(Probably not the best way to set limits…)

It seems as if a child with a serious medical condition should be free to express him or herself in any way they want, free from the boundaries we would normally enforce. But when does free expression reach a tipping point at which it is destructive, dangerous, or just downright counterproductive? In fact, an article in the journal Psychiatry suggests these adult-centered concerns are only one side of the argument for setting consistent, firm boundaries for kids with medical conditions. The fact is, no matter if a child is ill or well, boundaries can set the groundwork for a child’s feeling of safety, fairness and predictability.

Of course it’s a balance: if boundaries are too restrictive, they may not allow the child to experience difficult emotions and express these emotions in a way that allows him or her to externalize, process and eventually release them. On the other hand, overly lenient boundaries may allow the child to stay stuck in patterns that over time will not serve them well.

“Of the many skills a therapist [or parent] may exercise… the hardest, least researched, and possibly most important is limit setting,” the article writes.

Because the article’s audience is primarily psychiatrists, its focus is on setting limits for the purpose of therapy, but many of the following list of 9 purposes for limit setting are applicable to parents, teachers and other professionals as well. According to the article, the 9 purposes for setting boundaries with a child are:

  • To define boundaries
  • To provide physical and emotional safety and security for the adult and the child
  • To foster a positive attitude in the adult toward the child
  • To anchor the session in reality
  • To safely express negative feelings without fear or retaliation
  • To promote responsibility and control on the part of the child resulting in stability and consistency in the relationship
  • To provide a cathartic experience for the child
  • To protect the room and all its contents
  • To maintain legal, moral and professional standards

The article also suggests guidelines for setting these limits, offering the acronym ACT: “Acknowledge (the wants, feelings, and wishes of the child), Communicate (the limit), and Target (reasonable alternatives).”

I find this list interesting, in part because before becoming a psychotherapist, I was a middle school teacher and my strategy for classroom management depended on designing hands-on lessons so engaging that behavior problems were subsumed by motivation (most of the time… at least that was the theory…). And as a parent my limit-setting strategy has been to love the heck out of my kids, expect the best, and hang them by their big toes in the garage when things don’t work out – which has at least gotten me to ages 9 and 11 without major behavior issues. Of course, I’m kidding about hanging my kids by their toes, but in teaching, parenting and now the practice of psychotherapy, I’ve found that creating the groundwork of a strong relationship creates self-policing systems – middle schoolers shush each other so they can hear game directions and my kids are saints with teachers and coaches…at least most of the time.

And so I wonder if there’s a larger lesson to take away from the recommendations in this article. I wonder if these recommendations really set the groundwork for knowing, respecting and appreciating the young people in your life in a way that also helps them appreciate you. In my opinion, we could see these guidelines as a way to lay the groundwork of a relationship in which a child – even a child with medical challenges – knows these limits and respects them because they respect you and they respect themselves.

Kristi Pikiewicz

Dr. Pikiewicz earned her PhD in Clinical Psychology at Pacifica Graduate Institute in Carpinteria, CA. She completed pre-doctoral training at the Nan Tolbert Nurturing Center in Ojai, CA, and her post-doctoral internship at the Boulder Institute for Psychotherapy and Research. At both sites, Dr. Pikiewicz worked with a range of adult, adolescent and child clients in individual, couple, family and group settings. She also holds a B.S. in environmental science from Allegheny College and a teaching credential from Western Washington University.


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