The Still-Face: A Greater Challenge for Infants of Mothers With Borderline Personality Disorder

Associations among white matter microstructural changes and the development of emotional reactivity and regulation in infancy

Deficits in emotional reactivity and regulation assessed in infancy, including high levels of negative emotionality (NE), low positive emotionality (PE) and low soothability, can predict future affective and behavioral disorders. White matter (WM) tracts develop rapidly in the first postnatal year, paralleling the development of emotional regulation. During this period, examining the development of white matter microstructure in tracts connecting cortical and/or subcortical regions supporting emotional regulation, including the cingulum bundle (CB), uncinate fasciculus (UF), and forceps minor (FM), can provide neural markers reflecting pathophysiological processes underlying early emotional regulation development. The Neurite Orientation Dispersion and Density Imaging (NODDI) model can be used to estimate with high intercellular specificity microstructural integrity and myelination using the neurite density index (NDI), and dispersion, using the orientation dispersion index (ODI). Examining relationships among changes in WM tract NODDI measures and changes in emotional reactivity and regulation during the first 3-to-9-months of age (n = 39), we showed that larger 3-to-9-month increases in right UF, FM, and left CB ODI were associated with larger decreases or smaller increases in soothability during this period, while a larger increase in right UF NDI was associated with a smaller increase in PE. These findings suggest that in infancy, larger microstructural changes in major WM tracts interconnecting neural networks supporting emotional regulation are associated with disrupted development of PE and soothability. These findings could provide early neural markers of child emotional dysregulation and may have implications for future affective or behavioral trajectories.

Early Infant Prefrontal Cortical Microstructure Predicts Present and Future Emotionality

BACKGROUND

High levels of infant negative emotionality (NE) and low positive emotionality (PE) predict future emotional and behavioral problems. The prefrontal cortex (PFC) supports emotional regulation, with each PFC subregion specializing in specific emotional processes. Neurite orientation dispersion and density imaging estimates microstructural integrity and myelination via the neurite density index (NDI) and dispersion via the orientation dispersion index (ODI), with potential to more accurately evaluate microstructural alterations in the developing brain. Yet, no study has used these indices to examine associations between PFC microstructure and concurrent or developing infant emotionality.

METHODS

We modeled PFC subregional NDI and ODI at 3 months with caregiver-reported infant NE and PE at 3 months (n = 61) and at 9 months (n = 50), using multivariable and subsequent bivariate regression models.

RESULTS

The most robust statistically significant findings were positive associations among 3-month rostral anterior cingulate cortex (ACC) ODI and caudal ACC NDI and concurrent NE, a positive association between 3-month lateral orbitofrontal cortex ODI and prospective NE, and a negative association between 3-month dorsolateral PFC ODI and concurrent PE. Multivariate models also revealed that other PFC subregional microstructure measures, as well as infant and caregiver sociodemographic and clinical factors, predicted infant 3- and 9-month NE and PE.

CONCLUSIONS

Greater NDI and ODI, reflecting greater microstructural complexity, in PFC regions supporting salience perception (rostral ACC), decision making (lateral orbitofrontal cortex), action selection (caudal ACC), and attentional processes (dorsolateral PFC) might result in greater integration of these subregions with other neural networks and greater attention to salient negative external cues, thus higher NE and/or lower PE. These findings provide potential infant cortical markers of future psychopathology risk.

A thematic analysis of the subjective experiences of mothers with borderline personality disorder who completed Mother-Infant Dialectical Behaviour Therapy: a 3-year follow-up

BACKGROUND

Perinatal borderline personality disorder (BPD) is a common condition in perinatal mental health settings with few specialised treatment options, and little is known about the enduring effects of available treatment programs. This study explored the follow-up experiences of women with BPD after completing Mother-Infant Dialectical Behaviour Therapy (MI-DBT).

METHODS

Semi-structured interviews were conducted with eight women who had completed MI-DBT 3 years prior. Reflexive Thematic Analysis was used to analyse the interviews to gain a richer understanding of these mothers' lived experience.

