decreased over time among the control group mothers and not among the intervention mothers (Sleed, Baradon, & Fonagy, 2013). The Mothers and Toddlers Program (MTP) has resulted in an increased capacity for parental RF, higher caregiving sensitivity, and better caregiving behavior among the drug-abusing mothers involved in the program (Suchman, DeCoste, Ordway, & Mayes, 2012; Suchman et al., 2010). Pajulo and colleagues (2012) in Finland have also focused on enhancing parental RF as a way to mitigate the effects of parental drug use on the parent-child relationship.

Elements of Definition

There were seven elements of RF that emerged from the content analysis of the parental RF literature reviewed (Figure 1). All of these elements involve an awareness of one’s own mental states as separate from those of others. A critical element of parental RF is the maintenance of a curious stance by the parent (Fearon et al., 2006; Rutherford, Goldberg, Luyten, Bridgett, & Mayes, 2013; Slade, 2007). A curious stance is defined by three characteristics. First, one must be interested in the thoughts and feelings of another and remain open to alternative perspectives that may be held by another person. Second, one must be open to the possibility that one’s own thinking may be expanded or elaborated upon by another’s thoughts and feelings (Fearon et al., 2006). Third, the reflective individual with genuine curiosity, must resist the temptation to make assumptions or hold prejudices about another’s thoughts, while at the same time, remaining open to what may be discovered in the process (Bevington, 2010; Slade, 2007).

Figure 1. Parental Reflective Functioning Concept.

Figure 1

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Content analysis results including the antecedent conditions, definitional elements, and measures of the concept of parental RF. Adapted from Bevington, D. (2010). http://mbft-manual.tiddlyspot.com/ Retrieved December 9, 2010, 2010

The second element of successful parental RF is the assumption that human minds are opaque; a parent may not know why a child is behaving in a certain way, but the parent remains curious about the behavior (Slade, 2007). The parent needs to understand that he or she has a limited ability to truly know what is in another’s mind and uncertainty can occur. The third element of parental RF is non-compulsive contemplation and reflection, which involves parents being relaxed while mentalizing without forcing excessive control over the situation or their children, and avoiding excessive need for details. Perspective taking, a fourth component of parental RF, refers to the parent’s understanding that shared experiences may be thought of or perceived differently by their child (Lena, 2013). The fifth element, impact awareness, involves parents’ understanding that their own actions, thoughts, and feelings may influence their children (Rosenblum, McDonough, Sameroff, & Muzik, 2008). Parent’s inherent trust that their children’s thoughts and feelings are not a significant threat to them as parents is also crucial (Bevington, 2010). Lastly, effective parental RF requires an awareness or preview of their children’s development (Slade, 2005; Suchman, Pajulo, Kalland, DeCoste, & Mayes, 2012). Understanding the mental state of another person is challenging, especially in very young pre-verbal children. However, according to Slade (2005), parental RF can only occur within the context of development. For example, it is helpful for parents to have an accurate developmental understanding of why a 9-month old infant is throwing her food or a 3-year old child is experiencing a temper tantrum in the middle of a department store. A parent’s functional use of the attributes described above will result in effective parental RF and an enhanced parent-child relationship.

Antecedents

There are five antecedents that precede the development of effective parental RF (see Figure 1). Understanding the minds of others, as well as the dynamic interconnection of minds is inherently challenging, particularly in the face of distress. Parents often do not fully appreciate the impact of their thoughts and feelings on the child, or the child’s upon them, especially when they are upset. Self and affect regulation, typically an outgrowth of secure attachment, make it possible to remain organized in the face of these challenges, and to do the work of mentalizing (Fonagy & Target, 1997). However, while self-regulation is part of normal development, adverse experiences often limit a person’s capacity for regulation. Indeed, many of the individuals targeted by the interventions described here struggle to regulate their affects, impulses, and sense of self and, thus, RF. Regulation and RF are highly interconnected, and indeed as RF improves, so do self and affect regulation. In this way, regulation – while optimally an antecedent of the development of mentalization – may in fact be an outgrowth of enhanced capacities for reflection.

Parents’ capacity to mentalize or reflect about other key relationships in their lives (e.g. their relationship with their parents) prior to child rearing also influences their ability to mentalize about the child (Fonagy et al., 1995; Slade, Grienenberger, et al., 2005). Two key components of mentalization are an awareness of the nature of mental states and the capacity to connect feelings to behavior (Slade, 2005). These components must be present together as the capacity for RF involves the ability to recognize mental states and link mental states to behavior in meaningful and accurate ways (Slade, 2005).

