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1.5.6 Parental Personality Disorder


Contents

  1. Introduction
  2. Emotionally Unstable Personality Disorder (Borderline Personality)
  3. Personality Disorders that can be Associated with Fabricated or Induced Illness (FII)
  4. Those Diagnosed with or Suspected of having Antisocial Personality Disorder (also known as Psychopathic Personality)
  5. Useful Contacts
  6. References


1. Introduction

There is separate Leicester Safeguarding Children Board and Leicestershire and Rutland Safeguarding Children Board practice guidance in relation to Adult Mental Health and Child Protection Guidance. Readers are advised to read this guidance about parents with personality disorder in conjunction with the more general guidance about adult mental health

There are some particular factors to be aware of in regard to people with a personality disorder. They may have very limited ability to cope with the symptoms of relatively moderate mental health problems (e.g. mild anxiety or depression). Such parents will find it much harder to prioritise their children's needs or offer an appropriate consistency of care than some other parents. They are more likely to act impulsively and to be more easily overwhelmed by adversity.

Parents with Personality Disorder may be less likely to engage and sustain a commitment to treatment. They also may fluctuate in their capacity to relate to Social Care and Health Professionals. At times some parents may become upset and antagonistic towards professionals on other occasions they will be receptive and grateful for the support in the care of their children. The challenge for professionals is to develop and sustain a working relationship with the parent whilst keeping their focus on the child's welfare and safety.

There are different categories of personality disorder all of which vary in their presentation and the risks they pose to children.


2. Emotionally Unstable Personality Disorder (Borderline Personality)

People with emotionally unstable or borderline personality disorder tend to have poor patterns of attachment and fears of abandonment that impact negatively on their relationships, both personal and with professionals. There is a strong link for people with borderline personality disorder having themselves experienced severe abuse and trauma in childhood. These experiences may go on to have a negative effect on relationships and the parenting style they develop with their own children. They can present with chaotic and impulsive behaviours, and have great difficulty containing their emotions, which can affect their ability to maintain appropriate boundaries. To manage these intense feelings they often resort to negative coping strategies such as self-harming behaviour in the form of cutting, overdosing or substance misuse. These behaviours raise questions about their consistency, predictability and emotional availability as parents.

It is generally more helpful to think about the difficulties individual parents are trying to manage rather than the specifics of a diagnosis. Parents may present these styles of behaviour and may not have a diagnosis or only recently received a diagnosis. However the presenting issues may be part of long standing pattern that impacts on the welfare and safety of the child. Alternatively there may be specific trigger factors related to significant life events e.g. the particular age of a child, anniversary of a death that result in a breakdown of previous good coping strategies.

  • Treatment options for a parent/carer with emotionally unstable personality disorder (Borderline personality);
  • (see The National Institute for Health and Clinical Excellence (NICE) guidelines for borderline personality disorder Jan 2009);
  • It is often helpful to encourage a client with these difficulties to engage in therapy at Francis Dixon Lodge. Because trust is often a problem, this service makes a lot of effort to build an alliance with anxious clients and runs a number of informal introductory groups for those who find the process of therapy difficult. Eventually, with regular therapy over a prolonged period, the client manages better to contain their inner distress and develops some stability with a reduction in impulsive behaviour. At Francis Dixon Lodge, there are a number of different group programmes at various levels of intensity from the 5 day therapeutic community to once weekly therapy groups. This includes a twice weekly women-only programme which runs during school hours.


3. Personality Disorders that can be Associated with Fabricated or Induced Illness (FII)

No one specific personality disorder is associated with this behaviour but it is more common with an adult with a personality disorder. Only a small number of adults with personality disorder come into this category. One of the worrying presentations involve adults with somatisation disorders and/or with a history of fabricating or inducing illness in themselves. The very limited research evidence suggests that such adults, when they become parents, are more likely to engage in fabricating or inducing illness (FII) in their children. FII is extremely rare but it is also probably under-diagnosed. For further information please see Fabricated or Induced Illness Procedure.

Parents who engage in FII, who also have a psychiatric diagnosis, are more likely to be diagnosed with a personality disorder than any other mental disorder. Again the numbers are very small.


4. Those Diagnosed with or Suspected of having Antisocial Personality Disorder (also known as Psychopathic Personality)

Antisocial personality disorder is associated with a wide range of interpersonal and social disturbance.

People with antisocial personality disorder exhibit traits of:

  • Impulsivity;
  • High negative emotionality;
  • Low conscientiousness;
  • Irresponsible and exploitative behaviour;
  • Recklessness;
  • Deceitfulness.

These traits are apparent in:

  • Unstable interpersonal relationships;
  • Disregard for the consequences of one's behaviour;
  • A failure to learn from experience;
  • Egocentricity;
  • Disregard for the feelings of others.

These traits all present challenges for developing effective parenting. People with antisocial personality disorder have often grown up in fractured families in which parental conflict is typical and parenting is harsh and inconsistent. Families or carers are important in prevention and treatment of antisocial personality disorder. Due to the importance of development in antisocial personality disorder there are implications for children raised by individuals with antisocial personality disorder creating cyclical patterns

Criminal behaviour is central to the definition of antisocial personality disorder, although it is often the culmination of previous and long-standing difficulties, such as socioeconomic, educational and family problems. Antisocial personality disorder therefore amounts to more than criminal behaviour alone, otherwise everyone convicted of a criminal offence would meet the criteria for antisocial personality disorder and a diagnosis of antisocial personality disorder would be rare in people with no criminal history. This is not the case.

