PSYCHOANALYTIC SOCIAL WORK
2020, VOL. 27, NO. 2, 139–156
https://doi.org/10.1080/15228878.2020.1818108
Narcissistic Personality Disorder in Children: Applying a
Controversial Diagnosis to Guide Treatment
James Drisko
Smith College School for Social Work, Northampton, Massachusetts, USA
KEYWORDS
ABSTRACT
This paper examines the limited literature on narcissistic personality disorder in children, addressing the relevance of the
concept of ‘personality’ or enduring and consistent traits during childhood. Children are formally viewed by most diagnostic
criteria as lacking consolidated personalities. Still, some children present with consistent patterns of behavior like those
defining the adult disorder. Psychodynamic and other theories
that help us understand narcissistic disorders in childhood and
their treatment are then examined. These theories are heavily
developmental and descriptive in focus, with much less attention to treatment. A case example of a challenging, often silent
child who denied most difficulties is offered to illustrate treatment challenges. Recommendations for clinicians treating children who have narcissistic disorders conclude the article.
Children; narcissistic
personality disorder;
personality
disorders; treatment
Over the past 50 years there have been few publications on narcissistic disorders in childhood. Though Lasch (1979) identified a culture of narcissism
in the 1970s, few authors have explored the enduring and consistent
expression of personality disorder-like signs and symptoms in children.
The literature points to many similarities between adult and childhood presentations of narcissistic disorders despite concerns about applying a personality disorder label to developing children. Still, descriptions of
treatment for such child cases are rare. This paper examines the literature
on narcissistic personality disorder in children and describes the treatment
of one case. Features of the case, including family participation and consultation work with school personnel, are explicated. Understanding the
case as a personality disorder was useful in empathizing with the child and
in managing difficult countertransference reactions.
Personality disorders in childhood
Applying the concept of personality disorders to children is controversial. The
American Psychiatric Association (APA, 2020, para 1) defines a personality
CONTACT James Drisko
jdrisko@msith.edu
ß 2020 Taylor & Francis Group, LLC
Smith College School for Social Work, Northampton, MA, USA.
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disorder as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture.” The APA
(2020, para 5) further states that “Diagnosis is typically made in individuals 18
or older. People under 18 are typically not diagnosed with personality disorders because their personalities are still developing.” Of course, this view contrasts with that of many parents who note enduring traits among children
from their birth or their early years with remarkable consistency. It is also
contradicted by many clinicians and researchers who describe enduring patterns of behavior in children and young teens (e.g., Brummelman et al., 2015;
Cohen, 1991, Egan & Kernberg, 1984). In my clinical experience, teachers,
coaches, pastors, and friends also speak of consistent and enduring traits in
the children with whom they work. Personality seems to have utility as a heuristic concept even if we carefully limit its documented diagnostic use to avoid
stigma and labeling. How we think constructively to understand others and
guide treatment may differ purposefully from what we formally document.
Despite concerns about professionals labeling personality disorders prior
to age 18, several clinician/scholars have found it useful to apply these concepts to certain children. This is because some children present with patterns of interaction and other behaviors parallel to adult narcissistic
personality disorder and evoke very similar reactions in clinicians and in
others (Beren, 1992; Kealy & Ogrodniczuk, 2011; Nissen-Lie et al., 2020).
At the same time, such children often appear to have little motivation for
treatment and to view others’ shortcomings as the source of their difficulties. Viewing others as the source of one’s difficulties, an ego syntonic presentation, is also consistent with adult personality disorders. This
presentation further points to possible attachment difficulties and the need
to further assess for trauma.
This paper examines several theories of in both adults and in children. I
will try to point out the commonalities and the differences in work with
children and adults who appear to have narcissistic personality disorder or
its early precursors. Psychodynamic and other theories (neurobiological,
empirical, genetics) are discussed, though most have an adult focus. Theory
and developmental concerns are much more often addressed in the available literature than are case studies or practice theories and techniques
focusing on children. The provided case will illustrate the challenges of
working with children who present with narcissistic personality disorder features.
My initial engagement with thinking about narcissistic personality disorder and its equivalents in children came in work with a particularly challenging case. In the case of a client I will call Richard, several persons who
were not mental health professionals described Richard in a consistent and
enduring manner. They also described their internal personal reactions in
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ways that correspond closely to published clinicians’ reactions in work with
adults who have narcissistic personality disorder.
My work is mainly oriented by developmental and psychoanalytic theories. American object relations theories and ego psychology are my go-to
lenses, along with trauma theory and attention to diversity. Narcissistic disorders, after Kohut’s self psychology, do not fit simply into a developmental, age and phase, way of thinking but had relevance to the case. In my
first few meetings with Richard I found his presentation to be unusual and
quite off-putting. I felt helpless. My usual approaches did not help guide
my work and understanding. I had to look for other resources. The spark
for this came from a three-year-old psychological testing report in which
the tester from another city noted, in passing, that Richard seemed to be
“hard to reach” and “cut off.” This led me to think about cautiously applying narcissistic personality disorder concepts to this child’s treatment.
Overall, the theory was much more useful in understanding and managing
my own reactions than it was in offering descriptions of others’ experiences
with child clients. Managing one’s reactions is of course key to early work
with persons who warrant a narcissistic personality disorder or any personality disorder diagnosis, but is not all there is to creating an effective treatment plan. This may be especially so with a child who makes no initial
investment in therapy, whose in-session oral material is extremely limited,
and who’s family actively avoids and evades offered services. These are, of
course, signs of personality disturbance in adult clients.