Empathy, which can be thought of simply as the capacity to feel what someone is feeling, is an aspect of RF. But RF also refers to the capacity to make inferences about mental states, thus not only feel what someone is feeling, but also to think about what they are feeling and its potential effects (on behavior, other feelings, etc.).

Consequences

A parent’s capacity to reflect on their children’s mental states plays an important role in the children’s formation of a secure attachment and ultimately to the child’s capacity to mentalize (Fonagy, 2000; Fonagy et al., 1995; Slade, Grienenberger, et al., 2005). In addition, the enhancement of parental RF has been associated with improved parent-child relations in interventions developed for high risk mothers (Sadler et al., 2013), drug-addicted mothers (Suchman et al., 2010), and incarcerated mothers (Baradon et al., 2008; Sleed et al., 2013). Parental RF has also been described as a supportive factor for violence-exposed mothers in the formation of more balanced and integrated maternal mental representations of their children (Schechter et al., 2005), a protective factor in the development of children’s eating disorders (Rothschild-Yakar, Levy-Shiff, Fridman-Balaban, Gur, & Stein, 2010), and a facilitating factor in mothers’ sensitivity towards their child (Borelli, West, Decoste, & Suchman, 2012; Fonagy & Target, 1997). In a study by Grienenberger and colleagues (2005) that examined the relationship between maternal RF, mother-infant affective communication, and infant attachment the researchers found an inverse relationship between maternal RF and maternal-infant disruptive communication.

A critically important negative outcome of poor parental RF is the formation of insecure infant attachment (Slade, Grienenberger, et al., 2005). Additional negative consequences include a child’s experiencing unmet needs and feelings of not being understood. A parent who acts on false assumptions about the child’s mental states will cause confusion for the child and is not likely to be able to understand and meet the child’s needs. Additionally, a child may become aversive, withdrawn, hostile, or coercive as a result of the intense emotion resulting from the child’s feeling misunderstood by his or her parent (Fearon et al., 2006). The consequences of unsuccessful mentalization may result from either impaired parental RF or misuse of parental RF for coercive reasons.

Model case

The following vignette, involving a mother describing what it feels like to discipline her 18 month old daughter, exemplifies effective parental RF:

Pediatric Nurse Practitioner (PNP): So, your daughter is 18 months old now and we should talk about developmentally appropriate approaches to discipline. What are your thoughts on this topic?

Mother: Well, I find this stage really challenging and I often wonder what she is thinking [curiosity]. I can really see that she is starting to test me and sometimes it is really frustrating [recognition of mother’s own mental state]. She will often throw things and get mad and I am not sure why she feels that way or acts that way [opacity]. I think that sometimes she is trying to get my attention, especially if I am on the phone and my attention is diverted from her. I mean, I have to work and I am lucky to be able to work from home, but I can see how she does not understand that [perspective taking]; she just thinks ‘Mom is home and I want to play with her’ [perspective taking and forgiveness]. There are times, however, when I feel that she does need direct discipline, for example, when she hits or bites. If she does that, I immediately remove her from the situation and sit her down for a one minute time-out to let her know that hurting people is not OK [impact awareness]. She does not like to be in time-out and I feel badly and worry that she is mad at me, but soon afterwards, we are usually back to smiles and fun [trusting attitude].

PNP: You certainly seem to understand that the foundation of discipline is to teach children and it is not meant to be a threatening experience for either one of you. A large part of discipline is attaching meaning to behavior; you seem to do that well and this capacity to reflect on her thoughts and feelings as they relate to her behavior will really strengthen your relationship with one another.

This example of a mother’s capacity for parental RF highlights her ability to envision her own mental states as well as her daughter’s and make the connection between mental states and behavior. While some parents will sound self-reflective, it is the ability to link mental states with behavior that defines parental RF and enhances parent-child relationships. For example, the following description of the mother’s experience with her daughter illustrates her own capacity for self-reflection but falls short of linking mental states with behavior:

Mother: Well, I find this stage really challenging. I can really see that she is starting to test me and it is really frustrating. She will often throw things and get mad and I feel frustrated. I mean, I have to work and I am lucky to be able to work from home, but she does not understand - she just wants my attention all the time. I put her in time out sometimes and she does not like to be in time-out and I feel badly and worry that she is mad at me, but there are times when she needs to be disciplined.