RESULTS

A thematic analysis generated four main themes which indicated that participants found that MI-DBT improved their ability to hold their child in mind, be aware of their own internal state and behaviours, manage their own emotional reactions and stay calm, and manage interpersonal interactions within adult relationships. Mothers with perinatal borderline personality disorder also highlighted the need for ongoing support in the context of parenting.

CONCLUSIONS

This study is the first of its kind to explore the longer-term experiences of mothers following such an intervention, giving voice to this vulnerable group of women. The findings of this study provide a greater understanding of the complex challenges experienced as part of parenting for mothers with borderline personality disorder, and provides both insight into mothers' experiences of life after MI-DBT and the impact of the program on their lives. The clinical and research implications of the study's findings are discussed.

TRIAL REGISTRATION

This research was retrospectively registered on 07/03/2024, ACTRN12624000225516.

Maternal Borderline Personality Disorder Severity and Parenting Behaviors During Conflict Discussions With Adolescent Offspring

Examining the impact of maternal borderline personality disorder (BPD) on parent-child interactions could elucidate pathways of intergenerational risk and inform intervention. The current study used an expanded version of the Observing Mediational Interactions to investigate (a) associations between maternal BPD symptom severity and mediational parenting behaviors during conflict discussions with clinically referred early adolescent offspring (N = 56, age = 10-15, 54% female) and their mothers, and (b) the potential moderating role of early adolescent BPD symptom severity in those associations. Consistent with hypotheses, mothers with higher levels of BPD symptom severity engaged in fewer positive emotional/attachment-based behaviors and more negative (i.e., invalidating, controlling, coercive, or insensitive) parenting behaviors. Only parent-reported, but not self-reported, adolescent BPD severity moderated these associations; maternal BPD severity was significantly associated only with negative parenting in dyads with low-to-moderate levels of parent-reported adolescent BPD severity. We discuss implications including targeting attachment-based and negative parenting behaviors in intervention.

Parenting knowledge and parenting self-efficacy of mothers with borderline personality disorder and depression: "I know what to do but think I am not doing it"

Borderline personality disorder (BPD) is a complex mental health condition often associated with previous childhood adversity including maladaptive parenting. When becoming a parent themselves, mothers with BPD have difficulties with various parenting cognitions and practices, but unknown is whether they have appropriate knowledge of sensitive parenting. This study explored whether differences in parenting knowledge or self-efficacy are specific to BPD or also found in mothers with depression, and whether symptom severity or specific diagnosis better explain parenting perceptions. Mothers with BPD (n = 26), depression (n = 25) or HCs (n = 25) completed a Q-sort parenting knowledge task and a parenting self-efficacy questionnaire. Results showed mothers with BPD had the same knowledge of sensitive parenting behaviors as mothers with depression and healthy mothers. Self-reported parenting self-efficacy was lower in mothers with BPD and depression compared with healthy mothers, with symptom severity most strongly associated. A significant but low correlation was found between parenting self-efficacy and knowledge. Findings suggest that mothers with BPD and depression know what good parenting is but think they are not parenting well. Mental health difficulties are not associated with parenting knowledge, but symptom severity appears to be a common pathway to lower parenting self-efficacy. Future interventions should test whether reduction of symptom severity or positive parenting feedback could improve parenting self-efficacy.

Microsocial analysis of dyadic interactions with toddlers and mothers with borderline personality disorder

Borderline personality disorder (BPD) is known for disruptions in mother-child interaction, but possible underlying patterns of micro-behavior are barely understood. This is the first study examining behavioral dyadic synchrony-the coordinated and reciprocal adaptation of behavior-and regulation on a micro-level and relating it to macro-behavior in mothers with BPD and their toddlers. Twenty-five mothers with BPD and 29 healthy mothers participated with their 18- to 36-month-old toddlers in a frustration-inducing paradigm. Mother and toddler behavior was continuously micro-coded for gaze, affect, and vocalization. Synchrony, operationalized as the simultaneous engagement in social gaze and positive affect, and (co-)regulative behaviors and their contingencies were analyzed and associated with borderline symptom severity, the overall quality of interaction, and child internalizing and externalizing behavioral problems. Dyads with mothers with BPD showed significantly less synchrony compared to dyads with healthy mothers. Low synchrony was associated with high BPD symptom severity and low overall interaction quality. Dyads with BPD used the same amount of regulative behaviors as dyads with healthy mothers. Though both groups equally responded to children's negative emotionality, mothers with BPD were less effective in drawing the dyad back into synchrony. For dyads with BPD, regulative behaviors were negatively associated with child externalizing behaviors. BPD symptomology may reduce the effectiveness of mothers' attempts to attune to their child's needs. An emphasis on synchrony and regulative behaviors may be an important therapeutic target for parenting programs in mothers with BPD.