Narcissistic personality disorder in childhood
Bleiberg (1984) noted that diagnostic formulations of narcissism and narcissistic disorders in adults had not then been applied to children. He
stated that parents brought children for treatment for a wide range of concerns with a strong narcissistic component. These include being manipulative/exploitive, impulsive, exhibitionistic, needing to be the center of
attention, lying, and rule breaking. Such concerns link to difficulties in
school, with peers, and in the family, which the children deny and view as
externally caused by others. Yet these children are alternately described
as capable, shrewd, and charming. Bleiberg, however, did not address these
as forms of personality disorder, despite many consistent features.
Paulina Kernberg (1989) and others later argued that narcissistic personality disorder could be diagnosed in childhood. Kernberg states that the
contemporary DSM-III-R did not address narcissistic personality disorder
in children but that the manual “acknowledges that other personality disorder criteria may be used with children and adolescence [sic], if the maladaptive personality traits are stable” (p. 671). She described the behaviors
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of narcissistic children and some of their ways of understanding self and
others. Key features that characterize narcissistic children include an
inflated sense of self, grandiosity, inability to tolerate anything but immediate success, inability to tolerate or acknowledge personal shortcomings and
failures, coupled with limited awareness of others’ intentions and motives
(see also Cohen, 1991; Egan & Kernberg, 1984; Kernberg et al., 2000;
Pincus et al., 2014). These enduring characteristics are also notable among
adults who warrant a narcissistic personality disorder diagnosis.
Beren (1992) described children who might seem appropriate for psychoanalytic treatment but whose “cases end in a therapeutic stalemate or who
fall considerably short of the treatment goal” (p. 265). She added that these
clients evoke “unusual countertransference reactions … taking the form of
feeling bored, ineffectual, or doubtful about the usefulness of treatment” (p.
266). These children, she argued, have narcissistic disorders. To Beren, children who have narcissistic disorders are more vulnerable, more dependent,
and have a poorly developed sense of self than do others. They are unlikely
to acknowledge problems which are evaded and externalized. Developing a
therapeutic relationship may be difficult due to their “guardedness, denial
of problems and lack of empathy” (p. 268). These children may view being
in treatment as a narcissistic injury.
Beren (1992, p. 267) describes a case in which the narcissistic child client
“continually denied her unhappy and painful feelings or her role in any of
the difficulties … ” over four years of treatment. Beren further notes that
the most benign intervention or interpretation always was rejected or,
worse yet, caused her to become very hostile followed by a refusal to talk
to me. This high level of guardedness, denial of problems, and lack of
empathy in such children can pose difficulties for the therapist, making it
hard to feel that a mutual working relationship has been established
(p. 267).
Beren states that sessions with this child had a repetitive and formulaic
quality. Finally, she notes that the client displayed a complete disregard for
the rules of games, unlike typical latency aged children. Building an alliance
proved very difficult and many common psychoanalytic intervention techniques proved ineffective. These concerns are similar to those of clinicians
working with severe personality disorders in adults.
Bardenstein (2009) and Imbesi (2000) later elaborated a wider range of
presenting concerns among children with narcissistic disorders. They report
that entitlement, stemming from a sense of superiority and linked with limited awareness of others’ feelings and needs, may lead to antisocial traits
and often a hypervigilant, near paranoid, awareness of others. Material
goods may be sought to enhance and support the individual’s vulnerable
sense of self but their impact fades quickly, often leading to devaluing
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these goods once they arrived. Narcissistic children appear to envy what
others achieve while overtly devaluing other’s efforts and failing to express
gratitude or concern for others. Beyond these observable signs,
Bardenstein (2009, p. 149) states that internally, “narcissistic pathology
serves as a compensation for a sense of inadequacy that is too painful to
acknowledge.” Getting to know a child with narcissistic personality disorder characteristics does always start with statements of their inner feelings and worries.
In conceptualizing narcissistic disorders, we hypothesize that grandiosity
is one experience coupled with little sense of a cohesive self and a sense of
emptiness and inferiority. When child clients talk or enact very little, we
must infer, or assume, the child’s unstated feelings and motives. Through
the mechanisms of projective identification clinicians may experience the
affects of their clients. This would also fit Kohut’s concept of self-object
fusion. In defensive narcissism, Rosenfeld (1971) assumes that the self is
idealized and defended by omnipotent projective and introjective identification. In work with more verbal adults and children, this dynamic is often
directly described, providing support for the clinician’s inferences.
Similarly, selfobject experiences fuze client and clinician experientially.
These deeply intimate experiences help us understand clients with varying
levels of direct affirmation. In work with Richard, the consistency of my
countertransference with the statements of other adults supported the narcissistic personality disorder-like understanding even given his few statements describing his inner life.
Recent theory and empirical research have differentiated two forms of
narcissistic presentation: grandiose narcissism and vulnerable narcissism
(Dickinson & Pincus, 2003). Grandiose personalities in their nonclinical
sample displayed dramatic traits, were domineering and had vindictive
interpersonal problems. They also denied interpersonal distress while
reporting adult attachment styles reflecting positive self-representations.