The healthcare provider may say:

PNP/Nurse: It sounds like you are noticing some important developmental changes in your daughter. Children at this age are beginning to experience new emotions like frustration, possessiveness, guilt, and excitement. Because they do not yet have the vocabulary to label their feelings, this is a great opportunity to help them to name their feelings as a way of helping them to understand what they are feeling. What do you imagine your daughter is thinking when she gets mad when you are not paying attention to her?

In this example, the PNP assists the mother to become more reflective by taking a stance of curiosity and integrating child development information during the visit.

Measures of Parental RF

There are three validated measures of parental RF found in the literature. The Pregnancy Interview (PI) contains questions and probes to assess parental RF prior to birth (Slade, 2003) and the Parent Development Interview (PDI) (Slade et al., 2007) and Parental Reflective Functioning Questionnaire-1 (PRFQ) (Luyten et al., 2009) apply to parents after the birth. Slade (2007) developed the Pregnancy Interview, which is administered during the third trimester of a woman’s pregnancy. The interview is meant to elicit a conversation with the mother regarding a variety of mental states related to her emotional experience with pregnancy and her expectations, hopes and fears regarding her future relationship with her child. The scoring system is based on the same system used to score the PDI (see Slade, Bernbach, et al., 2005) and assesses three principle areas of interest: the mother’s developing representations of her baby, her parental representations, and her state of mind. The PI is a semi-structured clinical interview with 22 questions. Interviews are transcribed verbatim and scored for parental RF by trained coders. Reliability testing for the PI coding is similar to PDI (see below). The raters are trained by senior coders using a manual and practice transcripts previously coded by senior coders. Coders need to achieve at least 80% inter-rater agreement.

The Parent Development Interview (PDI) (Slade, Aber, Berger, Bresgi, & Kaplan, 2003) is a 20-item semi-structured clinical interview that assesses parents’ capacity to envision the mental states of themselves and their children. The 45–60 minute interview contains questions and probes designed to elicit conversation that allows the parent to think reflectively about her child, her internal experience of parenting, and her relationship with her child. Interviews are transcribed verbatim and scored for parental RF by trained coders. RF is scored on an eleven point scale (−1 to +9) with a score of 4 or greater indicating the capacity for RF (Slade, Bernbach, et al., 2005). Initial studies have reported acceptable levels of reliability and validity as well as a relationship between RF and adult attachment, child attachment, and parental behavior both in normal and drug using samples (Aber, Belsky, Slade, & Crnic, 1999; Grienenberger et al., 2005; Slade, Belsky, Aber, & Phelps, 1999; Slade, Bernbach, et al., 2005). Average scores on the PDI have been reported as 6 among mothers parenting in low stress environments and 4 among mothers living in poverty (Grienenberger et al., 2005; Levy, Truman, & Mayes, 2001; Slade, Grienenberger, et al., 2005).

The PDI offers clinically rich and detailed information but it is time consuming and the scoring can be expensive. Several researchers have developed a brief assessment of parental RF, the Parental Reflective Functioning Questionnaire-1 (PRFQ-1) (Luyten et al., 2009). The PRFQ contains 39 statements written to assess a parent’s understanding, curiosity, or disavowal of mental states and the relationship between mental states and behavior. The parent is instructed to rate the statements on a 7-point likert scale, where “1” represents “strongly disagree” and “7” represents “strongly agree”. The PRFQ has three subscales: a. pre-mentalizing modes subscale, b. not recognizing opacity subscale, and c. parental interest and curiosity subscale. Examples from the questionnaire include such statements as: “When my child is fussy he or she does that just to annoy me [pre-mentalizing modes subscale]” and “I always know why my child acts the way he or she does [not recognizing opacity subscale]” and “I like to think about the reasons behind the way my child behaves and feels [parental interest and curiosity subscale].” The psychometric properties, including validity of the PRFQ-1 are being evaluated (Luyten et al., 2009). A revised version of the PRFQ-1 with fewer items is presently in development (Luyten, 2010).

Discussion

Slade (2005) states that the capacity for parental RF emerges within the parent-child relationship and that “the centrality of the parent as mediator, reflector, interpreter, and moderator of the child’s mind cannot be overemphasized” (p. 273). A major challenge to parenting is the affect dysregulation that occurs in the child when his or her needs are not met with an appropriate response from the parent, and result in severe temper tantrums, explosive behavior, mood swings, and aggression. The concept of parental RF, which includes parents’ capacity to mentalize about their children’s thoughts and feelings related to their behavior, provides a parent-child paradigm that is more likely to result in secure attachment and affect regulation in the child (Fonagy et al., 2002). Further dissemination of this concept into the field of pediatric healthcare may offer clinicians an innovative approach to address the behavioral concerns and increasing mental health needs of children and families. Furthermore, the application of this concept is appropriate for use when counseling parents with behavioral concerns as well as when offering anticipatory guidance related to child development.