Early infant prefrontal gray matter volume is associated with concurrent and future infant emotionality

High levels of infant negative emotionality (NE) are associated with emotional and behavioral problems later in childhood. Identifying neural markers of high NE as well as low positive emotionality (PE) in infancy can provide neural markers to aid early identification of vulnerability, and inform interventions to help delay or even prevent psychiatric disorders before the manifestation of symptoms. Prefrontal cortical (PFC) subregions support the regulation of NE and PE, with each PFC subregion differentially specializing in distinct emotional regulation processes. Gray matter (GM) volume measures show good test-retest reliability, and thus have potential use as neural markers of NE and PE. Yet, while studies showed PFC GM structural abnormalities in adolescents and young adults with affective disorders, few studies examined how PFC subregional GM measures are associated with NE and PE in infancy. We aimed to identify relationships among GM in prefrontal cortical subregions at 3 months and caregiver report of infant NE and PE, covarying for infant age and gender and caregiver sociodemographic and clinical variables, in two independent samples at 3 months (Primary: n = 75; Replication sample: n = 40) and at 9 months (Primary: n = 44; Replication sample: n = 40). In the primary sample, greater 3-month medial superior frontal cortical volume was associated with higher infant 3-month NE (p < 0.05); greater 3-month ventrolateral prefrontal cortical volume predicted lower infant 9-month PE (p < 0.05), even after controlling for 3-month NE and PE. GM volume in other PFC subregions also predicted infant 3- and 9-month NE and PE, together with infant demographic factors, caregiver age, and/or caregiver affective instability and anxiety. These findings were replicated in the independent sample. To our knowledge, this is the first study to determine in primary and replication samples associations among infant PFC GM volumes and concurrent and prospective NE and PE, and identify promising, early markers of future psychopathology risk.

Study protocol for a multi-center RCT testing a group-based parenting intervention tailored to mothers with borderline personality disorder against a waiting control group (ProChild*-SP1)

Background/aims

Borderline personality disorder (BPD) is a severe mental disorder characterized by an unstable sense of self, intense and rapidly changing affect, as well as impulsive and self-destructive behaviors. Interpersonal relationships of individuals with BPD are characterized by marked instability, a lack of dependability, and quick changes between love and hate. For children of individuals with BPD, this can lead to permanent stress and attachment insecurity and an increased risk of adverse physical and mental health development. To reduce dysfunctional parenting and improve positive parenting, and in turn, to promote healthy child development, a group intervention for mothers with BPD was developed. This study aims to evaluate this first disorder-specific parenting intervention for BPD in a randomized controlled trial.

Method

In a parallel-group, two-arm, randomized controlled trial, an initial N = 178 mothers diagnosed with BPD and their children aged 6 months to 6 years are assigned to either the parenting intervention or a waiting control group. If taking place, participants of both groups continue their regular treatment for BPD diagnosis (e.g., individual therapy, medication). The primary outcomes are changes in parenting from baseline (day 0) to post intervention (week 12) and follow-up (6 months after group intervention; month 9). The waiting control group can attend the group intervention at the end of all assessments. Participants allocated to the intervention group are expected to show improvement in their parenting and a reduction in child abuse potential. Maternal emotion regulation and mental distress are analyzed as secondary outcomes.

Discussion

Mothers with BPD may need tailored help when reporting difficulties raising their children. The first disorder-specific parenting intervention has been developed to close this gap. ProChild is part of a large government-supported consortium, which aims to investigate different aspects of abuse and maltreatment in childhood and adolescence.