Their attachment styles appeared secure or dismissive in quality. On the
other hand, vulnerable narcissistic individuals appeared more avoidant with
high levels of interpersonal distress, associated with high levels of neuroticism (Jauk et al., 2017; Miller et al., 2018). Vulnerable individuals displayed
domineering, vindictive, cold, and socially avoidant interpersonal problems.
Their more fearful and preoccupied attachment styles reflect negative internalized self-representations (Dickinson & Pincus, 2003). Brogaard (2019)
states that most personality researchers view grandiose and vulnerable narcissism as independent traits. In contrast, Brogaard argues that because the
two forms may both be present, or may oscillate, in narcissistic personality
disorder this suggests that both forms may have a common or shared basis.
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The possibility of different types of narcissistic personality disorder among
children has not been well studied.
Multiple theories identify narcissistic problems in childhood
Psychoanalytically informed models are not the only conceptualizations of
narcissistic problems in children. There are several other theoretical models. Bleiberg (2002) and others have proposed an atheoretical, descriptive
model of narcissistic disorders in children. Their model emphasizes limited
capacity for empathy and reflective functioning, and limited capacity to
understand both one’s own and others’ thoughts, feelings, and motives.
Bleiberg’s focus is descriptive, pointing to internal capacities linked to
problem behaviors. Penney et al. (2017) have also proposed a schema-based
model of treatment for narcissistic children which reconfigures psychoanalytic ideas about use of self and countertransference into a more or less
cognitive-behavioral model. Considerable preliminary work may be
required to obtain agreement with a child client on identifying a shared
schema. The shift to formal schema work requires a relationship of acceptance and some overt, verbal, cooperation. Techniques for initial work with
uncooperative and avoidant children to develop a working alliance need
further development.
Still others have developed standardized empirical instruments for the
assessment and measurement of narcissistic traits or behaviors in children.
For example, Thomaes et al.’s (2008) Childhood Narcissism Scale claims
valid and reliable measurement of grandiosity, entitlement, and exploitative
relationships. Guile (1996) and Guile et al. (2004) adapted the Diagnostic
Interview for Narcissism for pre-adolescents, creating a reliable model for
assessing narcissism from the parents’ perspective. While rarely diagnosed
in childhood, narcissistic disorders continue to present in child practice, to
be empirically measured, and to generate models of treatment. There is
much overlap and few differences between childhood clinical presentations
and solely adult-focused portrayals of narcissistic personality disorder.
From a neurological perspective, Morrison (2004) summarizes that
observing others’ actions activates regions of the observer’s brain involved
in executing similar actions. This type of motor resonance via mirror neurons is used by the observer, unconsciously, to cortically simulate the
observed actions. Such simulation may support the development of awareness of the feelings of others when they undertake similar actions: empathy.
In personality disorders, or their precursors, Morrison (2004) states that
“disordered perceptions of self and others would go together. In fact, the
model implies that distorted perceptions of others are really the consequence of a dysfunctional internal model of self” (p. 71). In turn, this
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suggests that treatment might center on either a) teaching the individual
that their perceptions are distorted or b) focusing instead on distortions of
the self directly. The first model may assume both a more ego-dystonic
presentation than is often found in narcissistic personality disorder, and an
active, overt engagement by the child client. The second model uses the
therapeutic relationship to implicitly build new neuronal pathways.
Morrison’s model also points to the neurological events that seem to
underly the effectiveness of psychodynamic models of work with persons
who have personality disorders, a point the author states explicitly.
Morrison’s work is consistent with Schore’s (1994) view that “the infant’s
affective interactions with the early human social environment directly and
indelibly influence the postnatal maturation of brain structures that will
regulate all future socioemotional functioning” (p. xxx).
Genetic research by Jang et al. (1996, p. 438) concludes that while monozygotic twins may inherit and display from 0 to 58% (mode ¼ 45%) of the
same personality characteristics, “unique environmental influences account
for the largest proportion of the variance for most traits.” Genetics may
influence, but do not solely shape, personality development. Many theories
can guide our clinical work. Nonetheless clinicians’ reactions to working
with clients who have narcissistic personality disorder are complex, challenging and negatively tinged.
Clinicians’ reactions: professional stigmatization
Herkov and Blashfield (1995) found that clinicians use borderline and narcissistic personality disorder diagnoses more frequently than other types of
personality disorders. These are both challenging disorders to treat in childhood or in adults. Like borderline personality disorder, individuals who
have narcissistic personality disorder are often unwelcome by clinicians
who have experienced, or know of, its treatment challenges (Sheehan et al.,
2016). Penney et al. (2017) state that “narcissistic personality disorder
remains a highly stigmatised disorder, likely due to the challenges faced by
therapists in treatment (e.g., becoming the object of narcissistic rage or
devaluation), which evoke strong countertransference” (p. 63). That is, the
stigma is generated in part through the actions and reactions of clinicians.
Persons who have narcissistic personality disorder are unlikely to feel a
need for treatment, while therapy inevitably will evoke narcissistic and
paranoid vulnerabilities, and strong countertransference from clinicians.
Our attention to others, our empathy, and our consistent long-term actions
are needed to promote effective treatment. With clients displaying avoidant
or preoccupied attachment styles, a sense of connection and alliance is
often missing or minimal. Clinicians ‘hold,’ and viscerally experience, many
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strong and painful emptions during work with child or adult clients who
have narcissistic disorders.
