Parenting and
Personality Disorder
Dr Angus MacBeth
Clinical Psychologist
NRS Career Research Fellow
NHS Grampian
University of Aberdeen
Acknowledgements
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Phil Wilson, Lucy Thompson, John Norrie - University of Aberdeen.
Jane White, Andrea Williamson, Helen Minnis – University of
Glasgow.
Marion Henderson, Danny Wight - MRC/CSO SPHSU.
Linda Treliving – NHS Grampian.
Andrea Williams - NHS Greater Glasgow and Clyde.
Community midwives from NHS Ayrshire & Arran & NHS Greater
Glasgow & Clyde.
Rosemary Mackenzie, Christine Puckering, Harriet Waugh and the
Mellow Parenting team.
Scottish Collaboration for Public Health Research and Policy.
National Scientific Council on the Developing Child (2007). The Timing and Quality of Early Experiences Combine to Shape Brain
Architecture: Working Paper #5. http://www.developingchild.net
Early experience affects outcome
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Adverse Childhood Experiences (ACEs) Study
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Dose effect response linking ACEs to:
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Adult recall of childhood event
Cardiovascular disease
Chronic lung disease
Cancer
Depression
Alcoholism
Drug abuse
ACEs associated with greater life time risk of
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Life threatening psychiatric disorders
Overlapping mental health problems
Teen pregnancy
 Obesity
 Physical inactivity
 Smoking
Fellitti et al. (1998) Am J Prev Med; Edwards et al. (2003) Am J Psych; Anda et al 2006; Eur Arch Psych Clin Neurosci; Hillis et al. (2004)
Pediatrics; Fellitti et al. (2004) Circulation.
UNICEF Domains of Child
wellbeing
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Material deprivation
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Health and Safety
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family structure, peer relationships
Behaviours and Risks
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School achievement, post-15 education
Relationships
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Infant mortality, immunisations
Educational wellbeing
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Relative income, households without jobs
health behaviours, experience of violence
Subjective Well-being
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self-assessed indicators
Early experience affects outcome:
Dunedin Longitudinal cohort
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Socially isolated children at significant risk of poor adult
health compared with non-isolated children.
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Association independent of other childhood risk factors for
poor adult health (low childhood socioeconomic status, low
childhood IQ, childhood overweight).
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Not accounted for by health-damaging behaviors (lack of
exercise, smoking, alcohol misuse).
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Not attributable to greater exposure to stressful life events.
Socially isolated children 20 years later: Risk of cardiovascular disease. Caspi A, Harrington H, Moffitt TE, Milne BJ, and
Poulton R 2006 Archives of Pediatrics & Adolescent Medicine 160:805-811.
Dunedin Longitudinal cohort
Socially isolated children 20 years later: Risk of cardiovascular disease. Caspi A, Harrington H, Moffitt TE, Milne BJ, and
Poulton R 2006 Archives of Pediatrics & Adolescent Medicine 160:805-811.
National Scientific Council on the Developing Child (2007). The Timing and Quality of Early Experiences Combine to Shape
Brain Architecture: Working Paper #5. http://www.developingchild.net
Evidence for intergenerational
transmission
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Family association studies report 4-20 fold
increase in BPD prevalence in relatives
 Heterogeneity
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Familial aggregation of BPD core features
 Affective
instability
 Impulsivity
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Bidirectional relationships?
Distel et al., (2007). Heritability of borderline personality disorder features is similar across three countries. Psychological Medicine,
38, 1219–29;
Silverman et al. (1991). (1991). Affective and impulsive personality disorder traits in the relatives of patients with borderline
personality disorder. American Journal of Psychi atry, 148, 1378–1385.
Parenting and Personality Disorder
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Evidence for parenting difficulties for
parents with PD?
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Evidence for effective parenting
interventions for parents with PD and their
children?
 What
evidence…?