Nurses and primary care clinicians are well trained in child development and can assist the parents in understanding the behavior from a developmental perspective and also trusting that the disruptions in the parent-child relationship are repairable. Parents commonly approach their child’s healthcare provider with requests for advice on child behavior questions or problems. The American Academy of Pediatrics (AAP) has recently acknowledged advances in biological, behavioral, and social science research that suggest moving beyond thinking about pediatric healthcare in terms of disease screening and treatment, but rather towards an ecobiodevelopmental model that emphasizes how early experiences and environmental factors influence biology and genetics and together they affect health and development (Garner et al., 2012). The concept of parental RF provides a framework for clinicians to shift from a behavior “management” approach to a behavior “understanding” approach. This newer approach moves away from identifying and labeling the behavior as a problem within the child and towards identifying the issue as a disruption within the parent-child relationship.

Conclusion

By incorporating a mentalizing stance, primary care clinicians may provide a holding environment for the parent-child relationship and consider the patient to be the relationship and not just the child. By remaining curious about the behavior in question, the clinician may inquire about how the behavior is experienced by both the parent and the child allowing for the development of perspective taking and understanding of the opaqueness of another’s mind. The goal of this approach is understanding. Through this process parental advice is not focused on telling the parent what to do, but rather how to be with their child (Gold, 2011).

Relevance to clinical practice

The AAP has challenged pediatric clinicians to “develop their expertise in assessing the strengths and stresses in families, in counseling families about strategies and resources, and in collaborating with others in their communities to support family relationships” (Gorski et al., 2001, p. 195). The concept of parental RF offers pediatric health care providers a framework to accomplish these vital tasks with parents by challenging the providers to “activate patient’s ability to evolve an awareness of mental states and thus find meaning in their own and other people’s behavior” (Fonagy, 2000, p. 1129). The concept of parental RF represents a paradigm shift away from standard pediatric health care advice typically focused on fixing the behavioral problems presented by parents, to developing a stance of curiosity about children’s behavior and the emotions, attitudes, and feelings related to the problematic behaviors (Gold, 2011). This paradigm shift focuses on key aspects of parental RF, namely the capacity to envision mental states in the self and other (particularly the child) and to understand behavior in light of mental states. The new paradigm offers exciting and promising opportunities for pediatric health and new approaches for those who provide pediatric health care.

What does this paper contribute to the wider global clinical community?

  • Elaborate the concept of parental RF to apply to nursing

  • Highlight an approach to enhance parent-child relationships within pediatric healthcare settings

Acknowledgments

Financial Support: NIH/NINR 1F31NR011263-01; NIH/NICHD R01 HD057947; NIH 5T32NR008346-06; Evelyn Anderson Scholarship; Dr. Lorraine G. Spranzo Memorial Scholarship; Sigma Theta Tau-Delta Mu Grant; Nurse Practitioner Health Care Foundation/Community Innovations Award; Jonas Nurse Leaders Scholar Program

We would like to thank Nancy Close, PhD, Linda Mayes, MD, Robin Whittemore, PhD, APRN, FAAN, and Nancy Suchman, PhD for their editorial assistance and conceptual guidance.

Footnotes

Author Contributions

The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_1author.html), as follows:
  1. substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data,
  2. drafting the article or revising it critically for important intellectual content, and
  3. final approval of the version to be published.

Contributor Information

Monica Roosa Ordway, Email: monica.ordway@yale.edu, Assistant Professor, Yale University School of Nursing, Yale University West Campus, PO Box 27399, West Haven, CT 06516-7399, 203-737-5354.

Lois S. Sadler, Email: lois.sadler@yale.edu, Professor, Yale School of Nursing, Yale Child Study Center, Title IX Coordinator, Yale School of Nursing, Yale University West Campus, PO Box 27399, West Haven, CT 06516-7399, 203.737.2561.

Jane Dixon, Email: jane.dixon@yale.edu, Professor, Yale University School of Nursing, Yale University West Campus, PO Box 27399, West Haven, CT 06516-7399, 203-737-2234.

Arietta Slade, Email: arietta.slade@yale.edu, Clinical Professor, Yale Child Study Center, Co-director, Minding the Baby, Mailing address: 8 Hodge Road, Roxbury, CT 06783, Phone: 860-350-8789.

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