GEMS edition 16

Children of parents with a diagnosis of borderline personality disorder (BPD)

  • Author: Dianna Bartsch, M. Psych (Clinical) 
  • Series editors: Andrea Reupert and Darryl Maybery (Monash University) on behalf of the Australian COPMI national initiative.

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Quick facts

  • Mothers of infants with a diagnosis of BPD have reported high levels of dissatisfaction, feelings of incompetence and distress from their parenting role.
  • Children of parents with a diagnosis of BPD may experience greater social stressors and be more likely to witness maladaptive parental behaviour than other children. They are also at greater risk of psychopathology and psychosocial difficulties.
  • Further research is required to develop interventions to improve parenting capacity for parents with a diagnosis of BPD where concerns are identified. Programs should also aim to improve psychological, social and developmental outcomes for children.
  • Whilst the symptoms of BPD may present challenges, individuals with a diagnosis of BPD may still be capable parents.

Research summary

Borderline Personality Disorder (BPD) is a pervasive and difficult to treat disorder. It is characterised by dysregulation of emotions, behaviour, cognition, sense of self and interpersonal relationships. The prevalence of BPD in the Australian community is estimated at approximately 1% of the population. BPD is generally associated with significantly poorer psychosocial functioning and greater service utilisation, compared to other psychiatric diagnoses.

Parenting with a diagnosis of BPD and the potential impact on children

The symptoms of BPD such as labile moods, impulsivity, interpersonal difficulties, suicidal ideation and self-harm are likely to pose significant challenges for individuals who also have a parenting role. Indeed, mothers with a diagnosis of BPD have reported high levels of dissatisfaction, feelings of incompetence and distress from parenting.1

In turn, this may increase the likelihood that their children experience behavioural and/or emotional problems. This hypothesis is supported by research which suggests that the prevalence of BPD in first degree relatives is five times greater than that of the general population.2

Several studies have explored specific risks for children of parents with a diagnosis of BPD. Firstly, a number of infant studies have demonstrated that mothers with a diagnosis of BPD are less sensitive in their interactions with their infants.1,3 Furthermore, these infants have also been found to demonstrate behaviours associated with disorganised attachment.4 Studies of children aged from six to twelve years have shown that these children are more likely than others to experience changes to household composition and schooling, have greater exposure to parental substance abuse and suicide attempts, are more likely to experience maladaptive thinking patterns and insecure attachment styles, and are at greater risk of being diagnosed with a mental illness themselves.5-7 Studies of adolescents of parents with a diagnosis of BPD have also shown that these young people demonstrate higher rates of psychopathology, low self-esteem and social difficulties when compared to others.8,9 Perhaps of greatest concern was one study that found that 26% of children (aged 11- 18 years old) of parents with a diagnosis of BPD reported suicidal ideation and/or plans (compared to 9% of children where the mother did not have a psychiatric diagnosis), whilst 9% had attempted suicide in the past (compared to 2% where the mother did not have a psychiatric diagnosis).8 Finally, parents with a diagnosis of BPD are more likely to experience psychosocial stressors such as difficulties performing household tasks, maintaining employment, engaging in recreational activities and maintaining social relationships. As such, their children may be at greater risk of experiencing social isolation and poverty.10

Limitations

First, the available research is limited by small sample sizes and has predominately focussed on the experiences of mothers and children, with little consideration for the role of fathers with a diagnosis of BPD. Secondly, although it is acknowledged that children are at greater risk for transgenerational transmission of psychopathology, there is still a limited understanding of the mechanisms through which this may occur. In particular, there has been limited exploration into protective factors for children of parents with a diagnosis of BPD. This may include the involvement of spouses and other relatives such as grandparents, and participation in age-appropriate activities which promote healthy self-esteem and social relationships.

