Effectiveness of parenting training in mothers with a borderline personality disorder: A multiple baseline single-case experimental design study

doi:10.21203/rs.3.rs-1853036/v1

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Effectiveness of parenting training in mothers with a borderline personality disorder: A multiple baseline single-case experimental design study

https://doi.org/10.21203/rs.3.rs-1853036/v1

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Background: Parents with borderline personality disorder (BPD) experience deficiencies in parenting skills leading to increased family burden and stress, mental health problems in children and even family violence. The present study evaluated the effectiveness of a Dutch version of the parenting training based on Dialectical Behaviour Therapy (DBT) for mothers with BPD developed by Renneberg and Rosenbach (2016).

Methods: Given the high heterogeneity found in patients with BPD, a multiple baseline single-case experimental design study was conducted with standardised and idiosyncratic assessments of parenting behaviour and parental stress before, biweekly during, and after the training. Participants (N=10; mean age = 35.9, SD = 4.65) were mothers with a full diagnosis of BPD with at least one child under the age of 6 at the start of the training.

Results: Four participants discontinued the training. Among the six training completers, clinically reliable improvements in parenting skills between pre- and post-/follow-up training were most pronounced for inconsistent discipline, involvement, positive parenting and corporal punishment. Frequent, idiosyncratic assessments showed that for all six mothers the DBT training had positive effect on parenting skills, while for five mothers this effect was large. Positive changes in parenting stress were found in three (post) to four (follow-up) participants. Positive changes in parenting behaviour were also found for the four training non-completers. Participants were satisfied with the training.

Conclusions and implications: DBT parenting training has a great clinical value for mothers with BPD struggling with raising their children. In our effectiveness study, we found empirical evidence to confirm this clinical impression. Through tentative investigation of individual effects among the six training completers, we learned that, in comparison to other mothers, mothers with comorbid PTSD (N = 3) show almost no changes in the levels of parenting stress after the training. The mothers with most positive results received anti-depressants and had clear arrangements about the role of partners in the family. The complexity and heterogeneity of the condition requires a more idiosyncratic approach. Mothers with BPD could profit from more stress management regarding parenting and increasing commitment to participation in DBT parenting training.

This study was registered (retrospectively) in ISRCTN (ID ISRCTN74447767).

https://www.isrctn.com/ISRCTN74447767, March 2022

BPD

mothers

training

parental stress

parenting behaviour

single-case design

Borderline personality disorder (BPD) is defined by an extreme affective instability and

impulsivity resulting in self-damaging behaviour, interpersonal dysfunction, and unstable

identity (1). The aetiology of BPD, as Winsper considers it, can be seen

as a complex network of epigenetic and biological processes, invalidating interactions, and

social developmental pathways (2). Although the prevalence of BPD in the general population is relatively low (1.1%;(3), studies show that patients with BPD experience

detrimental consequences associated with this condition. BPD has a negative effect on

maintaining healthy relationships (4). For example, patients with BPD lack

problem solving skills during conversations with their spouse and their communication styles

appear to be more negative than in nonclinical couples. Moreover, marital violence and

marital problems increase with the increased severity of the BPD symptoms (5). Not only marital problems occur, but several studies also show that the

family and parenting burden for both patients with BPD and their children is very high (6–8).

So far, a strong association between BPD in mothers and deficiencies in parenting skills has been found. In general, mothers with BPD find it difficult to organise activities and structure their children’s daily routine (8,9). Recent systematic reviews demonstrate that mothers with BPD or BPD symptoms experience deficiencies in parenting skills; they seem to respond less sensitive and less attentive to their child’s needs and are less aware of their child’s inner world. In comparison to mothers without a BPD diagnosis, mothers with BPD act overprotective and more hostile towards their children and are more likely to have negative communication patterns with their children (6,7). Observational studies show that mothers with BPD express less emotionally supportive behavioural patterns. These mothers display greater difficulties comprehending their children’s emotions and needs and lack skills to handle these emotions (7). In addition, mothers with a BPD diagnosis report significantly higher levels of parenting stress and distress and significantly lower satisfaction as a parent than healthy mothers do (8). Qualitative research also shows that parenting is particularly stressful for mothers with BPD (10). These mothers feel insecure about their parent role, worry about the negative impact of BPD on their children and often feel guilty (10). Because of these difficulties experienced by mothers with BPD, some self-report studies show that mothers with BPD exhibit more dysfunctional parenting behaviours. On top of these dysfunctional parenting styles, mothers with BPD show signs of neglect and abuse more often than mothers without the diagnosis (7).