Similarities and differences between adult and childhood narcissistic
personality disorder
Narcissistic personality disorder in adults, and its equivalent(s) in children,
poses significant challenges to treatment, is theorized to have its origins in
developmental trauma and unempathic interactions, and typically evokes
strong countertransference reactions. Clients who have narcissistic personality disorder or present with similar behaviors can surely be challenging.
They often believe themselves superior to others and can be dismissive of
others. They may be unable to admit any faults or shortcomings. They can
fail to notice the impact of their actions on other people. When present,
moments of charm do not last long. Uncanny insight into other people’s
vulnerabilities may be used to hurt others deeply. Clients who have narcissistic personality disorder may dismiss or angrily respond to feedback from
others (Levy et al., 2009). Clients may be off-putting and may even seem
undeserving of services (Lewis & Appleby, 1988). Interacting with clients
who have narcissistic personality disorder can be difficult and personally
challenging for clinicians.
The early experiences of people who have narcissistic personality disorder often involve caregivers who were intolerant of any vulnerability,
emotionally-laden experiences, and poor performance. Serving their own
needs, caregivers often simultaneously fail to provide guidance and to set
adequate limits for inappropriate behaviors. This can lead to indulged,
grandiose children with a sense of entitlement. This type of low-key unsupportive interaction may not be evident to other adults and may not formally constitute abuse. Yet such interactions fail to support the child’s
development of socially useful and self-regulatory capacities. Status and
possessions may become substitutes for emotional connection and affection
(Behary & Dieckmann, 2013). These characteristics may continue and
solidify in adulthood to formal narcissistic personality disorder.
Note that while Kohut (1971) argued that countertransference reactions
of the clinician were key to diagnosing narcissistic personality disorder in
adults, many child focused models instead focus on behaviors of the child.
Still, the reactions of the clinician and significant others are key to
understanding the needs of the child and to managing the professional’s
use of self. Psychoanalytic ideas are reconfigured in other formulations, but
remain present and important.
When their vulnerabilities are provoked, persons with narcissistic personality disorder may react with volcanic rage and aggression (Penney et al.,
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2017). Such reactions appear disproportionate to others which may also be
viewed as inappropriate in some cultures. Clinician responses to such
behaviors include fear, feeling overwhelmed, helplessness, confusion, anxiety, resentment, wishes to withdraw and/or to retaliate. Such behaviors
intersect with our understandings of, and reactions to, the idealization of
the self or devaluation of others when no threat appears to be present,
exacerbating the clinician’s reactions and confusion. There may be initial
tolerance by adults when children show such rages, but such tolerance is
often limited.
Finally, as persons with narcissistic personality disorder seek to avoid
unwanted emotions, self-stimulating and/or self-soothing behaviors may be
present (Penney et al., 2017). Examples include drug and alcohol misuse,
binge eating, risk taking behaviors, or excessive dedication to work or hobbies. In therapy, discussion of such behaviors can lead to a ’walking on
eggshells’ experience, in which the clinician is uncertain and anxious about
how to explore these actions, leading to frustration and disengagement or
feeling stuck. The clinician may disengage, reenacting a failure of caregiver
empathy, failing to show concern, and failing to help the client set limits.
Early experiences are reenacted.
What does this look like in practice?
Richard
I first saw Richard1 as a consultant to a school classroom including children who had displayed significant behavioral concerns in school. He was a
white, overweight, clean cut boy of 10 years, appropriately dressed if a bit
disheveled. I came as an observer and watched from the back of the classroom. Richard would shoot his hand up, but yell answers to math problems almost before they were fully stated. He was loud and fast. He
beamed as he answered, looking at other children simultaneously (perhaps
for acknowledgment and affirmation). Most of his answers were incorrect,
which his teacher gently noted, urging him to think a bit more before
answering. She also gently asked that he let others have a turn at answering. His behavior continued unchanged. The other children looked at him
with sideways angry glances. Richard did not seem to notice yet the affect
was apparent and growing. Later, the teacher said it was hard to “stay
patient” with Richard, though her anger seemed close to the surface. I said
he “seemed to be a tough cookie” and she laughed, letting the tension
release. “He can be an unrelenting pain in the ass” said this terrific and
caring teacher in what I assume was an uncharacteristic assessment for her.
I asked, “Why do you think he does this?” She replied, “I really don’t
know. He’s very hard to reach. It seems like he has a glass wall around
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him which is impenetrable. Humor sometimes works but nothing really
seems to get through to him. I’ve tried my bag of tricks; nothing works.”
This is a description from a teacher with no mental health training that
closely parallels many comments in the literature on narcissistic personality disorder.
I was asked to do a clinical assessment of Richard and reached out to his
family. His mother was known to the school administration, but unseen.
She had not come to the school or met the teacher during her two years
living in this city. “She’s pretty disorganized” was the description I heard
repeatedly. She had her partner attend the IEP meetings, though it was
unclear if he could legally sign for the child as they were not married.
Following our policies, I called the mother, leaving a message asking to
meet. She did not return calls, but I got her on the phone in my fourth or
fifth try. She agreed to meet at my office in a nearby school, but she failed
to show and did not call. Realizing this cycle was not productive, I left a
message offering to meet at her home. When I arrived on that date, a protective service worker was leaving amid a lot of yelling. As we passed, the
protective worker asked who I was (I was wearing a jacket and tie). I said I
was a clinical social worker for the school system, to which she replied,
“You can have them!” Richard’s mother’s first words to me were “You
can’t take my kids!” which she expressed with considerable feeling. With
my hands out, I said I was here to hear her views, which seemed to calm
her a bit. I followed her inside, still formally uninvited. I reminder her who
I was and why I had come, making no demands. I was clear that Richard’s
behavior in school was not helping him learn to his ability and we hoped
to do better.
