Parenting and Personality Disorder

Dr Angus MacBethClinical Psychologist

NRS Career Research FellowNHS Grampian

University of Aberdeen

Acknowledgements

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 Adverse Childhood Experiences (ACEs) Study

Adult recall of childhood event

Dose effect response linking ACEs to: Cardiovascular disease Chronic lung disease Cancer Depression Alcoholism Drug abuse

ACEs associated with greater life time risk of 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 Material deprivation

Relative income, households without jobs Health and Safety

Infant mortality, immunisations Educational wellbeing

School achievement, post-15 education Relationships

family structure, peer relationships Behaviours and Risks

health behaviours, experience of violence Subjective Well-being

self-assessed indicators

Early experience affects outcome: Dunedin Longitudinal cohort Socially isolated children at significant risk of poor adult

health compared with non-isolated children.

Association independent of other childhood risk factors for poor adult health (low childhood socioeconomic status, low childhood IQ, childhood overweight).

Not accounted for by health-damaging behaviors (lack of exercise, smoking, alcohol misuse).

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 Family association studies report 4-20 fold

increase in BPD prevalence in relativesHeterogeneity

Familial aggregation of BPD core featuresAffective instability Impulsivity

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

Evidence for parenting difficulties for parents with PD?

Evidence for effective parenting interventions for parents with PD and their children?

What evidence…?

Parenting in BPD – Infant data

‘Still face’ experiment n=8 mothers with BPDn=12 mothers with no psychiatric disorder2-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

‘Still face’ experiment n=8 mothers with BPDn=12 mothers with no psychiatric disorder2-month-old infants

Infants from BPD group vs. control infantsmore dazed looksmore 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

80% of infants in BPD group classified as disorganised attachment

27% of infants in control group classified “D” 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

Story stem completion task (children of BPD vs control) BPD group increased likelihood vs controls to:

Talk about fantasies as well as material of a traumatic nature. Role reversal

e.g., child tells fighting parents to: “Stop that! Go to your room!”

Greater fears of abandonment Negative parent– child relationship expectations Relationships characterized by danger and/or unpredictability Incongruent representation

(e.g., child cleans his or her room then ruins it

Shameful self- representations 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: Infant-mother attachment disorganization and role reversal in mother’s child- hood. Attachment & Human Development, 10, 29 – 39.

Parenting in BPD – adolescent/adulthood outcomes 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

GxE Interactions

GxE interaction effects

Some children,for temperamental/genetic reasons are more susceptible to: Adverse effects of unsupportive parenting Beneficial effects of supportive parenting

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).

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.

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.

Genetic vulnerability/Differential Susceptibility

Evidence for differential susceptibility

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

Children (aged 4–18) of BPD mothers more likely to be exposed to environmental instability Frequent changes in housing and schoolingRemoval from the homeMaternal 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

Attachment Disorganization

Infant Disorganized/Disoriented attachment

Adult Unresolved (“U”)

Behaviour 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.

Striking 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 memoriesSubtle dissociation.

Concordance between infant and adult attachment patterns Adult attachment disorganisation (“U”)

over represented in clinical groups.

Infant attachment disorganisation linked toMaternal 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

Increased risk of psychopathology in adulthood e.g. link to dissociation (Carlsson, 1994).

Infant disorganized attachment associated with significantly greater risk of externalizing problems (d=0.34) in childhood (Fearon, 2010).

Attachment disorganization and care-giving Solomon and George emphasize that care-giving is

experienced as disorganizing. Rather than insensitive behaviour (Out et al, 2009).

Compartmentalized but contradictory representations of relationships. Not integrated in awareness… …but rapidly, unpredictably activated via behaviour.

AMBIANCE system (Lyons-Ruth et al., 1998) Contradictory parenting cues (approach/withdraw). Withdrawal behaviours (holding infant away).

Maltreatment often present but not a prerequisite.

Transmission Mechanisms

GxE Interactions Attachment Maternal representations

MentalizationCaregiving representations

Limitations of current theories

Specificity to PD (or BPD). Lack of diagnostically adapted parenting

measures in existing literature.Sensitivity to differences between depression,

anxiety, ASPD and BPD. Empirical testing. Subtle changes in variables of interest over

time.

Interventions

Interventions

Attachment based (e.g. Dozier et al) Child Parent Psychotherapy (Toth et al) Psychoeducational

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)

AimMellow Bumps RCT: Testing an antenatal psychological intervention

Design: Mellow Bumps intervention vs. control intervention vs. care-as-usual.

Aim: compare interventions’ impact on mental health of pregnant women with substantial additional health and social care needs.

 

Rationale

Can intervening in pregnancy improve outcomes?

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

Stress hormones affect foetal brain development resulting in negative effects on baby’s ability to cope with stressful stimuli

Can affect the quality of mother-infant bonding; especially if mother remains vulnerable in post-natal period.

Evidence of socio-emotional, educational and health inequalities for vulnerable children emerging at age 3

Interventions

Strategies to reduce stress

Awareness of baby

6 weekly 2 hour sessions

Baby topic

Activity for mum-to-be

> social connectivity> knowledge of

attachement and infant devellopment

< stress

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.

Strategies to reduce stress

6 weekly 2 hour sessions

Activity for mum-to-be

> social connectivity

< stress

Inclusion criteria

Outcome measures

8-12 weeks post-natal

5 days postnatal

Post-Intervention (26-36 weeks gestation)

Pre-Intervention (18-28 weeks gestation)

Adult Wellbeing Scale,Edinburgh Postnatal Depression Scale,

Saliva samples for cortisol assay

Adult Wellbeing Scale,Edinburgh Postnatal Depression Scale,

Saliva samples for cortisol assay

Saliva samples from baby pre-and post-Guthrie test

Adult Wellbeing Scale,Edinburgh Postnatal Depression Scale,

Saliva samples for cortisol assays, Semi-structured interview,

Mother-baby video

Recruitment

Withdrew n= 2 Failed contact n= 6

Withdrew n= 2 Failed contact n= 2

Declined n= 11 Failed contact n= 4

Referred n= 50

Recruited n= 35

Pre-intervention data n= 31

Post-intervention data n= 23

Participants

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

Adult Wellbeing Scale – Outward-directed irritability

Adult Wellbeing Scale – Inward-directed irritability

Preliminary results: Pre- and post- intervention

Preliminary results: Pre- and post- intervention

Edinburgh Postnatal Depression Scale

Active components of effective parent-child interventions?

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?

Thank youangus.macbeth@abdn.ac.uk