Trial registration

ClinicalTrials.gov NCT04169048. Registered on Nov 19, 2019.

Clinical Trial Data: Both Parents Having Psychiatric Symptoms as Risk Factor for Children's Mental Illness

Children of mentally ill parents represent a particularly vulnerable risk group for the development of mental illness. This study examines whether there is a predictive association between children's psychiatric symptomatology and (1) the clinical diagnosis according to the International Statistical Classification of Diseases and Related Health Problems (ICD-10) of their mentally ill parent as well as (2) to families both parents showing psychiatric symptoms. The study is part of the multicenter controlled trial project "Children of Mentally Ill Parents" (CHIMPS). For this purpose, the psychiatric symptomatology of the mentally ill parent (N = 196) and his or her partner (N = 134) as well as the psychiatric symptomatology of their children aged 4 to 18 years (N = 290) was measured using clinical rated ICD-10-diagnosis, self-rated Brief Symptom Inventory (BSI), and Child Behavior Checklist (CBCL). Using multilevel analyses, the severity of the parental psychiatric symptomatology (BSI) was identified as a significant predictor of children's psychiatric symptomatology (CBCL). Children of parents with a personality disorder (ICD-10) were not more affected than children of parents with another ICD-10-diagnosis. However, children with two parents showing psychiatric symptoms (CBCL) were significantly more affected than children with one mentally ill parent. The results of this study support the well-known view that parental mental illness is a risk factor for children's psychiatric symptoms. Therefore, increased support, especially in high-risk families, both parents having psychiatric symptoms, is highly necessary and should be implemented in the future psychotherapeutic family care.

Panda Unit, a Mother-Baby Unit Nested in a Neonatal Care Service

The PANDA unit is a full-time mother-baby hospitalization unit based on an original model of care for vulnerable dyads. It is located within a neonatal unit allowing tripartite care (perinatal psychiatry, neonatology and post-natal care). It thus differs from traditional mother-baby units in its close links with the other perinatal care actors, allowing comprehensive health and mental health care in the immediate post-partum period. Patients admitted to the Panda Unit may have been referred during the antenatal period or taken into care in an emergency if the mother's clinical condition requires it, in the aftermath of childbirth. During their stay, the dyads are evaluated daily by a perinatal psychiatrist. This includes assessment of maternal clinical state, the newborn's development and the quality of mother-infant interactions. During the first 6 months of use, 24 dyads have benefited from PANDA care. Three women among 5 were admitted during the antenatal period and almost one-third were aged under 21. The first primary diagnosis during the antepartum was major depressive disorder, two-fold that of personality disorder or bipolar disorder alone. At the end of PANDA stay, close to 3 women among 4 were back to their home with their child, and an out-of-home placement was mandated for 4 infants. PANDA unit is a step toward continuous and comprehensive integrative care. The mother and baby do not leave the maternity ward, and management of mother, baby, and their interactions can start immediately after birth. Considering the importance of the first months of life in the establishment of fundamental links and bonding, PANDA offers an innovative opportunity for what we hope will be both therapeutic and preventive for at-risk dyads. The detection, and ultimately prevention and management of risk of abuse and neglect is another major challenge that this unit hopes to address from the very beginning.

Patterns of Infant Amygdala Connectivity Mediate the Impact of High Caregiver Affect on Reducing Infant Smiling: Discovery and Replication

BACKGROUND

Behavioral research indicates that caregiver mood disorders and emotional instability in the early months following childbirth are associated with lower positive emotionality and higher negative emotionality in infants, but the neural mechanisms remain understudied.

METHODS

Using resting-state functional connectivity as a measure of the functional architecture of the early infant brain, we aimed to determine the extent to which connectivity between the amygdala, a key region supporting emotional learning and perception, and large-scale neural networks mediated the association between caregiver affect and anxiety and early infant negative emotionality and positive emotionality. Two samples of infants (first sample: n = 58; second sample: n = 31) 3 months of age underwent magnetic resonance imaging during natural sleep.