The small home was cluttered with tchotchkes and knickknacks but was
comfortable and generally clean. Her partner worked for a nearby major
company doing line production. She did not work, and said that she never
had worked: “My children are my life.” I said I thought Richard was clean,
and well-dressed for a 10-year-old boy. She smiled and relaxed. “I keep
them well fed” she replied. One prominent knickknack she pointed out was
a ceramic soup advertisement in the shape of the round and rosy
Campbell’s soup twins. Amazingly, the statuette was a dead ringer for
Richard and his year younger sister; idealized American children, if coy,
chubby and shy. Richard’s mother said she did not like school, had not
gone to school herself, but viewed both children as very intelligent hard
workers. She seemed at ease in telling me about the children, only seeming
uncomfortable when I asked if Richard had friends, which she did not
answer. She was willing to have me work with Richard at the school and
signed the needed consent papers. She agreed to meet from time to time
but was “too busy” to meet even biweekly on a scheduled basis.
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I only later learned that she could not read and that the sign-offs had little meaning. (Her signature was clear and seemed appropriate.) Initially, I
had no reason to believe that Richard was abused or neglected (except perhaps emotionally). I soon came to learn that Richard did all of the shopping for his mother, who was essentially agoraphobic, reinforced by her
illiteracy. He was a parentified child. He seemed to be his mother’s ego
ideal with practical benefits for her. Each piece of the puzzle came slowly.
When I first met with Richard in individual sessions at school, I began
as always with an informed consent/assent process. Public schools have few
privacy boundaries, and my professional values include informing the client
of the reasons and purposes of our interactions. I told Richard his teacher
and the principal had asked me to meet with him. They thought he was
bright and had good potential to learn, but that he was not using it fully. I
told him I had met with his mother who gave me permission to meet with
him, to which he reacted with a fleeting look of surprise. (She had not told
him this. He was taking it in. Yet his gaze was mainly averted.) During this
short speech he threw a nerf ball at the wall and caught it, but consistently
had his back to me. (This was unusual. Perhaps denying vulnerability
through avoidance and activity? Limited social skills?) In closing the
informed consent statement, I said that what we talk about together was
private from others unless he talked about harming himself or harming
others. I said I wanted him to call me on this and tell me if he thought I
did not keep my word. He then turned and looked at me. I had the feeling
I was being seen for the first time. (Kids often laugh or doubt I will keep
session content private. But they like to be informed and to be treated as
adults – with respect. Our relationship deepens later on when they find I
keep my word.) He went back to playing catch with himself, gaze averted
again, as I asked what he liked to do, what he was good at. But he said
nothing. I felt alone in the room again, alone and helpless. Drawing on my
own affect, I said sometimes it’s hard to know what we feel inside. I suggested that we get to know each other and talk, to find ways to help
Richard make the most of his abilities. (Leaving out their limitations but
suggesting a joint endeavor. I hoped to provide some guidance to our work
and to hint at a more give and take relationship.) As we went back to the
classroom, he agreed to meet with me again, saying “he was special” to be
out of the classroom. I nodded in agreement though my heart was not
quite in it. Rationally, I felt I had made a reasonable start with a less than
forthcoming child. Still, I felt I had accomplished nothing. A few quick and
furtive looks in 45 minutes. I felt angry. This would be a long and tough
one. Was this projectively identifying with how Richard felt?
Richard came easily to our appointments. He enjoyed the toys I brought,
though he avoided the families of toy animals most kids went to directly.
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He went to solitary play but sometimes asked to play Uno cards. (Cards
raised the issue of how he handled losing, not what I wished to address in
our early sessions.) He was very good at keeping silent. I tried to develop a
line of conversation that focused on (wondered about) his skills and interests, to draw him out. For example, I said that he was good at keeping
quiet but I thought he had a lot going on inside. I tried to keep a focus on
what I felt (or perhaps imagined?) were his feelings. It was difficult for me
not to become sarcastic and to remain empathic, especially with little
material other than his silent, shutting out behavior to work with.
Surprisingly, after several sessions he said “people leave me alone but don’t
like me.” Surprised, I said “Really?” He said he did not “get beat up” but
thought kids didn’t think he was good at anything. I said that must hurt
and feel lonely. He did not reply but somehow this seemed to penetrate.
He softened visibly. After some silence I asked what he thought he was
really good at (since kids did not notice these talents). He quickly said that
he shopped for his mother and helped her pay the bills: “I do lots of adult
stuff.” I said that must be a real help and quickly regretted I had not stayed
with his identifying his good points. He went silent; I had lost him to
silence again with a compliment, but that the compliment was directed to
his mother’s needs more than Richard’s. I apologized, saying I guess I
missed the point, that he did have real skills. He smiled. The smile made
me feel stupid, though I thought I had connected. (Projective identification
again? Or alternately selfobject fusion.) But he did not speak for the rest of
the session. (At no time did he seem to dissociate; somehow he came
across as ‘there,’ though deeply hidden. He did seem very
inwardly focused.)
