The Clinical Challenge of Mentalization-based Therapy with Children Who are in “Pretend Mode”

ABSTRACT

The “pretend mode” is one of the so-called “pre-mentalizing modes of thinking”, which were first introduced by Target and Fonagy over 20 years ago. In a series of papers about play and reality, “pretend mode” thinking was understood as a mode of pre-mentalizing thinking which is typical in the early years, but which can reappear in a more problematic way in adults. Although the concept of pretend mode was first introduced in a developmental context, as a clinical term it has primarily been discussed in the context of adult or adolescent psychotherapy. This paper suggests that the pretend mode is a valuable clinical concept for therapists working with school-age children, but that its use in this context needs some clarification. After reviewing how pretend mode has been understood as a normal part of early development, this paper goes to demonstrate the various roles of pretend mode in clinical work with school-age children and sets out a number of clinical strategies that may be used in therapeutic work.     

Japanese and British Children's Understanding of the Social Function of Pretend Crying

The purpose of this study was to investigate cross-cultural differences in children's understanding of pretend crying. Five- and 6-year-olds from Japan and the United Kingdom (N = 71) heard two hypothetical stories in which the protagonist of each story pretended to cry in front of another person. Children were asked about the appearance–reality distinction of pretend crying, the other character's thoughts and behavior, and the children's own moral judgment of pretend crying. Cultural differences were found in their understanding of the social function of pretend crying. Japanese children judged that pretend crying elicited another's concern and prosocial behavior more than British children. There were no significant differences in appearance–reality distinction or moral judgments between Japanese and British children. All participants successfully discriminated between pretend crying and real crying, and most participants judged pretend crying as “not good” behavior. These results suggested that Japanese children might be more expected to be sensitive to others’ feelings, and that such cultural differences in communication and socialization lead to different patterns in expectations of the social consequences of pretend crying.     

Holding in Mind Conflicting Information: Pretending,Working Memory,and Executive Control

Preschoolers' recall of the true and pretend identities of an object in pretense was examined along with a battery of executive functioning and working memory tasks. We expected that children would retain separate identities, as well as a link between them, after observing episodes of pretense, and that memory for pretense would be related to executive functioning and working memory. Children (aged 37–59 months) recalled the true identity of an object better than its pretend identity. Children's recall of at least one identity was correlated with executive functioning and “dual” working memory tasks, independent of age and verbal ability. Memory for both identities was only correlated with executive functioning. The findings are generally supportive of the claim that children form separate representations of the true and pretend identities of objects. The results extend findings of well-established relations between false belief tasks and executive functioning and working memory.     

A critical commentary on follow-up studies and “desistance” theories about transgender and gender-nonconforming children

ABSTRACT

Background: It has been widely suggested that over 80% of transgender children will come to identify as cisgender (i.e., desist) as they mature, with the assumption that for this 80%, the trans identity was a temporary “phase.” This statistic is used as the scientific rationale for discouraging social transition for pre-pubertal children. This article is a critical commentary on the limitations of this research and a caution against using these studies to develop care recommendations for gender-nonconforming children.

Methods: A critical review methodology is employed to systematically interpret four frequently-cited studies that sought to document identity outcomes for gender-nonconforming children (often referred to as “desistance” research).

Results: Methodological, theoretical, ethical, and interpretive concerns regarding four “desistance” studies are presented. The authors clarify the historical and clinical contexts within which these studies were conducted to deconstruct assumptions in interpretations of the results. The discussion makes distinctions between the specific evidence provided by these studies versus the assumptions that have shaped recommendations for care. The affirmative model is presented as a way to move away from the question of, “How should children's gender identities develop over time?” toward a more useful question: “How should children best be supported as their gender identity develops?”

Conclusion: The tethering of childhood gender diversity to the framework of “desistance” or “persistence” has stifled advancements in our understanding of children's gender in all its complexity. These follow-up studies fall short in helping us understand what children need. As work begins on the 8th version of the Standards of Care by the World Professional Association for Transgender Health, we call for a more inclusive conceptual framework that takes children's voices seriously. Listening to children's experiences will enable a more comprehensive understanding of the needs of gender-nonconforming children and provide guidance to scientific and lay communities.     

