It should come as no great surprise that mothers have a profound influence on their children. But what about mothers who have their own personality disorder symptoms, such as problems getting along with others?
Secure attachment is the goal – it is when children feel comforted by the presence of their parent of caregiver and is a significant factor for socio-emotional development and mental health in youth.
Previous research has shown that insecure attachment is associated with depression and anxiety, delinquency and substance use problems, and poorer social competence in children.
“When mothers struggle in their own interpersonal relationships, the passing on of secure attachment and healthy relationship functioning to adolescent offspring seem to be impeded,” reports Carla Sharp, professor of psychology and director of the University of Houston Developmental Psychopathology Lab, in the journal Borderline Personality Disorder and Emotion Dysregulation.
“Maternal interpersonal problems were associated with higher levels of insecure attachment in adolescent offspring such that adolescents would either dismiss the need for attachment with their moms or show angry preoccupation with the relationship with their moms.”
While mothers’ problems have long been shown to be associated with maladaptive adult attachment in close or romantic relationships, this is the first study to examine relationships with offspring attachment.
Parent-child attachment security continues to play an important role through adolescence, which is thought to be the second most critical developmental window after infancy and early childhood.
Participants were asked about distressing interpersonal behaviors that they find “hard to do” (e.g., “It is hard for me to feel close to other people”) or “do too much” (e.g., “I try to please other people too much”).
The team also examined whether mothers’ recalled bonding with their own mothers to explain the relationship with their children. It did.
“The way that parents recalled their experiences with their caregivers is likely impacted by their own interpersonal functioning and may impact the relationship that they build with their children,” said Sophie Kerr, first author of the article and graduate student of Sharp’s.
“Findings highlight the mediating role of the mothers’ recalled experiences with caregivers in the impact of their interpersonal problems on adolescents, suggesting interventions that enhance interpersonal function such as mentalization-based interventions may be helpful for mothers with interpersonal problems and personality pathology,” said Sharp.
Borderline Personality Disorder (BPD) is characterized by a pattern of intense and stormy relationships, uncontrollable anger, poor impulse control, affective instability, identity and cognitive disturbances, and recurrent suicidal behavior. Individuals with BPD are likely to face a host of negative outcomes, including poor treatment response, and poor social, occupational, and academic outcomes (Bagge, Nickell, Stepp, Durrett, Jackson, & Trull, 2004; Bender et al., 2001; Skodol et al, 2002).
The day-to-day life of those with this disorder is fraught with high levels of misery, which often endures even after symptoms of impulsivity and suicide behaviors remit (Zanarini, Frankenburg, Hennen, & Silk, 2003). In clinical settings, 75% of those carrying a BPD diagnosis are women (Skodol & Bender, 2003), and there are estimated to be over 6 million women in the United States diagnosed with BPD (Friedel, 2004).
There are likely a large number of women with BPD who are also mothers, which when combined with the extensive functional impairments associated with this disorder represents a problem of enormous public concern. Thus, it is somewhat surprising that the effects of maternal BPD on children’s outcomes have been the focus of little empirical attention or treatment development efforts. Given that parenting impacts both the mother and the child, we feel that developing a parenting intervention specifically for this high-risk population is a particularly important endeavor.
Our overall aim for this work is to review parenting mechanisms that might explain the transmission of psychosocial vulnerability from mothers with BPD to their offspring, from infancy through adolescence. We first review gene-environment interaction models to explain the transgenerational transmission of the disorder.
Second, we review evidence that suggests children of mothers with BPD should be considered a high-risk group given the wide array of poor psychosocial outcomes that have been found in these children. Next, we highlight parenting practices that may explain the transmission with a focus on particular parenting mechanisms that might be especially relevant for mothers with BPD across key developmental milestones. Finally, we discuss implications for interventions with mother-child dyads and provide recommendations regarding points of intervention for this population.
Transgenerational Transmission of Borderline Personality Disorder
There is good evidence for the transgenerational transmission of this disorder (for a review see White, Gunderson, Zanarini, & Hudson, 2003). For instance, family studies assessing the rates of BPD diagnoses and related traits in first-degree relatives have found a 4- to 20- fold increase in prevalence or morbidity risk for BPD compared to the general population (e.g., Barnow, Spitzer, Grabe, Kessler, & Freyberger, 2006; Zanarini, Gunderson, Marino, Schwartz, & Frankenburg, 1988). Research supports an even stronger familial aggregation of core features of BPD, namely affective instability and impulsivity, compared to the fully diagnosed disorder (Silverman et al., 1991).
These features have been found to aggregate separately, suggesting that they may be inherited independently. Given the familial aggregation of these traits in BPD, it is not surprising that relatives of probands with BPD are also at increase risk for related psychiatric disorders, including Major Depressive Disorder, Substance Use Disorders, and Antisocial Personality Disorder (Riso, Klein, Anderson, & Ouimette, 2000; Schulz, Soloff, Kelly, Morgenstern, Franco, & Schulz, 1989; Zanarini et al., 1988).
Given the high rate of family transmission with the disorder and associated features, offspring of parents with BPD may inherit genes predisposing them to a difficult temperament, emotional reactivity, and/or impulsivity. Twin studies offer evidence for the genetic transmission of BPD. In a large, multinational community-based adult twin sample, Distel and colleagues (2007) reported a heritability estimate of 42% for BPD features. Torgersen (2000) reported a much higher heritability estimate of 69% for the diagnosis of BPD in a relatively small twin sample of clinic-referred adult participants. The discrepancy in heritability estimates is likely due to differences in sample size and sample ascertainment across the two studies. In addition, genetic influences may be stronger for individuals with more extreme forms of the disorder (i.e., those that are clinically referred and carry the diagnosis). Thus, findings from the population-based study suggest a relatively strong influence for both genetic and unique environmental experiences in accounting for variation in BPD features.