Clinical implications

There is minimal research concerning the efficacy of parenting programs to support parents with BPD. However, there have been suggestions that parents with a diagnosis of BPD may benefit from psychoeducation about child development and recommended parenting practices, training in emotional regulation skills, mindfulness parenting strategies, and attachment-based therapies.11-13 The clinical practice guideline for the management of BPD also provides a number of recommendations for clinicians on how to support these families. In general, services that work with these families can aim to identify and support parents with a diagnosis of BPD from the beginning of their parenting journey; support parents whilst they are well to plan for the children’s care in the case of a possible relapse; prevent or minimise harm to children; and assist children and young carers to become educated about their parents illness and seek support and respite where appropriate. Finally, it is also important to acknowledge that many parents with a diagnosis of BPD are capable parents, and not all children will go on to experience difficulties. Future research could benefit from exploring the factors which promote resilience within families where a parent has a diagnosis of BPD, to inform strategies to support those families that are at greater risk of adverse outcomes.

References

  1. Newman LK, Stevenson CS, Bergman LR, Boyce P. Borderline personality disorder, mother-infant interaction and parenting perceptions: Preliminary findings. Australian and New Zealand Journal of Psychiatry. 2007;41(7):598-605.
  2. Links PS, Steiner M, Huxley G. The occurrence of borderline personality disorder in the families of borderline patients. Journal of Personality Disorders. 1988;2(1):14-20.
  3. Crandell LE, Patrick MPH, Hobson RP. ‘Still-face’ interactions between mothers with borderline personality disorder and their 2-month-old infants. British Journal of Psychiatry. 2003;183(3):239-47.
  4. Hobson RP, Patrick M, Crandell L, García-Pérez R, Lee A. Personal relatedness and attachment in infants of mothers with borderline personality disorder. Development and Psychopathology. 2005;17(2):329-47.
  5. Feldman RB, Zelkowitz P, Weiss M, Vogel J, Heyman M, Paris J. A comparison of the families of mothers with borderline and nonborderline personality disorders. Comprehensive Psychiatry. 1995;36(2):157-63.
  6. Weiss M, Zelkowitz P, Feldman RB, Vogel J, Heyman M, Paris J. Psychopathology in offspring of mothers with borderline personality disorder: A pilot study. The Canadian Journal of Psychiatry. 1996;41(5):285-90.
  7. Abela JRZ, Skitch SA, Auerbach RP, Adams P. The impact of parental borderline personality disorder on vulnerability to depression in children of affectively ill parents. Journal of Personality Disorders. 2005;19(1):68-83.
  8. Barnow S, Spitzer C, Grabe HJ, Kessler C, Freyberger HJ. Individual characteristics, familial experience, and psychopathology in children of mothers with borderline personality disorder. Journal of the American Academy of Child & Adolescent Psychiatry. 2006;45(8):965-72.
  9. Herr NR, Hammen C, Brennan PA. Maternal borderline personality disorder symptoms and adolescent psychosocial functioning. Journal of Personality Disorders. 2008;22(5):451-65.
  10. Ansell EB, Sanislow CA, McGlashan TH, Grilo CM. Psychosocial impairment and treatment utilization by patients with borderline personality disorder, other personality disorders, mood and anxiety disorders, and a healthy comparison group. Comprehensive Psychiatry. 2007;48(4):329-36.
  11. Newman L, Stevenson C. Issues in infant-parent psychotherapy for mothers with borderline personality disorder. Clinical Child Psychology and Psychiatry. 2008;13(4):505-14.
  12. Stepp SD, Whalen DJ, Pilkonis PA, Hipwell AE, Levine MD. Children of mothers with borderline personality disorder: Identifying parenting behaviors as potential targets for intervention. Personality Disorders: Theory, Research, and Treatment. 2012;3(1):76-91.
  13. Ben-Porath DD. Dialectical behavior therapy applied to parent skills training: Adjunctive treatment for parents with difficulties in affect regulation. Cognitive and Behavioral Practice. 2010;17:458-65.

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