Worryingly, children of mothers with BPD are shown to have poorer mental health compared to healthy controls, higher levels of depression and suicidal tendencies, anxiety, behaviour problems and attention deficit problems (8). The relationship between parents with BPD and their children is at risk. There is a higher risk for disruptive attachment styles, children are more negative about their expectations of the relationship with their parents and children more often fear their parents abandoning them (8). Thus, if we could help these mothers with BPD to enhance their parenting skills, this could, in the long term, have positive and preventative effects on the health of their children.

Steele et al. conducted an overview and meta-synthesis of systematic reviews about the need for parenting skill training and advocate greater emphasis on parenting in the clinical practice and development of parenting interventions for patients with personality disorders (11). To address emotion dysregulation and problems in interpersonal relationships in patients suffering from BPD experience, Dialectical Behaviour Therapy (12) is often implemented. While DBT is considered a highly efficacious treatment for BPD (1,13), it does not focus specifically on parenting skills. In several studies researchers have stressed the urgency to help mothers diagnosed with BPD by teaching them more effective parenting skills (10,14). Not only researchers are aware of this matter, but perhaps even more important, mothers with BPD also report the need to address their parenting in therapy. Qualitative research shows that mothers with BPD wish parenting was integrated more in their current treatment, as especially because most of the mothers with BPD lack a positive role model (10,15). Acknowledging this need, Renneberg and Rosenbach (16) developed a 12 two-hour weekly sessions DBT parenting skills group training for mothers with BPD with children under the age of six. The training consists of both group and individual sessions with mothers. The major goal of the program is to help mothers learn about the impact of BPD on their children and practice new skills (e.g., communication, dealing with conflicts, dealing with emotions) by means of role plays as well as to learn to read and understand the needs and emotions of their child. Important to note is that self-care of the mothers is also addressed during training to help them maintain their own emotional stability.

Clinical benefits of parenting program using DBT perspective were, as far as known, investigated in two studies. First, Renneberg and Rosenbach conducted a feasibility study of the above-mentioned training in 15 mothers with children aged 0-6 years. Results from qualitative interviews with mothers conducted post-training indicated that, on average, participants experienced the training as highly acceptable. Further, participants reported that they benefited from the training in terms of better understanding of their children’s needs and reacting more appropriately to their own and to their children’s emotions and impulsive behaviours (16). In a second study, parenting training named mother-infant DBT was piloted in a group of 29 mothers BPD (symptoms), with a child in infant age range (0-2 years) (17). This training lasted for 24-weeks (2.5 hours per week) and both mothers with BPD diagnosis and BPD symptoms were included in the study. Post-training improvements in maternal BPD symptoms and caregiver-infant relationships were found as well as significant changes in mood, anxiety levels, borderline symptoms, and reflective functioning of the mothers.

So far, the results of offering a DBT training to mothers with BPD are encouraging. In the study described in this article, we aim to bring this field a step further by conducting an effectiveness study of a Dutch version of the DBT parenting training in mothers with BPD. Previous studies used qualitative reports and/or pre- or post-training assessments only (16). The narrow age category in the second study, inclusion of mothers with various levels of BPD symptoms and adjustments to standard protocol, makes it harder to generalise the outcomes. Our study aims to add to previous research in several ways. Given the high heterogeneity of mothers with BPD and fluctuations in symptoms over time (18), we conducted a single-case experimental design study that enabled us to investigate changes in parental stress and parenting behaviours before, biweekly during, and after (short and long term) the training. In addition, as described in the Methods section, idiosyncratic assessment methods were used. Since DBT parenting training aims to tap into self-reported clinical needs of mothers with BPD (10) and the results from initial studies were positive, we expect that DBT parenting training will have beneficial effects on parenting behaviour of the mothers and that the training will reduce maternal stress. Also, clinical experience suggests that discussing motherhood, openness about the parenting problems these mothers face and providing parenting strategies often reduces parental stress and parenting skills improve after treatment.