The Expression of Femininity in the Male

SUMMARY

This article by Virginia Prince, writing as Virginia Bruce, was first published in The Journal of Sex Research, vol. 3, no. 2, 1967, pp. 129–139. Prince distinguishes sex from gender. Sex is the biological division we share with other animals. Gender-the division of masculine and feminine-is a human invention. Socialisation entails children being pushed into one or other gender direction and the suppression of characteristics of the “opposite” gender. Transvestism is the expression in males of suppressed femininity. The “true transvestite” is a “FemmePersonator” who “personates,” that is, makes a real person out of and brings to life his feminine self. Questionnaire data is used to reject ideas that true transvestism is a sexual deviation, and true transvestites are psychiatrically disturbed.     

Is young children’s recognition of pretense metarepresentational or merely behavioral? Evidence from 2- and 3-year-olds’ understanding of pretend sounds and speech

When young children observe pretend-play, do they interpret it simply as a type of behavior, or do they infer the underlying mental state that gives the behavior meaning? This is a long-standing question with deep implications for how “theory on mind” develops. The two leading accounts of shared pretense give opposing answers. The behavioral theory proposes that children represent pretense as a form of behavior (behaving in a way that would be appropriate if P); the metarepresentational theory argues that children instead represent pretense via the early concept PRETEND. A test between these accounts is provided by children’s understanding of pretend sounds and speech. We report the first experiments directly investigating this understanding. In three experiments, 2- and 3-year-olds’ listened to requests that were either spoken normally, or with the pretense that a teddy bear was uttering them. To correctly fulfill the requests, children had to represent the normal utterance as the experimenter’s, and the pretend utterances as the bear’s. Children succeeded at both ages, suggesting that they can represent pretend speech (the requests) as coming from counterfactual sources (the bear rather than the experimenter). We argue that this is readily explained by the metarepresentational theory, but harder to explain if children are behaviorists about pretense.     

Size-distance perception in preschool children.

Children between three and six years of age matched the “apparent” and “real” size of familiar and unfamiliar objects 3, 6, or 9 feet away. Prior to the experimental sessions, the children were divided into two groups: (a) those who could distinguish the phenomenal from the real sizes of the arcs in the Jastrow illusion (the “Realists”) and (b) those who could not (the “Phenomenalists”). The results suggest that all children perceived size constancy up to distances of 9 feet solely on the basis of visual information.     

Young children understand multiple pretend identities in their object play

This set of studies examined the ability of 3‐year‐olds to conceptualize multiple pretend identities with objects. Rather than relying on verbal response measures, as has been done in the past, children's creative and inferential pretend actions were used as indicators of their understanding. The common structure to all four studies was that children were confronted with one pretend scenario, moved to a second pretend scenario and then back again to the first. Children proficiently tailored their pretence to an object whose pretend identity changed between scenarios despite being less able to name each identity. Thus, using an inferential action methodology, these studies provide early and particularly convincing evidence that children can track the multiple pretend identities of objects.     

Influences of schooling and urban-rural residence on gender differences in cognitive abilities and academic achievement

A total of 1151 children from indigenous Quechua-speaking families residing in squatter settlements of the city and in two remote rural environments in Peru was given a battery of 16 tests of academic achievement and cognitive abilities. The former tests assessed reading and mathematics achievement and the latter tapped a broad range of cognitive functions. Children were enrolled in first, second, or third grade or did not attend school. “Younger” children were from 6 to 8 years old, and “older” children were from 9 to 12 years old. Large differences in cognitive functioning were associated with attendance at school, grade in school, age, and urban-rural residence. Gender was found to account for less than 5% of the variance in children's performance on cognitive and academic tasks. Gender effects appeared to decline with increased amount of schooling. This was reflected in interactions involving gender and schooling and in a greater number of significant gender effects for children who did not attend school or were in first grade. The results present a complicated picture of various interactional effects of task, location, age, and schooling on the detected gender differences in cognitive abilities and academic achievement.     