The prevalence of antisocial personality disorder among prisoners is slightly less than 50%. It is estimated in epidemiological studies in the community that only 47% of people who meet the criteria for antisocial personality disorder have significant arrest records. A history of aggression, unemployment and promiscuity were more common than serious crimes among people with antisocial personality disorder. The prevalence of antisocial personality disorder in the general population is 3% in men and 1% in women.

Under current diagnostic systems, antisocial personality disorder is not formally diagnosed before the age of 18, but the features of the disorder can manifest earlier as conduct disorder. The course of antisocial personality disorder is variable and although recovery is attainable over time, some people may continue to experience social and interpersonal difficulties. Antisocial personality disorder often co-exists with depression, anxiety, and alcohol and drug misuse. All of these are risk factors for child abuse and neglect.

People who prey on or exploit Adults at Risk are more likely to have this diagnosis than other psychiatric diagnoses. Similarly predatory paedophiles and sex offenders are more likely to have this diagnosis. Multi-Agency Public Protection Arrangements (MAPPA) may well be needed for the small numbers of such people who pose a significant risk to children and young people (and to others), see People Posing a Risk to Children - Guidance and Procedure.

  • Treatment implications
    • See The National Institute for Health and Clinical Excellence (NICE) guidelines for borderline personality disorder;
    • Due to the nature of antisocial personality disorder not all individuals will be suitable for treatment by mental health services. Provision of services for people with antisocial personality disorder often involves significant inter-agency working. Effective communication needs to occur among clinicians and organisations at all points to establish care pathways and intervention/treatment;
    • Individuals engaged in criminal activities are more appropriately managed by criminal justice agencies including police, probation, MAPPA and youth offending teams. Liaison with these agencies is crucial if they are involved with the individual;
    • Professionals working with people with antisocial personality disorder should recognise that a positive and rewarding approach is more likely to be successful than a punitive approach in engaging and retaining people in treatment Professionals should explore treatment options in an atmosphere of hope and optimism, explaining that recovery is possible and attainable;
    • Professionals working with individuals with antisocial personality disorder should be aware of the potential for these individuals to disengage from treatment or for drug use and other factors to interfere with treatment. Successful treatment is likely to require multi-agency involvement and be of lengthy duration.
  • Treatment options
    • Treatment options include cognitive group work programmes e.g. the Stop and Think group (available via Francis Dixon Lodge or the Forensic Mental Health Service) or Enhanced thinking Skills available for those on probation orders or on prison sentences. Referral to specialist adult mental health/forensic services can be requested for specialist assessment and advice. Family therapies/systemic therapy, where available and where the individual will engage, can be helpful;
    • There are few parenting courses for parents with anti-social personality disorder that have proved effective. Incredible Years Groups (see Incredible Years Website) or Mellow Parenting Groups (see Mellow Parenting Website) may be useful for new mothers with this diagnosis. Local Prisons are not currently offering any specialist parenting courses for such parents. Local open access parenting groups might well struggle to engage such parents;
    • Where there are specific concerns about the safety of children-I feel we should be more specific here -what do we mean; and what about the cases where there is suspected abuse: e.g. emotional, non-compliance with child's multi-agency intervention treatment and so not catering for child's emotional, social and cognitive development?, referrals can be made as a result of a child protection case conference to the forensic mental health service for a psychological assessment regarding the parents' capacity to safeguard the child and to assist in the identification of risks and treatment options. Such referrals are not just for parents with the diagnosis of personality disorder.


5. Useful Contacts

Francis Dixon Lodge,
Personality Disorder Service,
Gipsy Lane,
Leicester
LE5 0TD

0116 225 6800

Forensic Mental Health Service;
Psychology Team,
Herschel Prins Centre,
Glenfield Hospital,
Leicester,
LE3 9DZ.

0116 2953037


6. References

Within this manual:

Practice guidance in relation to Adult Mental Health and Child Protection Individuals who pose a risk Procedure

Fabricated or Induced Illness Procedure

The National Institute for Health and Clinical Excellence (NICE) guidelines for borderline personality disorder Jan 2009; publications@nice.org.uk

Managing Individual Cases where there are Child Safety and Welfare Concerns

Dept of Health Guidance, Safeguarding Children in whom illness is fabricated or induced

Supplementary guidance to Working Together to Safeguard Children produced by DCSF in 2008 - now archived) (updates the Dept of Health Guidance re Fabricated or induced illness) Department for Education

The National Institute for Health and Clinical Excellence (NICE) guidelines for antisocial personality disorder Jan 2009; publications@nice.org.uk

Incredible Years Website

Mellow Parenting Website

FDL Document on Personality Disorders (can be obtained from Francis Dixon Lodge)

FDL Document on Francis Dixon Lodge and interventions available (can be obtained from Francis Dixon Lodge).

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