Participants and procedure

Inclusion criteria for this study were: (1) DSM – 5 diagnosis of BPD assessed with SCID-P-5, a structured clinical interview (19); (2) age above 18 years; (3) the primary caregiver to a child preferably under the age of six (at least primary school age) at the start of the treatment; whereby the acute welfare of the child was not endangered; (4) able to comprehend and speak Dutch at a level sufficient to complete self-report instruments, the assignments, the group training and individual sessions; and (5) willing and able to commit to attending a 2-hour group once a week for 12 weeks and 45 minutes individual session every other week. Exclusion criteria were: (1) lifetime psychosis or bipolar disorder type I; (2) insufficient cognitive capacity to comprehend the topics being discussed; screened by the SCIL (screener for intelligence and learning difficulties) with a cut-off score of 19 (20); (3) significant substance abuse that would have an impact on group functioning; as per clinical judgement following discussion with the research team; (4) start of new medication within 3 months before the start of this study. Participants were not excluded due to concurrent treatment (pharmacological or non-pharmacological). Pharmacological treatment should have been kept stable at least 2 months prior to entering this study.

Following the medical ethical approval of the VU Medical Centre in Amsterdam, mothers with BPD were actively informed about this research project by their clinician. When they were interested in the parenting training and the study, they were referred to the coordinating researcher, a mental health psychologist trained to be a specialist, who provided extensive information about the parenting training and the study and was responsible for the informed consent and assessments. The clinician decided whether it was indicated for the mother to participate in the parenting training at that very moment. During this screening appointment all inclusion and exclusion criteria were checked.

The sample consisted of ten mothers (mean age = 35.9, SD = 4.65). Eight mothers were from Dutch, and two from Turkish descent. The age of the focus child was between 3 and 8 years old (M = 4.6, SD = 1.71). Nine mothers had a child under 6 years old and one with a child of 8 years old. She did not meet one of the inclusion criteria (age of child under 6 years), but the burden of parenting was so high that we decided she could join the group and the study. Three mothers had one child, five mothers had two children and two mothers had three children. In nine cases, the biological father or a father figure was involved to some extent in parenting. One mother reported that the father was not involved in the childrearing (he visited once a week for an hour). Five of the ten mothers considered the involvement limited (e.g., only during the weekends).

Six of the ten mothers met criteria for one or more comorbid disorders. Three of ten met criteria for depression, four of ten met criteria for posttraumatic stress disorder, two of ten met criteria for an additional personality disorder. Seven of the ten mothers had been taking medication (i.e., antidepressants, antipsychotics in small dosage, and benzodiazepines) but did not change the dosage in the three months prior to the start of this study. Of the ten mothers, two of them received additional treatment during the baseline or intervention phase. One mother received schema focused therapy and the other received pedagogical support at home during the baseline and intervention phase.

Study design

A multiple baseline single-case experimental design with a baseline phase (A-phase) and an intervention phase (B-phase) was used in this study to evaluate the effectiveness of parenting skill training. A multiple baseline design is considered an experimental single-case designs and allows testing whether changes in parenting behaviour and parental stress are the result of the intervention and not of time, and whether the change is meaningful (21,22). Because a multiple baseline design requires few participants and because the participants act as their own controls, multiple baseline designs are viewed as a practical and ethically responsible choice in hard to treat and research populations. This is especially the case in parents with BPD who are considered a group with high drop-out rates from large-group research studies (23,24). A minimum of N=4 is suggested for this design (25). Based upon sample sizes in a similar study (26), and the possibility of drop-out, a sample of N=10 seems sufficient. In 1995, the Task Force of the Society of Clinical Psychology (27), a division of the American Psychological Association, classified interventions tested in nine replicated single-case studies as ‘well-established’ interventions.

In our study, the A-phase is the baseline period during which participants did not receive parenting training (T0-T1). Participants were randomised to one of the two baseline lengths (3 and 5 weeks), based on their residence and location registration. Subsequently, the training phase B started during which the mothers received DBT parenting skills training in a group (T1-T3). Timing of assessments was as follows. Extensive assessments (full questionnaires APQ and NOSI-K, described below) were administered before (T0) and after the baseline period (T1), at mid-treatment (T2) and after the training phase at post (T3) and follow-up (T4) assessment. During the two phases (T0-T3) frequent short (biweekly) idiosyncratic assessments of parenting behaviours and parental stress were conducted. In addition, at the end of every group session the participants filled in a very brief, four-question questionnaire to assess group atmosphere at both locations.