Israeli kindergarten children's gender constancy for others' counter‐stereotypic toy play and appearance: the role of sibling gender and relative age

To test divergent theoretical predictions as to the impact of having a younger or older, same‐sex sibling or opposite‐sex sibling on other gender constancy, Israeli kindergarten children in two‐child families responded to a gender constancy task in which a male and female picture target engaged in counter‐stereotypic toy play and adopted counter‐stereotypic appearance. Children were also asked whether the target child could change sex at will and to explain the difference between boys and girls. Relative age of sibling, both independently and in interaction with participant sex, was associated with greater gender constancy in the face of counter‐stereotypic toy play. Relative age of sibling and sibling sex was independently associated with greater gender constancy in the face of counter‐stereotypic appearance. In both cases, children with a younger sibling evidenced greater gender constancy. Boys, especially ones with a male sibling, referred most explicitly to target's birth sex in accounting for his or her being unable to change sex at will. Genital and anatomical differences between boys and girls were cited more often by children who referred explicitly to target's birth sex and had a younger sibling. The results were discussed in the context of theories of gender development and the socialization of gender within the family. Copyright © 2008 John Wiley & Sons, Ltd.     

Pokémon: Exploring the Role of Gender

In Study 1 college students (47 men, 104 women) watched Pokémon cartoons, and afterward they rated one of four trainers (persons who train creatures called Pokémon) on 28 characteristics. James, the male “bad” trainer, was rated lowest of four trainers on “masculine” traits including strength, assertiveness, certainty, and being a leader. Jesse, the female “bad” trainer, was rated as sexiest and most aggressive. In Study 2 sixty-two elementary school children (28 girls, 34 boys) were individually interviewed. Fewer than 50% of the children could name a female Pokémon, and participants were more likely to choose a boy than a girl as a favorite trainer. Male Pokémon and trainers may be more central to the cartoon, and counter-stereotypical gender portrayals may be one way to portray a “bad” character even more negatively.     

儿童性别恒常性发展

性别恒常性发展是儿童性别认知发展的关键问题,该文介绍了这一领域研究的最新进展。儿童获得性别恒常性是一个渐进的过程,在6、7岁时已完全获得,儿童的认知发展水平、文化背景、社会经济地位、教育影响性别恒常性发展,性别恒常性与性别类型活动存在相关,但关系复杂。最后,作者对该领域的研究趋向做出了展望。     

The effects of books and gender constancy development on kindergarten children's sex-role attitudes

The effects of symbolic models and level of gender understanding on children's sex-role attitudes was investigated. Kindergarten boys and girls heard and discussed books whose characters depicted either traditional or nontraditional sex-role behaviors. Attitudes toward males and females were measured before and after the picture book treatment. When the study began, children were screened for gender understanding so that half were able to make other-gender constancy judgments, and half were not able to make other-gender constancy judgments. Prior to the treatment, boys and children who had attained gender constancy were slightly negative toward males and neutral toward females, whereas girls and children who had not attained gender constancy were very negative toward males and very positive toward females. Exposure to traditional books had the effect of enhancing attitudes toward males and decreasing attitudes toward females. Exposure to nontraditional books had the opposite effect of decreasing attitudes toward males and enhancing attitudes toward females. The effects of the picture book treatment on attitudes toward females were more pronounced for children who had attained other-gender constancy. Implications for social learning and cognitive-developmental theories of sex-role development are discussed.     

学前儿童性别恒常性的发展

采用改进的访谈方法,考察了3、4、5、6岁儿童的性别恒常性的发展。结果表明：3、4岁儿童已获得性别认同的能力,4、5岁儿童逐步获得性别稳定性的能力,5、6岁是性别一致性发展的快速期,大多数的6岁被试儿童已获得性别恒常性。研究还发现,在提示条件下,各年龄获得性别恒常性的被试人数大大增加;儿童对自己的性别恒常性的认知发展早于对他人,但这一差异仅表现在3岁儿童身上     

Cognitive factors in the development of sex-typed preferences

This study considered how children coordinate their understandings of gender identity and sex stereotypes to produce sex-typed preferences. Sex-typed preferences and gender constancy were assessed at ages 4 through 8 years on a cross section of urban black and white children (N=819). Findings verified that sex-stereotyped preferences are highly developed among young children prior to the period when gender constancy is fully developed. Additionally, by age 5, most children accurately attributed sex-stereotyped preferences to peers of the opposite sex. A distinction was made between a sex stereotype and a same-sex bias as a basis for a sex-typed preference. Gender constancy was shown to strengthen the same-sex bias as a determinant of a sex-typed preference, but this effect was context specific. Under certain conditions sex-stereotyped knowledge constrained the same-sex bias as a determinant of preferential choice.     