Parenting in BPD – Infant data
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‘Still face’ experiment
 n=8
mothers with BPD
 n=12 mothers with no psychiatric disorder
 2-month-old infants
Crandell, L. E., Patrick, M. P. H., & Hobson, R. P. (2003). “Still-face” interactions between motherswith borderline personality
disorder and their 2-month-old infants. British Journal of Psychiatry, 183, 239–247.
Infant still face paradigm
Parenting in BPD – Infant data
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‘Still face’ experiment
 n=8
mothers with BPD
 n=12 mothers with no psychiatric disorder
 2-month-old infants
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Infants from BPD group vs. control infants
 more
dazed looks
 more gaze aversion
 less overall responsiveness towards mother
Crandell, L. E., Patrick, M. P. H., & Hobson, R. P. (2003). “Still-face” interactions between motherswith borderline personality
disorder and their 2-month-old infants. British Journal of Psychiatry, 183, 239–247.
Parenting in BPD – Infant data
Same sample, infants now 12 months
 Strange Situation Test
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 80%
of infants in BPD group classified as
disorganised attachment
 27% of infants in control group classified “D”
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Limited by small sample size
Hobson, P. R., Patrick, M. Crandell, L., Garcıa- Perez, R., & Lee, A. (2005). Personal relatedness and attachment in infants of
mothers with border- line personality disorder. Development and Psychopathology, 17, 329–347.
Early Childhood data
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Story stem completion task (children of BPD vs control)
BPD group increased likelihood vs controls to:
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Talk about fantasies as well as material of a traumatic nature.
Role reversal
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Greater fears of abandonment
Negative parent– child relationship expectations
Relationships characterized by danger and/or unpredictability
Incongruent representation
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e.g., child tells fighting parents to: “Stop that! Go to your room!”
(e.g., child cleans his or her room then ruins it
Shameful self- representations
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e.g. the child says he or she is bad
Macfie, J., Fitzpatrick, K. L., Rivas, E. M., & Cox, M. J. (2008). Independent influences upon mother- toddler role reversal: Infantmother attachment disorganization and role reversal in mother’s child- hood. Attachment & Human Development, 10, 29 – 39.
Parenting in BPD –
adolescent/adulthood outcomes
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School-aged and adolescent children of BPD diagnosed
mothers with are at risk for both internalizing and
externalizing problems (Feldman et al., 1995; Abela et
al., 1996; Barnow et al., 2006).
Cognitive and interpersonal vulnerabilities
 Negative attributional style
 Ruminative response style
 Dysfunctional attitudes
 Self-criticism
 Insecure attachment style
 Excessive reassurance seeking.
Children in the Community
(CIC) Study
Children in the Community
(CIC) Study
Transmission Mechanisms
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GxE Interactions
GxE interaction effects
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Some children,for temperamental/genetic reasons are more
susceptible to:
 Adverse effects of unsupportive parenting
 Beneficial effects of supportive parenting
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Only highly distressed/irritable 4-month- old boys who experienced
coercive and rejecting mothering continued to show evidence at 9
months of of emotional and behavioural dysregulation (Murray &
Morell, 2003).
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Males, longitudinally followed from early childhood most likely to
manifest high levels of antisocial behavior when they had both a
history of child maltreatment and a particular variant of the MAO-A
gene (Caspi & Moffitt, 2006).
Belsky, J., Bakermans-Kranenburg, M.J., & Van IJzendoorn, M.H. (2007). For better and for worse: Differential
susceptibility to environmental influences. Current Directions in Psychological Science, 16, 300-304.
Genetic vulnerability/Differential
Susceptibility
Bakermans-Kranenburg, M.J. & Van IJzendoorn, M.H. (2007). Genetic vulnerability or differential susceptibility in child
development: The case of attachment. Journal of Child Psychology and Psychiatry, 48 (12), 1160-1173.
Evidence for differential susceptibility
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Children with reactive or fearful
temperament appear to suffer most
from persistent family conflict or low
quality of day care but also appear
benefit disproportionately from
supportive environments.