Assessment

Extensive assessments at T0-T4

The Dutch version of the Alabama Parenting Questionnaire (APQ; (28)) was used to measure parenting behaviour. The questionnaire consists of 42 items on parenting practices, divided in five categories/scales: positive involvement with children (1), supervision and monitoring (2), use of positive discipline techniques (3), consistency in the use of discipline (4) and use of corporal punishment (5) (28). The questions were filled in on a five-point rating scale (1= never, 2=almost, 3=sometimes, 4=often, and 5=always). 7 items do not belong to one of the subscales. It takes about 10 minutes to fill in the questionnaire. Research shows that the APQ has good psychometric properties (29). Internal consistency reliability alphas for the involvement scale (.80) and the positive parenting (.80) scales were strongest. Poor supervision/monitoring (.67) and inconsistent discipline (.67) had marginally acceptable reliabilities. The corporal punishment (.46) did not yield an acceptable reliability. The criterion validity is rated as good (30).

The Dutch Parental Stress Index-child report (Nijmeegse Ouderlijke Stress Index Kinderen; NOSI-K; (31,32)) was used to measure parental stress. The NOSI-K is the Dutch version of the Parenting Stress Index (PSI (33)). The NOSI-K is a self-report questionnaire consisting of 25-items, about experiences related to child and parent characteristics and situations related to upbringing. The questions were filled in on a six-point rating scale (1=totally disagree, 2=disagree, 3=slightly disagree, 4=slightly agree, 5=agree, and 6=totally agree) which yield together a sum score ranging from 25-150. It takes about 5 minutes to fill in the questionnaire. The PSI has acceptable internal reliability (.83), and test-retest reliability (.81) and content, concurrent and construct validity (32,34). Research showed that the NOSI-K has a good reliability (Cronbach’s alpha .92-.95), the criterion validity is rated as good (35).

Idiosyncratic Assessment (IA)

The IA was a personalised questionnaire of a maximum of 15 items, chosen by the mothers, out of the full APQ and NOSI-K questionnaires. Mothers choose items that represented the top parenting problems they experienced, as indicated during the screening appointment with the research coordinator. The idea was to select the items representing problems that the mother had the most difficulties with and wanted to change the most in her parenting behaviour or parenting stress.

Group atmosphere

Group Session Rating Scale (GSRS) is a brief four-item visual analogue scale to measure group therapy alliance (36). The participants score the session, after each session on a visual bipolar analogue scale, a line of ten centimetres. The four items include the relationship, goals and topics, approach of the session and overall cohesion. The four items yield together a sum score ranging from 0-40, with a mean score of 10. Cut-off score indicating a good alliance is set to a mean score of 8.5 per subscale for clinical populations (37). It takes about 2 minutes to fill in the questionnaire. The GSRS is adapted from the SRS (Session Rating Scale), the preliminary evidence was found that the four items of the GSRS can be thought of as a measure of global alliance within group therapy, which has adequate reliability (both alpha estimates and test-retest correlations) (38).

DBT parenting training

The DBT based parenting training evaluated in this study is the Dutch version of the training for mothers with BPD developed by Renneberg and Rosenbach (16). The content of the training is based on the concept of DBT and is outlined in Table 1. All sessions were described in detail in the original training manual by Renneberg and Rosenbach. Each session is divided into two parts, the first part focuses on the discussion of participants’ homework, and in the second part a new topic is introduced. Every session has the same structure: each session starts with a short mindfulness practice, subsequently homework assignments of the previous session are discussed to facilitate learning and implementation of newly learned behaviours into daily life. After a break, the new subject is introduced followed by a specific exercise (e.g., role-play). In each session a short summary about the topic and homework assignments in print were provided. In addition to the group intervention, mothers had an individual coaching session every other week. During the individual sessions, mothers shared daily cards as well as sensitive topics concerning motherhood, that were too difficult to share in the group (16).

Two female trainers (a clinical psychologist and psychiatric nurse or psychologist) experienced in working with patients with BPD and trained in DBT facilitated and instructed the group training. The group was conducted by two trainers every session. There were different trainers per location. All four trainers had children of their own, which is an important prerequisite according to the training developers. They had monthly peer-to-peer learning sessions in which they discussed their difficulties as a trainer during the program. Individual coaches were trained prior to this research program. They were either psychologists or psychiatric nurses and were trained in DBT. Participants saw the same professional every individual session.

