Children referred to mental health services frequently experience a mixture of emotional and behavioural difficulties. Anxiety may coexist with anger, withdrawal with disruptive behaviour, or sadness with conflict at home and school. Many evidence-based treatments were developed around a single diagnosis, creating a mismatch between research and the complexity clinicians encounter in routine practice. Midgley et al. (2023) describe the Emotion Regulation in Children (ERiC tria), the first large randomised clinical trial designed to evaluate a brief form of Mentalization-Based Treatment for children aged 6–12 with co-occurring internalising and externalising difficulties. The intervention aims to strengthen children’s and parents’ ability to understand behaviour in relation to thoughts, feelings and intentions, seeking to improve emotion regulation within the child and across the parent–child relationship.
The limits of single-disorder thinking
Diagnostic categories can help clinicians organise information, communicate with other professionals and identify potentially appropriate treatments. However, co-occurring difficulties are common in clinically referred young people. Internalising experiences such as fear, low mood and withdrawal may interact with externalising behaviours such as anger, opposition or aggression. Research also suggests that these patterns cannot always be understood as separate conditions operating independently of one another (McElroy et al., 2018). Treatments developed for one disorder may consequently be an imperfect fit for young people experiencing several interconnected problems. Bearman and Weisz (2015) describe a range of responses to this challenge, including modular interventions and conceptually unified treatments targeting processes shared across diagnostic categories. The ERiC study adopts the latter approach and rather than selecting a treatment according to one primary diagnosis, it focuses on emotion regulation as a transdiagnostic mechanism that may contribute to both emotional and behavioural difficulties (Midgley et al., 2023).
Emotion regulation as a shared clinical target
Emotion regulation refers to the processes through which people recognise, manage and respond to emotional states. It comprises reducing overwhelming negative emotions, maintaining or increasing positive emotional experiences, tolerating distress and selecting responses that fit the situation. Difficulties in this area can take different forms: a child may become rapidly overwhelmed, struggle to identify what they feel, suppress emotion until it emerges explosively, repeatedly focus on distressing thoughts, or rely on avoidance. Weissman et al. (2019) found that emotion-regulation difficulties, including heightened emotional reactivity and rumination, helped explain the longitudinal relationship between childhood maltreatment and broad psychopathology. Emotion dysregulation may therefore represent one pathway through which trauma contributes to apparently diverse clinical outcomes. There is evidence that psychological interventions can improve emotion regulation in young people. Moltrecht et al. (2021) found moderate effects for reducing emotion dysregulation and smaller effects for strengthening adaptive regulation. However, only four of the 21 trials in their meta-analysis focused on children aged 6–12. The ERiC study was designed partly in response to this age-related gap.
How mentalising may support regulation
Mentalising is the capacity to interpret one’s own and other people’s behaviour in relation to underlying mental states. It involves recognising that actions may be shaped by feelings, wishes, fears, beliefs and intentions and that these internal states are not always immediately obvious. For a child, mentalising might involve moving from “Mum shouted because she hates me” towards a more tentative understanding: “Mum may have been frightened, stressed or worried, although I cannot be completely sure.” For a parent, it may involve seeing apparently defiant behaviour not simply as deliberate provocation but as a possible expression of shame, fear, confusion or emotional overload. This does not excuse harmful behaviour or suggest that every action has a benign explanation. Instead, it creates space between behaviour and reaction, allowing children and adults to consider alternative interpretations, regulate arousal and respond more flexibly. Mentalising becomes more difficult under conditions of stress, threat or intense emotion, people may become highly certain about another person’s intentions, lose curiosity, focus only on observable behaviour or struggle to reflect on their own contribution to an interaction. Complex family exchanges can then become organised around rapid assumptions and escalating reactions. The ERiC model proposes that strengthening mentalising should support emotion regulation, which may in turn reduce both emotional and behavioural symptoms (Midgley et al., 2023).