RESULTS

During infancy, greater resting-state functional connectivity between the amygdala and the salience network and, to a lesser extent, lower amygdala and executive control network resting-state functional connectivity mediated the effect of greater caregiver postpartum depression and trait anxiety on reducing infant smiling (familywise error-corrected p < .05). Furthermore, results from the first sample were replicated in the second, independent sample, to a greater extent for caregiver depression than for caregiver anxiety.

CONCLUSIONS

We provide evidence of early objective neural markers that can help identify infants who are more likely to be at risk from, versus those who might be protected against, the deleterious effects of caregiver depression and anxiety and reduced positive emotionality.

Differences in interactional behaviour in postpartum depression with and without pre-existing mental disorder

BACKGROUND

Mothers with postpartum depression (PPD) show impaired affects and behaviour patterns in the mother-child interaction, which affects an infant's emotional and cognitive development and the maternal course of disease. However, impairment of the mother-child relationship does not occur in every case of PPD.

AIM

The aim of this exploratory-descriptive video-based study was to investigate the possible associations between mother-child interactions and aspects of maternal biography and clinical history, with a focus on pre-existing mental disorder.

METHODS

Sixty-two mother-child dyads (31 mothers with PPD and pre-existing mental disorders and 31 mothers with PPD but no further mental disorder) hospitalized at the mother and baby unit (MBU) of the LWL-Hospital Herten were included in this study. The Marcé Clinical Checklist and the "Mannheimer Beurteilungsskala zur Erfassung der Mutter-Kind-Interaktion im Säuglingsalter" (MBS-MKI-S) were used to explore sociodemographic and clinical parameters, and video-based interaction behaviour was examined.

RESULTS

Mother-infant interaction behaviour showed a significant group difference on the MBS-MKI-S-Vm subscale (variability in maternal behaviour) before psychiatric treatment (exact Mann-Whitney U test: U = 555, p = 0.023), with higher scores in mothers with a pre-existing mental disorder. Furthermore, significant differences were shown on the MBS-MKI-S-RSm (maternal reactivity/sensitivity) (U = 259, p = 0.019) and MBS-MKI-S-Rc (child's reactivity) subscales at discharge (U = 251, p = 0.021). Among mothers with a pre-existing diagnosis, the MBS-MKI-S-Tm (maternal tenderness) and MBS-MKI-S-Rc (child's reactivity) subscales were significantly correlated after treatment.

CONCLUSIONS

Mothers with PPD and a pre-existing mental disorder displayed significantly more behavioural variability than mothers with only PPD. Maternal behaviour seems to influence the child's responsive behaviour; thus, mothers and their children can benefit from inpatient treatment at an MBU. Further investigations with larger samples should be conducted.

A systematic review and meta-analysis of 'Systems for Social Processes' in borderline personality and substance use disorders

Deficits in social processing (SP) have been proposed to underpin interpersonal dysfunction in both Borderline Personality Disorder (BPD) and Substance Use Disorders (SUD). This study aimed to explore potential transdiagnostic cognitive and behavioral phenotypes of these disorders utilizing the NIMH Research Domain Criteria 'Systems for Social Processes'. A systematic review and meta-analysis of the published research was conducted on 134 studies identified through our database searches. Four meta-analyses were conducted, which revealed significant overlapping deficits in the ability to identify facial emotions and infer the mental states of others in both BPD and SUD. Further, people with BPD displayed a higher ostracism effect following perceived social exclusion. Systematically reviewed studies also revealed significant dysfunction amongst individuals with BPD and SUD across both self and other SP constructs, which were broadly similar in magnitude. Taken together, these results support the proposition that SP dysfunction may be considered a core transdiagnostic phenotype of BPD and SUD.

Familiäre Transmission der Borderline-Persönlichkeitsstörung

Hintergrund

Forschungsergebnisse weisen übereinstimmend darauf hin, dass Kinder von Müttern mit einer Borderline-Persönlichkeitsstörung (BPS) ein erhöhtes Risiko aufweisen, emotionale und verhaltensbezogene Auffälligkeiten zu entwickeln und/oder im Jugendalter selbst BPS-spezifische Symptomausprägungen zu zeigen.