Many aspects of our work together had this dynamic. I would say something I thought and felt was empathic and mirroring only to have Richard
respond dismissively or to turn away silent. Still, he did not feel “gone.”
Sometimes there was a verbal comment but more often a feeling; he had
found a way to get under my skin effectively. (Maybe attributing too much
agency to him.) I thought I was working appropriately and tried to imagine
what I felt as mirroring his inner life. I could see he could not tolerate
shame or challenge and expected others to be critical. I seemed to hold all
the affect.
Slow and careful efforts to get Richard to think about others’ motives
and actions moved glacially. I asked if he had a favorite story. “No.” A
favorite TV show? “No.” He liked his teacher but wished she would “help
him more.” He could not say how she might do this. I mentioned figuring
things out like this was what we do in therapy. His stories were short and
concrete, functional, and careful. Affect was limited. He felt his mother
“needed him a lot” which fit with his many activities like shopping. He felt
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she “was the one who said he was great” which was surely the case when
we met in a few family sessions. What he did for her got clear rewards and
affirmation. Despite my encouragement, he very rarely elaborated further.
Mom was positive and smothering with Richard in these sessions, talking
up his abilities unrealistically. She described him as an adult, as her caregiver. I noted she wanted a lot from him, to which he said “I can do it.” I
said that could be a bit unfair to him as a growing boy. He said nothing,
showed no reaction. I said it could be a lot for a child but many kids had
to care for others. No reaction. His “step-father” actually Mom’s boyfriend, David met with us only once. He was a shadowy figure. David
seemed distant and perhaps schizoid. One comment of David’s suggested
he was jealous of my meeting with Richard’s mother. (He was rarely mentioned by her.) Richard never mentioned him without prompting. Richard
did not seem afraid of David, merely unattached.
Over a couple of months, while I felt mired in my helplessness, the
school principal and his teacher both said that they felt Richard was
becoming less pushy and more attentive. They perhaps too generously
attributed this to my work. I was touched but also felt like a phony, a
fraud. Perhaps once again my reactions were best understood as mirroring
Richard’s inner life, but this was not affirmed by him.
After six months of work the school year ended. I worked hard to get
Richard into a two-week structured day camp with Mother’s consent and
grant funding for it. My contract with the schools allowed four sessions
with children over the summer. Meeting at his home, Richard at first
seemed more organized and said he’d go to camp (but with little enthusiasm). When the time came, his mother did not let him go. Richard said he
was OK with the decision but looked unsettled (he did not show emotion
much). Over our next contacts (no one was home for one session) he
looked less comfortable and more disheveled. The lack of structured contact and support was having a disruptive impact.
When school opened in the fall, he was placed in a mainstream classroom that was taught by his previous (and excellent) special education
teacher. He quickly rallied. The teacher was behaviorally oriented but had a
big heart and a fine sense of humor. Richard was quiet but did more work
and was much less disruptive in class. He even looked a bit happy. In my
classroom visits he did appear focused on his work, but was quiet. He had
a bemused smile as he worked. He had no friends and sat alone at recess.
One day I came to meet with him only to have his teacher say she “had
blown it.” She was frustrated with him and yelled at him (though her aide
told me this was not really so bad). She was ashamed of her actions.
Richard was like a bowl of Jello. He was shaken and sobbing. He followed
slowly when I suggested that we take a walk. I said he seemed really hurt.
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“She thinks I’m stupid! I am trying really hard. I thought she liked me.” I
stayed with his affect. He said little as usual but seemed to regroup. For the
first time with Richard I felt useful and maybe even effective. All it took
was a colleague feeling helpless and ashamed; carrying the affect. Sadly, this
was a unique session and Richard later went back to being quiet and hidden as I tried to tune in and to be supportive.
I worked with Richard for a second school year. I left this job in June
as the school year ended. He moved on to middle school and a big new
set of social and emotional challenges. His mother came to a school meeting (her first!) along with Richard. Richard was more productive in class
and was overtly acknowledged for his improved school work. Several
teachers said he was calmer and better behaved (i.e., less of a management problem.) Still he withdrew and went silent when stressed and we
had only begun to explore how he felt inside. We talked about the social
challenges of middle school and that he might be picked on. Richard
doubted this (withdrawal and avoidance work to some degree). We began
a transition to a new clinician. He still spoke little but we had begun to
have some connection.
Work with narcissistic personality disorder is long term and change is
slow. There are a few poignant moments and many more moments of
doubt and helplessness. I found that I felt rage in my countertransference
reaction to feeling as though I was not present in the room, that I did
not exist. This was pretty common in our first months of work. I never
felt it was appropriate to articulate this directly, though I would sometimes say “Ouch” when Richard said or did something that stung me.
More often I would try to articulate what I felt he was feeling. A year
later he said “ouch” once when confronted by a teacher’s aide. She was
shocked but apologized for being quite “edgy.” Maybe Richard’s skill set
was growing through identification or transmuting internalization. The
rupture and repair process was a key part of our work, but it always felt
a bit off. I think Richard had had so little experience with others tuning
into his needs that his emotional capacities were limited, partial, and not
helpful in self soothing. Yet there did seem to be some progress, bit
by bit.
It is hard to terminate when you do not feel very attached or connected.