Trauma and the disruption of mentalising
Although the ERiC protocol is not specifically a trauma-treatment study, its model may be relevant to trauma-informed work. Experiences of threat, abuse or relational instability can make it difficult for children to interpret internal and interpersonal experiences safely. Vigilance may be adaptive in dangerous environments, but it can contribute to rapid threat interpretations in later relationships. Strong affect may also narrow the child’s capacity to consider several possible explanations for what another person is thinking or doing. Ensink et al. (2016) examined reflective functioning among children aged 7–12, including children who had experienced sexual abuse. Child mentalising partially mediated associations between abuse and both depressive symptoms and externalising difficulties. Higher maternal reflective functioning was also associated with fewer externalising problems. These findings do not prove that improving mentalising will reverse the effects of trauma, but they support its relevance as a potential protective resource. A trauma-informed mentalising stance therefore requires more than encouraging children to talk about thoughts and feelings. Clinicians must attend to emotional arousal, developmental capacity, the child’s need for safety and the relational conditions under which curiosity becomes possible.
Why the parent–child relationship matters
For school-age children, emotion regulation does not occur solely within the individual. Children continue to rely on adults to help name feelings, interpret situations, tolerate distress and recover from emotional activation. Parental mentalising refers to a parent’s capacity to understand the child as a person with an independent mind. It includes curiosity about the child’s experience, awareness that behaviour may have several meanings and recognition that the parent’s interpretation may be mistaken. Charpentier Mora et al. (2022) found that parental mentalising in middle childhood was associated with children’s internalising and externalising symptoms and their social-emotional competencies. Camoirano’s (2017) review similarly highlighted links between parental reflective functioning, caregiving, attachment, child emotion regulation and psychological development. These associations should not be interpreted as evidence that parents cause their children’s difficulties. Parenting takes place within wider contexts that may include trauma, poverty, parental mental health problems, neurodevelopmental differences, discrimination and inadequate support. Parents may also find it hardest to mentalise when they are frightened, blamed or emotionally overwhelmed themselves. A systemic approach consequently asks not only whether a parent can mentalise the child, but whether professionals can maintain a reflective stance towards the parent and the wider network. Supporting mentalising may require reducing blame, making interactions understandable and creating conditions in which curiosity can return.
What does the ERiC intervention involve?
The trial plans to recruit 320 children aged 6–12 with clinically significant emotional and behavioural difficulties, together with their parents or carers. Families are randomly allocated either to Mentalization-Based Treatment or to treatment as usual. The MBT intervention consists of six to eight sessions, generally delivered fortnightly. Different family members may be involved flexibly, but the primary focus is on strengthening mentalising and emotion regulation within the parent–child relationship. The intervention is designed for delivery in ordinary Child and Adolescent Mental Health Services rather than a highly specialised research clinic. Participating practitioners receive three days of training, fortnightly supervision and access to an online treatment manual. The study will examine whether clinicians from different professional backgrounds can deliver the model with sufficient fidelity. Treatment as usual may include cognitive behavioural therapy, parenting groups or social-skills work. The comparison therefore tests MBT against existing clinical provision rather than against no intervention.
What the evidence does and does not currently show
Mentalisation-based approaches for middle childhood are promising but not yet supported by the same evidence base available for some adult populations. Midgley, Sprecher, and Sleed (2021) identified 29 mentalisation-informed interventions for children aged 6–12 and their carers. These included individual, family, parent-focused and whole-system models. However, only a minority of publications reported outcome data, and many evaluations were small or methodologically limited. Some findings nevertheless support further investigation. Halfon and Besiroglu (2021), for example, found that parental reflective functioning and children’s mental-state talk predicted aspects of outcome in psychodynamic child psychotherapy. Such studies suggest clinically meaningful relationships but cannot substitute for a sufficiently powered randomised trial. The ERiC protocol therefore represents an important next step rather than confirmation of effectiveness. Until outcome data are published, clinicians should not describe this specific brief intervention as proven to outperform usual care.
Implications for clinical practice
Several principles from the paper can inform practice even while the trial results are awaited.
First, clinicians can formulate across diagnostic boundaries. When anxiety, sadness, anger and disruptive behaviour coexist, it may be useful to consider whether difficulties recognising, communicating and regulating emotion connect these presentations.
Second, behaviour can be explored without being reduced to a fixed meaning. A mentalising stance asks what may be happening internally while preserving uncertainty.
Third, assessment should include relationships and context. For children, regulation often depends on interactions with parents, carers, teachers and wider systems.
Fourth, parental involvement should not be equated with parental blame. Parents may need support to recover their own capacity to reflect under stress.
Finally, clinicians should distinguish theoretical plausibility from demonstrated treatment effect. Mentalising offers a compelling framework, but the value of the ERiC study lies in subjecting that framework to rigorous evaluation.