Children w/ DRD4 7-repeat allele &
unresponsive mothers displayed more
externalizing behavior problems than
children without the DRD4 7-repeat
variant
…but children with the DRD4 7-repeat
allele and responsive mothers showed
the lowest levels of externalizing
problem behavior.
Bakermans-Kranenburg, M.J., & Van IJzendoorn, M.H. (2011). Differential susceptibility to rearing environment depending on
dopamine-related genes: New evidence and a meta-analysis. Development and Psychopathology, 23, 39-52.
doi:10.1017/S095457941000063
Environmental Instability
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Children (aged 4–18) of BPD mothers
more likely to be exposed to
environmental instability
 Frequent
changes in housing and schooling
 Removal from the home
 Maternal suicide attempts.
Feldman, R. B., Zelkowitz, P., Weiss, M., Vogel, J., Heyman, M., & Paris, J. (1995). A comparison of the families of mothers with
borderline and non- borderline personality disorders. Comprehensive Psychology, 26, 157–163.
Transmission Mechanisms
GxE Interactions
 Attachment
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Attachment Disorganization
Infant
Disorganized/Disoriented
attachment
Adult Unresolved (“U”)
Behaviour
Striking
of infant is with attachment
figure disorganised/disoriented,
indicative of collapse of coherent
attachment strategy.
E.g. freezing;
Rising then falling;
Prone;
Clinging to attachment figure while
crying.
lapses of monitoring or
reasoning in the specific instance of
discussing loss and/or abuse.
Indicated through speech:
E.g. belief that deceased is still
alive or eulogising discourse,
Absorption into sensory memories
Subtle dissociation.
Concordance between infant and
adult attachment patterns
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Adult attachment disorganisation (“U”)
over represented in clinical groups.
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Infant attachment disorganisation linked to
 Maternal
Unresolved trauma/loss (“U”)
 Maternal frightened/frightening or disruptive
behaviour
van IJzendoorn, M.H. (1995). Adult Attachment representations, parental responsiveness, and infant attachment: A
meta analysis of the Adult Attachment Interview, Psychological Bulletin, 117, 387-403.
Sequelae of disorganization
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Increased risk of psychopathology in adulthood
e.g. link to dissociation (Carlsson, 1994).
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Infant disorganized attachment associated with
significantly greater risk of externalizing
problems (d=0.34) in childhood (Fearon, 2010).
Attachment disorganization and
care-giving
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Solomon and George emphasize that care-giving is
experienced as disorganizing.
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Compartmentalized but contradictory representations of
relationships.
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Not integrated in awareness…
…but rapidly, unpredictably activated via behaviour.
AMBIANCE system (Lyons-Ruth et al., 1998)
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Rather than insensitive behaviour (Out et al, 2009).
Contradictory parenting cues (approach/withdraw).
Withdrawal behaviours (holding infant away).
Maltreatment often present but not a prerequisite.
Transmission Mechanisms
GxE Interactions
 Attachment
 Maternal representations
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 Mentalization
 Caregiving
representations
Limitations of current theories
Specificity to PD (or BPD).
 Lack of diagnostically adapted parenting
measures in existing literature.
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 Sensitivity
to differences between depression,
anxiety, ASPD and BPD.
Empirical testing.
 Subtle changes in variables of interest
over time.
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 Interventions
Interventions
Attachment based (e.g. Dozier et al)
 Child Parent Psychotherapy (Toth et al)
 Psychoeducational
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 Family
connections (Fruzetti)
 Systems Training for Emotional Predictabilty
and Problem Solving (STEPPS; Blum)
 Multigroup family skills as part of DBT
Stepp, S., Whalen, D., Pilkonis, P., Hipwell, A., & Levine, M. (2011). Children of mothers with borderline personality disorder: Identifying
parenting behaviors as potential targets for intervention. Personality Disorders: Theory, Research, and Treatment, 3, 76–91.