I was concerned for Richard, even came to honestly like his effort and persistence. Over two months we (well, mainly I) reflected on our work
together. We planned ahead for the summer and next year in middle
school and a new therapist. There was no sense of loss from Richard. I told
him honestly that I would miss working with him. This was true. Yet I was
also relieved to end. I was clear with my colleague, Richard’s soon-to-be
new therapist, that he would take continued, serious work.
PSYCHOANALYTIC SOCIAL WORK
153
Narcissistic personality disorder in children
The descriptions and theories of adult narcissistic personality disorder, its
core signs and symptoms, its treatment, and its impact on clinicians, all
appear to have clear parallels in children. This contrasts sharply with the
formal view set forth in the American Psychiatric Association’s (2013)
Diagnostic and Statistical Manual (DSM) which applies the diagnosis only
to adults. Yet published reports suggest that children who appear to fit narcissistic personality disorder criteria present with a wide variation in signs
and symptoms, in levels of acting out, and in levels of verbal skill and comfort. They also vary widely in the ability to articulate experiences and feelings. Depth theories of personality can be usefully applied to child practice,
though some modifications are needed. Treatment of narcissistic personality disorder particularly requires professional use of self and ongoing selfreflection. Affirming statements or actions may be infrequent.
Treatment planning for clients who do not seek treatment, and whose
families seek to avoid engagement with others, is inherently challenging.
Such ego-syntonic presentations limit cooperation and only slowly lead to
meaningful relationship development and a long course of treatment
(Shedler & Gnaulati, 2020). Given the sensitivity to criticism among persons who have narcissistic personality disorder, great care is needed to
avoid interactions that encourage flight or dismissal. Where the ‘material’
of therapy is more action and enactment than words, it can be very difficult to feel “tuned in” to a client. Limited family support further limits progress. In the case of Richard, thinking of his needs as a personality
disorder was helpful in guiding treatment planning and implementation.
Ongoing supervisory support is also very useful in formulating these
cases and staying focused in treatment. Projective experiences can be confusing and create doubt in the clinician. Supervision helps keep the focus
on the child and to use these experiences as ‘grist’ for more accurate formulation of the case and of the client’s needs.
Working within a public institution—the public schools—adds another
dimension to such clinical work. Progress is evaluated in linear terms of fitting in and behaving in ways that fit adults’ expectations. Where a child’s
presentation is parallel to an adult personality disorder, change is likely to
be slow and erratic. The uneven, progressive and regressive, course of psychotherapy may be spoken of but does not orient evaluation of improvement in schools. Nonetheless, clinical work in schools allows for
consultation with teachers and administrators that may be helpful and
affirming to them personally as well helping to guide their professional
work with the child.
Psychoanalytic and other theories point to many similarities between
narcissistic disorders in childhood and in adults. Whether these are
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understood as personality disorders, as in adults, or as either a precursor
disorder or a distinct narcissistic disturbance remains unclear. Clinicians
are encouraged to consider how some child and adolescent clients may fit
adult personality disorder criteria. These ideas and ways of thinking may
help us understand child clients and their guide treatment usefully.
Note
1. The specifics of Richard’s case, including his name and setting, have been altered to
protect his and his family’s privacy.
ORCID
James Drisko
http://orcid.org/0000-0003-4188-858X
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Author.
American Psychiatric Association (APA). (2020). What are personality disorders? https://
www.psychiatry.org/patients-families/personality-disorders/what-are-personality-disorders
Bardenstein, K. K. (2009). The cracked mirror: Features of narcissistic personality disorder in
children. Psychiatric Annals, 39(3), 147–155. https://doi.org/10.3928/00485713-20090301-01
Beren, P. (1992). Narcissistic disorders in children. The Psychoanalytic Study of the Child,
47, 265–278. https://doi.org/10.1080/00797308.1992.11822676
Behary, W., & Dieckmann, E. (2013). Schema therapy for pathological narcissism: The art
of adaptive reparenting. In J. Ogrodniczuk (Ed.), Understanding and treating pathological
narcissism. (pp. 285–300). American Psychological Association.
Bleiberg, E. (2002). Developmental pathogenesis of narcissistic disorders in children. Bulletin
of the Menninger Clinic, 66(4), 385–315. https://doi.org/10.1521/bumc.66.4.385.23394
Bleiberg, E. (1984). “Narcissistic disorders in children” A developmental approach to diagnosis. Bulletin of the Menninger Clinic, 48(6), 501–517.
Brogaard, B. (2019, June 23). Vulnerable vs. grandiose narcissism: Which is more harmful?
Psychology Today. https://www.psychologytoday.com/us/blog/the-mysteries-love/201906/
vulnerable-vs-grandiose-narcissism-which-is-more-harmful
Brummelman, E., Thomaes, S., Nelemans, S. A., Orobio de Castro, B., Overbeek, G., &
Bushman, B. J. (2015). Origins of narcissism in children. Proceedings of the National
Academy of Sciences, 112(12), 3659–3662. https://doi.org/10.1073/pnas.1420870112
Cohen, Y. (1991). Grandiosity in children with narcissistic and borderline disorders. A
comparative analysis. The Psychoanalytic Study of the Child, 46, 307–324. https://doi.org/
10.1080/00797308.1991.11822369
Dickinson, K., & Pincus, A. (2003). Interpersonal analysis of grandiose and vulnerable narcissism. Journal of Personality Disorders, 17(3), 188–207. https://doi.org/10.1521/pedi.17.
