Methodological challenges in identifying parenting behaviors as potential targets for intervention: commentary on Stepp et al. (2011).

Stepp, Whalen, Pilkonis, Hipwell, and Levine (2011) have offered us an extremely timely paper given the surge of interest in borderline psychopathology in general, and its parenting correlates in particular. This is an ambitious overview that assesses the current state of knowledge concerning the parenting of mothers with borderline personality disorder (BPD). The authors also grapple with what we can make of this literature in setting directions for prevention/intervention strategies for children of parents with BPD. This was a comprehensive and thoughtful review. In this commentary, I would like to elaborate on three issues brought to the fore by the current paper. First, I came away concluding that there is still very little in the literature that describes parenting behaviors specific to parents with BPD. This occurs in part because of the wide range of child ages included in existing studies, with some studies focused on mothers of infants only and others covering wide ranges of child age into adolescence. Infants, elementary school children, and adolescents make very different demands on parents, and procedures for assessing parenting differ markedly for these different age groups. In addition, diagnostically specific parenting constructs are generally not assessed in parenting studies of BPD, in part due to the need to use well-validated instruments for the assessment of parenting. Because most parenting constructs and parenting assessments have been developed for normative samples, parenting deviations that are specific to particular diagnostic groups are unlikely to be represented. There are strong clinical observational reasons to think that the parenting behaviors of individuals with depression, anxiety, or antisocial or borderline personality disorders, to name only a few diagnoses of interest, will be different. However, current parenting assessments have not been developed with the aim of being sensitive to these differences. Thus, not surprisingly, the literature to date primarily documents very generic parenting differences in hostility and involvement that appear similar across diagnostic groupings. One challenging but rewarding frontier in this area will be to combine validated parenting assessments with exploratory development work focused on extending those instruments to reliably capture deviations thought to be characteristic of a particular clinical group. Although the authors advance the clinically congenial proposition that parents with BPD will be likely to alternate between withdrawal and hostility, it is not clear that the available data support this description of BPD parenting. One promising advance in attachment-related research has been the development of coding systems for assessing parental behavior related to infant disorganization, namely frightened, frightening, or disrupted maternal behavior. These parenting behaviors have been validated in a metaanalysis of 12 studies and found to be associated with both maternal lack of resolution of loss or trauma and infant disorganization of attachment strategies (Madigan et al., 2006). Both of these constructs are also associated with BPD (Barone, 2003; Patrick, Hobson, Castle, Howard, Maughan, 1994; Hobson, Patrick, Crandell, Garcia-Perez, & Lee, 2005), as is overall disrupted communication (Hobson et al., 2009). The availability of these instruments opens an array of theoretical issues for further exploration, such as whether there are specific kinds of disruption in early communication (i.e. frightening vs. dissociative vs. role-confused) that are particularly characteristic of parents with different kinds of disorders. Arriving at more specific characterizations of variations in parenting will be important to the development of more specific interventions for particular forms of caregiving risk. Progress in understanding the parenting of those with BPD will also require more specificity of the observational protocols to particular developmental periods of the child. Attachment-related interactions are especially central to parenting during infancy, whereas lax or inconsistent discipline is not an issue in infancy but becomes important in toddlerhood. Role-confusion initially may appear during the preschool years but can continue to evolve in parent-child relationships through young adulthood as the child gains capacities to guide and care for the parent. If parents with BPD are more likely to exhibit shifting and contradictory stances toward the child, as proposed by the authors and described in other relationships of BPD patients, then we will also want to assess parenting across different situations (such as attachment situations calling for comfort and intimacy, play situations involving relaxation and spontaneity, teaching situations where the child’s perspective needs to be appreciated, and situations calling for parental structuring or discipline where role-confusion and parental helplessness can be assessed). Another important factor contributing to the lack of specificity in the findings regarding BPD and parenting is the small number of studies that have included both normal controls and controls with another diagnosis so that specificity can be assessed in regard to parenting difficulties (e.g. Hobson et al., 2009). It will be important going forward to assess whether parents with BPD show difficulties similar to or different from those of parents with a variety of other psychopathologies and stressors. What is evident from this review is that mothers with BPD consistently exhibit parenting difficulties relative to those without BPD. This is certainly a cause for concern and an important impetus for further work honing in on the nature of those difficulties at different stages in the child’s development. Finally, the authors did not comment on the likelihood that gene-environment transactional processes will contribute to difficulties in parent-child relationships among those with BPD, with both the child’s and parent’s genetic vulnerabilities playing a role (Gunderson & Lyons-Ruth, 2008). It will be crucial for parenting studies and interventions in this area to acknowledge the potential for such processes and to assess both child and parental contributions to the emergence of relational problems. Thus, our current understanding of parenting difficulties particular to parents with BPD is quite fragmentary. In my reading, the research base does not yet support the need for new intervention formats specific to the difficulties of patients with BPD. Instead, it seems that we should start our consideration of appropriate parenting interventions with evidence-based programs whose efficacy is supported by randomized clinical trials. This emphasis on evidence-based programs was missing from the review paper, although it is essential to grounding initial intervention efforts in a new field. Thus, a useful first step would be to take evidence-based parenting programs and adapt them to take account for our limited understanding of parenting practices particularly associated with BPD. In their review, the authors discussed in particular attachment-focused interventions, in part because research has consistently indicated that attachment disorganization is more frequent among BPD patients and their children than among normal controls (Gunderson & Lyons-Ruth, 2008). However, the randomized evidence base for the efficacy of these programs was not presented, and intervention formats with the most positive support from randomized clinical trials were not mentioned in the review (Cicchetti, Rogosch, & Toth, 2006; Heinicke, Fineman, Ponce, & Guthrie, 2001; Lieberman, Van Horn, & Ippen, 2005; Toth, Rogosch, Manly, & Cicchetti, 2006). For example, Cicchetti, Toth, and colleagues have presented strong evidence from randomized trials that a year of weekly joint child-parent psychotherapy (CPP) reduces rates of disorganized attachment among young children of both depressed and maltreating mothers, two groups with particular relevance to borderline psychopathology. Lieberman, Van Horn, and Ippen (2005) have also demonstrated its efficacy for mothers and young children exposed to marital violence. Thus, this program would be a strong candidate for use with mothers with BPD. Despite the success of this model, however, the mechanisms contributing to observed changes, such as changes in caregiver representations or interaction patterns, have not yet been identified. In addition, efficacy has only been shown in relation to infants and preschoolers, and joint parent-child treatment may not be appropriate or effective for older children. In summary, I would add three emphases to the points made by Stepp and colleagues (2011). First, we need greater specificity in our hypotheses and in our assessments of the parenting difficulties likely to be experienced by parents with BPD; second, we need to assess specificity of parenting difficulties through studies that include control groups with related diagnoses; and, third, given the lack of data on the specificity of parenting difficulties in BPD, we need to begin parenting intervention efforts with one of the number of parenting program models already supported by randomized controlled trials.