Effects of an attachment based
intervention on cortisol (Dozier et al.,
2008)
Mellow Bumps RCT: Testing an
Aim
antenatal psychological
intervention
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Design: Mellow Bumps intervention vs. control
intervention vs. care-as-usual.
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Aim: compare interventions’ impact on mental
health of pregnant women with substantial
additional health and social care needs.
Rationale
Interventions in first 3 years of
life improve long-term child
outcomes
Woman vulnerable in
pregnancy due to
mental ill-health,
substance abuse,
domestic violence or
having complex social
care needs
Foetus exposed to
high levels of
stress hormones
in utero
Infant more
sensitive to stress
and difficult to
soothe
Stress hormones affect
foetal brain development
resulting in negative
effects on baby’s ability
to cope with stressful
stimuli
Can intervening in pregnancy improve
outcomes?
Can affect the quality
of mother-infant
bonding; especially if
mother remains
vulnerable in postnatal period.
Increases risk of
child maltreatment
Poorer long-term
child outcomes
Evidence of socioemotional, educational
and health inequalities
for vulnerable children
emerging at age 3
Interventions
6 weekly 2
hour sessions
> social connectivity
Baby topic
Strategies to
reduce stress
Awareness of
baby
> knowledge of
attachement and
infant devellopment
< stress
Activity for
mum-to-be
Breustedt, S. & Puckering, C. (2013) Qualitative evaluation of women’s experiences of
the Mellow Bumps antenatal intervention. British Journal of Midwifery, 21, 3, 100-7.
6 weekly 2 hour
sessions
Strategies to
reduce stress
Activity for
mum-to-be
> social
connectivity
< stress
Inclusion criteria
Mental
health
problem
Substance
misuse in
last 12
months
Young
person
leaving care
Involved in
criminal
justice
system (self
or partner)
Child
protection
concerns
Complex
social
care needs
Complex
homeless
Domestic
abuse
Outcome measures
Pre-Intervention (1828 weeks gestation)
Adult Wellbeing Scale,
Edinburgh Postnatal Depression Scale,
Saliva samples for cortisol assay
Post-Intervention (2636 weeks gestation)
Adult Wellbeing Scale,
Edinburgh Postnatal Depression Scale,
Saliva samples for cortisol assay
5 days postnatal
Saliva samples from baby pre-and post-Guthrie test
8-12 weeks post-natal
Adult Wellbeing Scale,
Edinburgh Postnatal Depression Scale,
Saliva samples for cortisol assays,
Semi-structured interview,
Mother-baby video
Recruitment
Referred
n= 50
Declined n= 11
Failed contact n= 4
Recruited
n= 35
Withdrew n= 2
Failed contact n= 2
Pre-intervention
data n= 31
Withdrew n= 2
Failed contact n= 6
Post-intervention
data n= 23
Participants
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Age: 17 – 42 years (mean 27.14, SD 7.49)
Deprivation: 66% (n=23) SIMD 1
26% (n=9) SIMD 2
8% (n=3) SIMD 4
Parity:
29% (n=10) first time parent
51% (n=18) had one-two children
20% (n=7) had three or more
children
Baseline
Preliminary results:
Pre- and post-intervention
Adult Wellbeing Scale - Depression
Adult Wellbeing Scale - Anxiety
Preliminary results:
Pre- and post- intervention
Adult Wellbeing Scale –
Outward-directed irritability
Adult Wellbeing Scale –
Inward-directed irritability
Preliminary results:
Pre- and post- intervention
Edinburgh Postnatal Depression
Scale
Active components of effective
parent-child interventions?
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Bakermans-Kranenburg et al. (2003) – “Less is more
meta analysis”
 Moderate number of sessions (5-16).
 Clear focus in families with, as well as without,
multiple problems.
 Emphasis on interaction.
 Interventions more effective in enhancing parental
sensitivity also more effective in enhancing
attachment security.
Challenges ahead
Further testing of interventions
 Which components are effective in
interventions?
 Mentalization based approach for
parenting?
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Thank you
angus.macbeth@abdn.ac.uk