Gene-environment interaction models demonstrate the importance of an individual’s unique social environment in moderating the effects of genes on the development of psychopathology and other maladaptive outcomes (Cacioppo, Berntson, Sheridan, & McClintock, 2000). Parenting serves as an important environmental context for offspring of mothers with BPD. Theoretical models (Linehan, 1993; Fruzzetti, Shenk, & Hoffman, 2005) posit that invalidating parenting experiences transact with a child’s genetic vulnerabilities to put them at risk for poor psychosocial outcomes, including BPD and related psychopathology.
Children lower in emotional reactivity may be more likely to maintain a positive parent-child relationship since their caregivers are willing to respond positively to their emotional expressions. In contrast, negative parent-child relationships can exacerbate both the internalizing and externalizing symptoms in youth who are already emotionally dysregulated (Feinberg et al., 2007; Huh, Tristan, Wade, & Stice, 2006). Warm and accepting parenting can shield a child from negative outcomes associated with genetic and physiological vulnerabilities (Eley et al., 2004). Alternatively, children with certain genetic and physiological factors may be protected from the effects of social environments characterized by abuse, neglect, and conflict (Kaufman et al., 2006). Although it is impossible to modify a child’s genetic vulnerabilities, parenting practices may be modified and thus offer an environmental context ripe for intervention.
Several lines of evidence suggest that individuals with BPD would face heightened challenges in parenting, which could have a deleterious effect on the child’s development. First, Hobson and colleagues (1998) demonstrated that individuals with BPD displayed dysfunctional moment-to-moment relatedness with a psychotherapist, including hostility and intense, idealizing, and devaluing exchanges when compared to individuals with dysthymia. If these patterns of interaction are typical between mothers with BPD and their children, then the impact on the child’s social-emotional development would be substantial. Second, individuals with BPD tend to have attachment styles classified as disorganized and unresolved (Levy, 2005).
These attachment styles may influence the manner in which a mother relates to her child; specifically, mothers with unresolved trauma may relate to their child in a manner that oscillates between hostility and passivity (Main & Hesse, 1990). Evidence suggests that maternal BPD impacts infant affect and early markers of self and emotion regulation skills (Crandell, Patrick, & Hobson, 2003; Hobson, Patrick, Crandell, García-Pérez, & Lee, 2005; Newman, Stevenson, Bergman, & Boyce, 2007). In sum, findings from moment-to-moment interpersonal exchanges and attachment strategies highlight that parenting styles oscillating between hostile control and passive, devaluating behaviors may lead to poor regulation in infants among mothers with BPD. Based on the biosocial theory (Linehan, 1993), mothers with BPD may inadvertently create these invalidating environments for their own children by modeling their parents’ strategies; indeed, these parenting strategies may be “passed down” from generation to generation.
Mothers with personality disorders
Other studies have examined the effect of general personality pathology on parenting. Conroy and colleagues (2009) recruited a community sample of 200 mothers 8 weeks postpartum to participate in at-home assessments and observations. The authors found significant main effects of depression and personality disorders on infant care practices scores even after controlling for infant irritability, suggesting that women with depression and women with a personality disorder reported engaging in fewer recommended infant care practices (e.g., “baby is placed supine to sleep at night,” “baby is never exposed to cigarette smoke”) and lower observational ratings of maternal involvement compared to mothers without depression and without a personality disorder.
When examining the effect of personality disorder on infant care at the personality disorder cluster level (A, B, and C), there was a main effect for cluster B personality disorder status (which includes BPD, histrionic, narcissistic, and antisocial) on infant care practices but not on maternal involvement observational ratings. The lack of association between cluster B personality disorder status and maternal sensitivity observational ratings is inconsistent with findings from other studies. This discrepancy may be due to the lack of diagnostic specificity as a result of grouping personality disorders into clusters. Additionally, the observational ratings were based on one 3-minute videotaped play interaction which may not have been able to detect differences in maternal sensitivity and responsiveness.
Additionally, the Children in the Community Study (CIC; e.g., Cohen, 1996) has provided a longitudinal prospective account of parenting, parental psychopathology, and child outcomes, and was one of the first to look at child rearing in parents with Axis II disorders, but not specifically BPD. In ten recent papers using data from late childhood and early adolescence, they have shown that: (1) parental personality disorder is associated with problematic parenting; (2) maladaptive parenting is predictive of later personality disorder symptoms in offspring; and (3) parental personality disorder is associated with symptoms and disorders in offspring (Berg-Neilsen, Vikan, & Dahl, 2002; Bezirganian, Cohen, & Brook, 1993; Cohen, 1996; Cohen, Crawford, Johnson, & Kasen, 2005; Johnson, Cohen, Brown, Smailes, & Bernstein, 1999; Johnson, Cohen, Chen, Kasen, & Brook, 2006; Johnson, Cohen, Gould, Kasen, Brown, & Brook, 2002; Johnson, Cohen, Kasen, & Brook, 2006; Johnson, Cohen, Kasen, Smailes, & Brook, 2001; Johnson, Cohen, Smailes, Skodol, Brown, & Oldham, 2001). This work illustrates the importance of parenting in the transgenerational transmission of personality disorders.
reference link : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3268672/
Original Research: Open access.
“Maternal interpersonal problems and attachment security in adolescent offspring” by Sophie Kerr et al. Borderline Personality Disorder and Emotion Dysregulation