Gender and computers. II. The interactive effects of knowledge and constancy on gender-stereotyped attitudes

A number of studies have failed to find that gender constancy (understanding that one's gender is permanent) predicts gender-typed attitudes and behavior. This study (run with a predominantly white sample) tests the hypothesis that gender constant children are motivated to master gender roles, but that how well they do so depends on their knowledge of gender stereotypes. We predicted that attitudes toward computer use (a stereotypically male activity) would be less positive only for 5–9-year-old gender constant girls who also had rich gender stereotypes. Predictions were confirmed, especially for girls whose constancy had recently increased. These data thus suggest that the clearest picture of gender role development emerges when both the unique and interactive effects of gender constancy and gender schema development are assessed. They also indicate that gender differences in computer attitudes can develop through self-socialization processes.This research was supported in part by research Grant No. R37 MH37215 and Research Scientist Development Award No. 00484 from the National Institute of Mental Health to the third author. The first two authors gratefully acknowledge the support of the James S. McDonnell Foundation. All authors would also like to thank Tom Alfieri, Faith Greulich, and Lisa Cyphers for their help at various stages of this project.     

Are children any more logical than monkeys on the five-term series problem?

Six-year-old children were tested on several versions of the five-term transitivity problem as used by B. O. McGonigle and M. Chalmers (1977, Nature (London), 267, 694–696) with squirrel monkeys as subjects. Both binary and triadic versions of the tests were administered in both verbal and nonverbal modes to help determine whether or not any major procedural differences between the monkey version and that used conventionally in research with children might account for the monkey's apparently nonlogical solution of the problem. The main result is that children showed very similar response profiles to that of monkeys in all the conditions used. In addition, “labeling”, direct seriation, and “association” post-tests suggest that nonlogical strategies can underwrite ostensibly impeccable transitive “reasoning” in child as well as monkey.     

Experimenter's Pantomimes Influence Children's Use of Body Part as Object and Imaginary Object Pantomimes: A Replication

Young children asked to pretend to use a series of absent objects typically pantomime by using a body part as the object (BPO) rather than by acting as if using an imaginary object (IO). This replication of Lyons's work (1983, 1986) examines whether different pretend contexts when requesting pantomimes influence children's use of IO and BPO pantomimes. Forty-three children aged 3;6 to 6;6 were asked to pretend to use 8 objects in 1 of 3 contexts: request, request after participating in an experimenter-provided imaginary context, and request after seeing the adult model the requested pretend action. The experimenter used IO pantomimes in the last 2 contexts. Children produced, on average, the most IO pantomimes in the modeling context, fewer in the imaginary context, and the fewest in the request context. Older children overall produced more IO pantomimes than did younger children; however, when pretend contexts were examined separately, ontogenetic differences in IO pantomimes were present for the request condition only. Externally directed actions resulted in more IO pantomiming than self-directed actions for only the youngest children.     

Effects of Contact on Children's Attitudes Toward Disability: A Longitudinal Study1

A quasi-experimental study was conducted on temporal effects of intergroup contact on nondisabled (ND) children's attitudes toward disability. Children from a mainstream primary school were involved in an integration program with children from a school for children with severe learning disabilities (SLD). ³ 3 Severe learning disabilities (SLD) is the term currently used in the U.K. to describe people who might formally have been described as having “severe mental handicap” or “severe retardation.” This term is interchangeable with “severe learning disabilities.”
Measures were administered 3 times over a period of 3 months to 26 integrating (experimental) and 24 nonintegrating (control) children. Social orientations in the experimental group became significantly more positive over time, while the control group showed little change. The experimental and control children initially categorized on the basis of gender and disability; subsequently the strategies of the experimental children were more idiosyncratic while the control children still used the same two dimensions.