Introduction Personality Disorders in Childhood and Adolescence

This theme issue considers paediatric narcissistic and borderline personality disorders from the perspectives of either diagnosis or treatment. Patients with borderline pathology, in particular, present with considerable frequency to paediatric emergency rooms for the assessment of suicidal ideation and attempts, and challenge the clinician to find innovative treatment interventions to address their distress and interpersonal difficulties. Not by any means an exhaustive overview of paediatric personality disorders in general, this issue is intended to stimulate questions concerning the validity of such constructs and their detection and management.

Many clinicians are reluctant to diagnose personality disorders (PDs) during youth, viewing paediatric personality deviations instead as reflective of given developmental stages. This is so despite evidence that certain youth are indeed at risk for the eventual development of PDs as adults. Unfortunately, late identification of these disorders prevents timely treatment and potentially increases morbidity.

This theme issue deals with three predominant questions. First, is there a paediatric construct analogous to BPD of adulthood? If a paediatric form of such a disorder exists, then according to the validity criteria of Robins (1985) it should be characterised by a specific course and treatment response as well as correlates (psychosocial and neurocognitive) serving as external validators. Second, can empathy serve as an endophenotypic marker which could further delineate certain PDs and thus promote evidence-based research? Third, can we as yet reliably identify narcissistic behaviours in youth and characterise their treatment responses and interactions with caregivers?

The first article by Bondurant et al offers an overview of the literature concerning the BPD construct during adolescence. Cross-sectional studies tend to support both the convergent and discriminant validity of this construct, but when using the adult criteria and threshold to diagnose the adolescent form of the disorder, it lacks predictive validity. This is in contradistinction to other studies (Crawford et al, 2001) which have shown an overall greater stability among Cluster B personality disorders from early adolescence to adulthood than externalizing and internalizing disorders. Nonetheless, it leads one to question whether the adult symptom criteria and threshold should be used to make the adolescent diagnosis. Prospective studies may indicate which BPD traits are most enduring.

The paper by Zelkowitz et al gives an overview of their research program into paediatric borderline pathology. Addressing a debate in child psychiatric circles concerning a potential overlap between ADHD and the borderline construct, they compared two groups of children, one suffering from borderline pathology and the other not, both attending a day hospital program. No inter- group differences were found with respect to the occurrence of ADHD. They then describe a second study wherein they demonstrated that neurocognitive deficits and a history of abuse made significant and independent contributions to the variance in borderline pathology. Their work thus provides empirical data to support the concurrent validity of this construct in children. Furthermore it stimulates paediatric research on neurobiological correlates which have been already tested in the adult BPD population (Siever et al, 2002)

Nixon et al discuss the development and initial pilot of a combined Dialectical Behavioural Therapy and Therapeutic Support Group for the treatment of self-injuring adolescents, many of whom present with borderline pathology. They provide a detailed description of their therapeutic groups and the process by which they were implemented within their therapeutic milieu. Their treatment approach, including concurrent parent and adolescent groups, were thus consistent with current treatment trends with this population and could lend themselves to implementation in other settings.

The fourth paper by Morrison explores the neurobiology of empathy which is clinically impaired or underdeveloped in several PDs, especially the narcissistic, antisocial and schizoid types. Morrison refers to a neurocognitive model, the forward model, wherein motor and emotional aspects of an experience are imprinted in our neural networks. This neural template is then automatically and non-consciously activated when the person is feeling empathetic towards another person’s experience. This theory has been consistently verified during the past decade (Singer et al, 2004), and corresponds to other neurobiological research on consciousness (Edelman, 2003). This is based on the premise that a multitude of potential synaptic connections can be formed in the brain in response to any stimulus. However, only those that are adaptive (as determined by feedback from the environment) are consolidated, and can be accessed subsequently in similar situations. This applies to the motor, emotional and cognitive components. Applied to psychopathology of personality disorders, this model suggests that such disorders are marked by either defective environmental feedback or defective integration of that feedback, leading to distorted perceptions of reality and corresponding distorted self-perceptions. These findings, which give biological and empirical credence to the construct of personality disorders, resonate with psychodynamic models of PDs as elaborated by Kernberg and Bergeret (Posner et al, 2003). Morrison considers the implications of this model for such therapeutic interventions as the cognitive-behavioural technique of role modelling, play therapy and psychodrama where the body of the therapist plays an important role.

The next two papers deal with the measurement and treatment of paediatric narcissistic conditions. Accordingly, Guile et al describe the reliability of one of several paediatric measures of those conditions which they have been studying. This measure, which was developed and tested in their psychometric research program, corresponds to the DSM-IV and was adapted from the Diagnostic Interview for Narcissism developed by Gunderson and his team (Gunderson et al., 1990) for NPD in adults. This set of instruments should allow for longitudinal studies on this disorder.

The last paper, emanating from the same research team, deals with two principle findings with respect to treatment consisting of both parent counselling and psychodynamic therapy. First, it suggests that parents of youth suffering from narcissistic disorders tend to sabotage access to treatment, perhaps concerned that such treatment would disturb an idealised dyadic relationship. Second, such youth manifest a constellation of responses to treatment, both as forms of resistance to treatment and as essential components of the treatment process, such as mirroring. Interestingly, children with underdeveloped empathic abilities resort readily to mirroring of the therapist’ attitude, reminiscent of the aforementioned findings on the neurobiology of empathy

In conclusion, research in the area of paediatric personality disorders is moving us closer to discerning the validity of these constructs in youth, their identification, treatment implications and the ultimate outcome of affected individuals.