3.188.22146
Egan, J., & Kernberg, P. F. (1984). Pathological narcissism in childhood. Journal of the
American
Psychoanalytic
Association,
32(1),
39–62.
https://doi.org/10.1177/
000306518403200104
PSYCHOANALYTIC SOCIAL WORK
155
Guile, J., Sayegh, L., Bergeron, L., Fortier, H., Goldberg, D., & Gunderson, J. (2004). Initial
reliability of the diagnostic interview for narcissism adapted for pre-adolescents: Parent
version (P-DIN). Canadian Academy of Child and Adolescent Psychiatry Review, 13(3),
74–80.
Guile, J. (1996). Identifying personality disorders in pre-adolescents. Canadian Journal of
Psychiatry, 41(6), 343–349.
Herkov, M., & Blashfield, R. (1995). Clinician diagnoses of personality disorders: Evidence
of a hierarchical structure. Journal of Personality Assessment, 65(2), 313–321. https://doi.
org/10.1207/s15327752jpa6502_7
Imbesi, L. (2000). On the etiology of narcissistic personality disorder in children and adolescents. Issues in Psychoanalytic Psychology, 22(2), 43–58.
Jang, K., Livesley, W., Vernon, P., & Jackson, D. (1996). Heritability of personality disorder
traits: A twin study. Acta Psychiatrica Scandinavica, 94(6), 438–444. https://doi.org/10.
1111/j.1600-0447.1996.tb09887.x
Jauk, E., Weigle, E., Lehmann, K, Benedek, M., Neubauer, A.C. (2017). The relationship
between grandiose and vulnerable (hypersensitive) narcissism. Frontiers in Psychology, 8,
1–10. https://doi.org/10.3389/fpsyg.2017.01600
Kealy, D., & Ogrodniczuk, J. (2011). Narcissistic interpersonal problems in clinical practice.
Harvard Review of Psychiatry, 19(6), 290–301.
Kernberg, P. F. (1989). Narcissistic personality disorder in childhood. The Psychiatric
Clinics of North America, 12(3), 671–694. https://doi.org/10.1016/S0193-953X(18)30421-0
Kernberg, P. F., Weiner, A., & Bardenstein, K. K. (2000). Personality disorders in children
and adolescents. Basic Books.
Kohut, H. (1971). The analysis of the self. International Universities Press.
Lasch, C. (1979). The culture of narcissism: American life in an age of diminishing returns.
W.W. Norton.
Levy, K. N., Chauhan, P., Clarkin, J. F., Wasserman, R. H., & Reynoso, J. S. (2009).
Narcissistic pathology: Empirical approaches. Psychiatric Annals, 39(4), 203–213. https://
doi.org/10.3928/00485713-20090401-03
Lewis, G., & Appleby, L. (1988). Personality disorder: The patients psychiatrists dislike. The
British Journal of Psychiatry: The Journal of Mental Science, 153, 44–49. https://doi.org/
10.1192/bjp.153.1.44
Miller, J. D., Lynam, D. R., Vize, C., Crowe, M., Sleep, C., Maples-Keller, J. L., Few, L. R.,
& Campbell, W. K. (2018). Vulnerable narcissism is (mostly) a disorder of neuroticism.
Journal of Personality, 86(2), 186–199. https://doi.org/10.1111/jopy.12303
Morrison, J. (2004). Understanding others by understanding the self: Neurobiological models of empathy and their relevance to personality disorders. The Canadian Child and
Adolescent Psychiatry Review ¼ La Revue Canadienne de Psychiatrie de L’enfant et de
L’adolescent, 13(3), 68–73.
Nissen-Lie, H., Johnsen Dahl, H.S., & Høglend, P. (2020) Patient factors predict therapists’
emotional countertransference differently depending on whether therapists use transference work in psychodynamic therapy. Psychotherapy Research. ttps://doi.org/10.1080/
10503307.2020.1762947
Penney, E., McGill, B., & Witham, C. (2017). Therapist stigma towards narcissistic personality disorder: Lessons learnt from borderline personality disorder. Australian Clinical
Psychologist, 3(1), 63–67.
Pincus, A., Cain, N., & Wright, A. (2014). Narcissistic grandiosity and narcissistic vulnerability in psychotherapy. Personality Disorders: Theory, Research, and Treatment, 5(4),
439–443. https://doi.org/10.1037/per0000031
156
J. DRISKO
Rosenfeld, H. (1971). A clinical approach to the psychoanalytic theory of the life and death
instincts: An investigation into the aggressive aspects of narcissism. The International
Journal of Psycho-Analysis, 52(2), 169–178.
Shedler, J., Gnaulati, E. (2020, March/April). The tyranny of time: How long does effective
therapy really take? Psychotherapy Networker. https://www.psychotherapynetworker.org/
magazine/article/2436/the-tyranny-of-time
Sheehan, L., Nieweglowski, K., & Corrigan, P. (2016). The stigma of personality disorders.
Current Psychiatry Reports, 18(1), 11–17. https://doi.org/10.1007/s11920-015-0654-1
Schore, A. (1994). Affect regulation and the origin of the self. Lawrence Erlbaum Associates.
Thomaes, S., Stegge, H., Bushman, B., Olthof, T., & Denissen, J. (2008). Development and
validation of the childhood narcissism scale. Journal of Personality Assessment, 90(4),
382–391. https://doi.org/10.1080/00223890802108162
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