Extending research on Parenting in mothers diagnosed with BPD: Commentary on Stepp et al

With this review, Stepp and colleagues (2011) have advanced our understanding of parenting and child development within the context of maternal borderline personality disorder (BPD). It is commendable that these authors have initiated the first theoretical description of how a diagnosis of BPD may affect the quality of parenting. At the same time, this article highlights the disheartening lack of research in this area. Given the paucity of prior theoretical and empirical work exploring parenting in mothers diagnosed with BPD, advances in this area could be buttressed by current conceptualizations of parenting and empirical evidence from related parenting research. In this commentary, we highlight two main concerns and provide suggestions for moving the research in this area forward. First, we raise questions about how some of the identified parenting deficits thought to be specific to mothers with BPD will be operationalized in future basic research. Second, we suggest that the use of a behavioral approach to examining parenting in this population will facilitate both basic research and future intervention work.

Stepp et al.’s (2011) review of the existing parenting research with mothers diagnosed with BPD highlights the emphasis within this area to date on an attachment-based perspective of parenting, with little or no attention given to a behavioral perspective of parenting (which may be particularly useful for understanding parenting in this population). A behavioral perspective on parenting attends to both affective and control components (Cummings, 2000). Affective components refer to maternal warmth, responsiveness, sensitivity, and rejection (Maccoby, 2000; McLeod, Weisz & Wood, 2007). Control is comprised of behavioral and psychological control components (Barber, 1996), with behavioral control including limit setting and consistency (Hill, Bush, & Roosa, 2003) and psychological control including intrusiveness and withdrawal of affection. By taking a behavioral approach, we can more systematically operationalize and target specific parenting behaviors that are emitted more or less often by mothers diagnosed with BPD.

Stepp and colleagues raise several important points about parenting in mothers with BPD, highlighting some of the deficits that might be specific to this group. In particular, oscillations in parenting behaviors refers to fluctuations between over- and under-involvement as well as between hostile control and coldness or withdrawal (pp. 15). Presumably driven by the hallmark features of BPD, namely mothers’ affective instability and impulsivity, oscillations in parenting behaviors may be experienced by children as unpredictable, likely leading to unclear behavioral expectations or creating confusion when a mothers’ emotional responses frequently change. Consistent with a behavioral perspective on parenting, oscillations in parenting behaviors may encompass both affective aspects (wherein mothers might shift between warm affection and hostile negativity) and control aspects of parenting (shift from appropriate control to harsh, intrusive control or lax undercontrol). Although it seems highly plausible that mothers diagnosed with BPD would engage in inconsistent parenting, there have been no studies to date examining this. Before such an empirical question can be answered, though, the behaviors involved in the sequencing of oscillations in parenting must be operationalized. What exactly would we expect to observe if a mother was engaging in oscillations of parenting? Would this take the form of oscillations between different negative parenting behaviors, such as alternating between withdrawn and intrusive behaviors? Or would these be oscillations from periods of positive parenting to periods of negative parenting? Temporally, would we expect this behavioral sequence to occur within seconds, minutes, days, or weeks, or all of these variations? What observations of maternal behavior would constitute a high rating of oscillations in parenting behaviors? Would we even expect to see such oscillations in a 10-minute laboratory task or a one-hour natural home observation? Although capturing negative aspects of parenting is a challenge inherent to any observational parenting design, it seems particularly challenging to capture a construct as complex as oscillations in parenting.

By raising these questions, our goal is to highlight the sophistication of conceptualization and coding that will be required to reliably measure this complicated construct. However, we believe that such efforts are critical, as these behaviors are likely to be specific to mothers diagnosed with BPD. Because of the potentially strong merit of this construct, we anticipate that careful consideration of measurement issues will be critical to the overall pursuit of understanding ways in which mothers diagnosed with BPD may differ from mothers without psychopathology or from mothers diagnosed with other forms of psychopathology.

An additional consideration, as Stepp et al. point out, is that it is unclear what parenting deficits are specific to someone diagnosed with BPD. Oscillations or inconsistency in parenting behaviors are seen in mothers with other forms of psychopathology, such as depression (where such oscillations are thought to result from changes in the depression status of the mothers; Goodman & Gotlib, 1999). Because BPD is a chronic condition, rather than a recurrent mood state (i.e. depression), it is possible that although inconsistent parenting may be seen in mothers diagnosed with both depression and BPD, a diagnosis of BPD may lead to more rapid shifts of parenting. Efforts are needed to identify similarities and differences in children’s experiences of having a depressed mother versus a mother diagnosed with BPD.

We were also pleased to read Stepp et al.’s acknowledgement of individual differences of children that may factor into parenting success or challenges. Specifically, as Stepp et al. point out, “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” (p. 6). To buttress this argument, we point readers to the growing evidence of studies testing the transactional nature of parenting and children’s temperament (Kiff, Lengua, & Zalewski, 2011). The transaction between parenting and children’s temperament refers to the bidirectional and interactional effects inherent in parent-child relations. For instance, children lower in temperamental reactivity may elicit less negative parenting behaviors from their mothers or may be less adversely affected by negative parenting behaviors from their mothers. Given this literature, future studies examining the effects of parenting among mothers diagnosed with BPD on children’s mental health should take into account children’s temperament, which may clarify those effects. In addition, children’s temperament may be a critical factor in explaining treatment outcomes associated with future parenting intervention efforts.

Conducting more basic research from a behavioral perspective will also benefit future treatment development efforts. Stepp and colleagues identified several critical components of an effective intervention, including parenting psychoeducation, skills to promote nurturance and warmth, and mindfulness. Although we do not disagree that these are important targets, we were expecting a greater incorporation of behavioral parenting skills taken from established parent-training programs, including an emphasis on teaching parents effective use of reinforcement and punishment. Overall, we argue that the two most important components of a parenting intervention for mothers diagnosed with BPD would be a) behavioral parenting training and b) maternal emotion regulation skills training to facilitate implementation of effective parenting skills.

At a conceptual level, we believe that the most beneficial parenting intervention for mothers diagnosed with BPD will be one that is theoretically consistent with their individual treatment. Combining components of dialectical behavior therapy (Linehan, 1993), with its emphasis on mindfulness and emotion regulation, with behavioral parenting interventions (McMahon & Forehand, 2003; Webster-Stratton, 1992) will increase the likelihood of mothers learning and implementing parenting changes. Threading concepts of behavioral management, emotion management, and transactions between parent and child will afford mothers with BPD the best chance to learn how these principles cut across all domains of their lives.

In sum, precise behavioral definitions of parenting deficits specific to maternal BPD and a greater emphasis on behavioral parenting training will be critical for the empirical pursuits of basic and treatment development research for this population. We are thrilled that these authors have initiated this discourse, and hope that the rest of the field can finally take notice of, and contribute scientifically to, these endeavors.