Fragestellung

Welche Faktoren sind bei der familiären Transmission der BPS involviert, und welche Implikationen für die Praxis können darauf aufbauend abgeleitet werden?

Material und Methode

Auf der Basis einer umfassenden Literaturrecherche wurden aktuelle Forschungsbefunde zur familiären Transmission der BPS von Müttern zu ihren Kindern zusammengetragen und Kernbefunde in einem Transmissionsmodell integriert.

Ergebnisse

Das hier postulierte Transmissionsmodell bildet ein komplexes Zusammenspiel verschiedener Einflussfaktoren und Übertragungsmechanismen ab. Neben Faktoren aufseiten der Mutter und des Kindes werden externe Faktoren in das Modell integriert. Darüber hinaus werden (epi-)genetische und pränatale Einflüsse, die Bedeutung der Mutter-Kind-Interaktion und familiäre sowie soziale bzw. gesellschaftliche Einflüsse als Übertragungsmechanismen betont. Zudem wird eine potenziell präventive Wirkung der Hilfesysteme angenommen.

Schlussfolgerung

Aus dem Modell werden Ansatzpunkte abgeleitet, die dazu beitragen könnten, die Vulnerabilität sowie Belastungsfaktoren zu reduzieren und somit eine gesunde kindliche Entwicklung in dieser Risikogruppe zu fördern.

Parenting in Patients with Borderline Personality Disorder, Sequelae for the Offspring and Approaches to Treatment and Prevention

PURPOSE OF REVIEW

We review recent findings concerning the implications of borderline personality disorder (BPD) on parenting behaviors, the parent-child relationships, and parental and child outcomes. We focus on self-report and interview data characterizing parents with BPD and their children as well as on observational paradigms investigating parent-child relationships and the quality of dyadic interactions. Novel treatment approaches are discussed.

RECENT FINDINGS

Parents with BPD suffer from increased parenting stress and display characteristic behavioral patterns towards their children, impeding the formation of a healthy parent-child relationship and disrupting offspring emotional development. Offspring are at greater risk of maltreatment and developing BPD themselves, with parental affective instability playing a substantial mediating role. Mothers with BPD face a meaningful burden in their parenting role. Mechanisms of the transmission of BPD pathology onto the following generation are beginning to be understood. Targeted interventions have been devised recently, with preliminary testing producing encouraging results.

Impact of prenatal stress on mother-infant dyadic behavior during the still-face paradigm

BACKGROUND

Mother-infant interaction provides important training for the infant's ability to cope with stress and the development of resilience. Prenatal stress (PS) and its impact on the offspring's development have long been a focus of stress research, with studies highlighting both harmful and beneficial effects. The aim of the current study was to examine the possible influence of both psychological stress and hypothalamic-pituitary-adrenal (HPA) axis activity during pregnancy with mother-child dyadic behavior following stress exposure.

METHODS

The behavior of 164 mother-infant dyads during the still-face situation was filmed at six months postpartum and coded into three dyadic patterns: 1) both positive, 2) infant protesting-mother positive, and 3) infant protesting-mother negative. PS exposure was assessed prenatally according to psychological measures (i.e., psychopathological, perceived and psychosocial PS; n = 164) and HPA axis activity measures (maternal salivary cortisol, i.e., cortisol decline and area under the curve with respect to ground (AUCg); n = 134).

RESULTS

Mother-infant dyads in both the high- and low-stress groups showed decreasing positive and increasing negative dyadic behavior in the reunion episode, which is associated with the well-known "still-face" and "carry-over" effect. Furthermore, mother-infant dyads with higher psychosocial PS exhibited significantly more positive dyadic behavior than the low psychosocial PS group in the first play episode, but not in the reunion episode. Similarly, mother-infant dyads with high HPA axis activity (i.e. high AUCg) but steeper diurnal cortisol decline (i.e. cortisol decline) displayed significantly less negative behavior in the reunion episode than dyads with low HPA axis activity. No significant results were found for psychopathological stress and perceived stress.