Conclusion
The ERiC protocol responds to a frequent clinical problem: children often present with complex combinations of emotional and behavioural difficulties, while treatment research remains organised largely around individual disorders. Its proposed solution is a brief, transdiagnostic intervention focused on mentalising, emotion regulation and the parent–child relationship. The model is especially relevant to systemic and trauma-informed practice because it directs attention beyond symptoms towards the interpersonal processes through which emotions are understood, shared and regulated. The trial will test whether strengthening mentalising leads to better regulation and whether these changes produce meaningful improvements for children and families. Until those findings are available, the paper offers a thoughtful clinical rationale and a rigorous plan for finding out—not a final verdict.
Where next?
Join us on 14 October for a fantastic event on ‘Mentalising with complex clinical presentations in children and families: a systemic and trauma-informed approach‘ with Dr. Emma Morris.
Dr. Emma Morris leads webinar workshop helping clinicians use a mentalizing and systemic approach to assess, formulate, and treat complex trauma in children, young people, and families. Through practical training and a pre-recorded MBT introduction, participants learn to apply trauma-focused mentalization techniques across clinical work and wider support systems.
References
- Bearman, S. K., & Weisz, J. R. (2015). Review: Comprehensive treatments for youth comorbidity—Evidence-guided approaches to a complicated problem. Child and Adolescent Mental Health, 20(3), 131–141. doi: 10.1111/camh.12092
- Camoirano, A. (2017). Mentalizing makes parenting work: A review about parental reflective functioning and clinical interventions to improve it. Frontiers in Psychology, 8, Article 14. doi: 10.3389/fpsyg.2017.00014
- Charpentier Mora, S., Bastianoni, C., Koren-Karie, N., Cavanna, D., Tironi, M., & Bizzi, F. (2022). Parental mentalizing during middle childhood: How is the adoption of a reflective stance associated with child’s psychological outcomes? International Journal of Environmental Research and Public Health, 19(10), Article 6205. doi: 10.3390/ijerph19106205
- Ensink, K., Bégin, M., Normandin, L., & Fonagy, P. (2016). Maternal and child reflective functioning in the context of child sexual abuse: Pathways to depression and externalising difficulties. European Journal of Psychotraumatology, 7(1), Article 30611. doi: 10.3402/ejpt.v7.30611
- Halfon, S., & Besiroglu, B. (2021). Parental reflective function and children’s attachment-based mental state talk as predictors of outcome in psychodynamic child psychotherapy. Psychotherapy, 58(1), 81–94. doi: 10.1037/pst0000347
- McElroy, E., Shevlin, M., Murphy, J., & McBride, O. (2018). Co-occurring internalizing and externalizing psychopathology in childhood and adolescence: A network approach. European Child & Adolescent Psychiatry, 27(11), 1449–1457. doi: 10.1007/s00787-018-1128-x
- Midgley, N., Mortimer, R., Carter, M., Casey, P., Coffman, L., Edbrooke-Childs, J., Edridge, C., Fonagy, P., Gomes, M., Kapoor, A., Marks, S., Martin, P., Moltrecht, B., Morris, E., Pokorna, N., & McFarquhar, T. (2023). Emotion regulation in children (ERiC): A protocol for a randomised clinical trial to evaluate the clinical and cost effectiveness of Mentalization Based Treatment (MBT) vs Treatment as Usual for school-age children with mixed emotional and behavioural difficulties. PLOS ONE, 18(8), e0289503. doi: 10.1371/journal.pone.0289503
- Midgley, N., Sprecher, E. A., & Sleed, M. (2021). Mentalization-based interventions for children aged 6–12 and their carers: A narrative systematic review. Journal of Infant, Child, and Adolescent Psychotherapy, 20(2), 169–189. doi: 10.1080/15289168.2021.1915654
- Moltrecht, B., Deighton, J., Patalay, P., & Edbrooke-Childs, J. (2021). Effectiveness of current psychological interventions to improve emotion regulation in youth: A meta-analysis. European Child & Adolescent Psychiatry, 30(6), 829–848. doi: 10.1007/s00787-020-01498-4
- Weissman, D. G., Bitran, D., Miller, A. B., Schaefer, J. D., Sheridan, M. A., & McLaughlin, K. A. (2019). Difficulties with emotion regulation as a transdiagnostic mechanism linking child maltreatment with the emergence of psychopathology. Development and Psychopathology, 31(3), 899–915. doi: 10.1017/S0954579419000348