CONCLUSIONS

The results suggest a beneficial effect of higher psychosocial PS and higher prenatal maternal HPA axis activity in late gestation, which is in line with "stress inoculation" theories.

[Supporting the encounter of mothers suffering from borderline conditions with their baby]

Mothers suffering from borderline conditions are overwhelmed by emotions. Their interactions are tainted with qualitative discontinuities, unpredictable for infants. These high-risk situations must not be trivialised. They are characterised by the importance of providing rapid support to the baby and by the existence of maternal suffering. The infant's basic needs guide the professionals working with these families.

Update on Mental Health of Infants and Children of Parents Affected With Mental Health Issues

This paper highlights the most recent publications, in the field of psychiatry, on offspring of patients with psychiatric illnesses such as schizophrenia and bipolar disorder, and then summarizes what we know about the progeny of adults with mood disorders, the most prevalent of parental disorders. Studies examining personality disorders and contextual factors such as stress and trauma are examined with a focus on the crucial question of development and attachment status in children. Findings converge to reveal that offspring of parents (generally mothers) with most major psychiatric disorders present a higher risk for all mental disorders, and a wide range of disorders are also found in children, adolescent, and finally adult offspring of mothers with mood and anxiety disorders. Developmental psychopathology and infant and child psychiatry have focused on early relationship formation through social interaction and attachment patterns as pathways affected by vulnerability or resilience factors. First year of life longitudinal studies following mothers and infants has shown that maternal psychopathology is positively correlated with higher risk of attachment issues. It would seem that pathology appears when adaptation to real-life contexts becomes difficult in association with an accumulation of negative individual characteristics and environmental circumstances. We suggest that in order to move forward psychiatry should embrace a developmental cascade model, which posits a cumulative pathway for the emergence of psychopathology in the developing child. We propose that we have sufficient knowledge today to start implementing multilevel approaches to enhance the health and mental health of the next generation.

The global problem of child maltreatment: Perspectives on mechanisms of influence and illness presentation

Child abuse and neglect negatively impact both neurological and psychological development. Patterns of abuse are learned and repeated in families. Adverse childhood experiences are a risk factor for psychopathology later in life, including borderline personality disorder (BPD). BPD is prevalent in clinical populations in the United States, but its prevalence has not been well-documented in most other parts of the world. The aim of this paper is to explore the impact of culture upon the intergenerational transmission of childhood maltreatment and the clinical presentation of abused children. To facilitate this exploration, we will consider the cases of four adolescent girls in unique socioeconomic and cultural settings around the world: Liberia, El Salvador, India, and a Congolese immigrant in France. Each of these girls endorsed some features of BPD, but only two met full criteria. In societies in which externalizing behaviors are not acceptable, children may internalize their distress or separate from their families. Defining BPD in terms of internal experience makes it more difficult to identify, but it would allow for the inclusion of cases in which symptoms may manifest differently while the underlying problem is similar.

"There is not much help for mothers like me": Parenting Skills for Mothers with Borderline Personality Disorder - a newly developed group training program

BACKGROUND

Dysfunctional relationships and emotion dysregulation are hallmark features of borderline personality disorder (BPD). Women with BPD are, therefore, particularly challenged when raising a child. A group training program was developed for mothers with BPD to enhance their parenting skills and help them raise their children. The program is based on cognitive-behavioral principles and skills derived from Dialectical Behavior Therapy (DBT).

METHODS

N = 15 mothers with BPD who had young children (aged 0-6 years) participated in a 12-week training program. To estimate the participants' impairment, parental stress and psychological distress were assessed before the training. After the training, participants and trainers were asked to provide feedback regarding the evaluation of and the changes due to the training.

RESULTS

Participants' self-reported stress related to parenting, as well as psychological distress and depressive symptoms, was high. Participants' acceptance of the program was very good. Especially role plays were rated as useful. Trainers evaluated the program as helpful and reported visible changes in participants' behavior and attitudes towards parenting.

CONCLUSIONS

The results on the acceptance of the training program are promising.

TRIAL REGISTRATION

NCT02935218, Unique Protocol ID: RenRos01 Initial release 80 August 2016, last release 13 October 2016; 'retrospectively registered'.