Table 1. [MM1] Theme and content of the 12 sessions of the DBT parenting training

Session	Theme	Content
1	Psycho education	To comprehend the impact of maternal borderline symptomatology on child development.
2	Mindfulness	To point out the importance of mindfulness in the interaction with children to better perceive and understand the needs of the children and to gain a greater control over own dysfunctional behaviour impulses.
3	Children’s basic needs	To understand children’s needs as well as to assess their own competences to satisfy these needs.
4	Stress and stress management	To develop and maintain stress strategies to better cope with individual stressors.
5	Stress and stress management	Idem.
6	Structure and flexibility	To clarify the importance of rules and rituals and to better differentiate between fixed rules and flexible structures.
7	Dealing with conflicts	To promote a non-violent and solution-oriented management of mother-child conflicts. To develop new ideas and ways to cope with conflicts.
8	Dealing with emotions	To comprehend their children’s emotions and needs. To better understand and handle intense emotions.
9	The body	To enhance the understanding of physical functions and reactions as well as to enhance the empathy for children’s needs for body care.
10	Basic assumptions about parenting	To identify and modify basic assumptions about parenting into realistic views.
11	Self-care	Developing strategies to enable better maternal self-care.
12	Summary	Summarizes the content of the training and outlines the individual changes in the participants’ perception and parental behaviour.

Data-analysis

To investigate changes in parenting behaviours and parental stress across phases, we conducted the following analyses. First, the total scores on the full questionnaires assessing these two variables were calculated, and the Reliable Change Index (RCI;(39)) was determined between extensive assessment points (T0-T1; T1-T3; T1-T4). Following Jacobson and Truax, an RCI > 1.96 or < −1.96 (z-scores) indicates clinically reliable change (39).

Second, the Nonoverlap of All Pairs (NAP; (40)) method was used with idiosyncratic assessments to investigate the probability that a random measurement in one phase (i.e., baseline) is different from a random measurement in another phase (i.e., treatment). NAP values were calculated using Shiny SCDA ((41,42). For defining a rule when a NAP value indicates that the change between the baseline and treatment is meaningfully different, we used the following criteria: NAP 50% is chance level, >50% is indicative of an effect in the expected direction (40). NAP values lower than 65% are labelled as weak effect, values between 66-92 as medium effect, and values above 93% are characterised as large effect.

Finally, and to support quantitative data-analysis, the data was presented visually, using graphs. Total scores of the rated group atmosphere are presented.

The final sample consisted of ten mothers. Six mothers completed the entire training and all assessments. Four mothers discontinued their treatment after 2 (P6), 4 (P5), 5 (P9), and 8 (P8) weeks due to motivational concerns, corona related problems and psychiatric problems in combination with pregnancy. Due to corona related complaints a few parenting training sessions were conducted online. Regarding location 1, mothers joined via screen an estimated 10% of the time, and location 2 an estimated 8.3% of the time. In Table 2 the demographics of the final sample are shown.

Table 2. Demographic data of participating mothers (N =10)

Variable

Mean (SD)/ Number (%)

Age (in years)

Range 30-43

35.9 (4.1)

Country of origin

Age focus child

Gender of focus child

Number of children

Marital status

Education level Highest completed

Comorbid disorder

Involvement of the father/father figure

Medication at baseline

Dutch

Turkish

Range 2-8

Female

Male

One child

Two children

Three children

Married/living together

Lasting relationship/not living together

Single

Primary school not completed

High school

Vocational education

Higher vocational only

propaedeutic year

Schizoid personality disorder

Paranoid personality disorder

PTSD

Depression

None

To some extent

Active

No medication

Antidepressants

Antipsychotics

Benzodiazepines

8 (80%)

2 (20%)

4.65(1.96)

2 (20%)

8 (80%)

4 (40%)

5 (50%)

1 (10%)

5 (50%)

1 (10%)

4 (40%)

5 (50%)

4 (40%)

1 (10%)

4 (40%)

1 (10%)

4 (40%)

5 (50%)

3 (30%)

5 (50%)

3 (30%)

1 (10%)

Reliable Change

In Table 3 total scores on the APQ subscales and NOSI-K are presented at extensive assessment points (T0-T4). Reliable change index (RCI) could be calculated for six training completers (P1-P4, P7, P10). RCI was calculated for each participant (P) for the APQ-subscale scores and the total NOSI-K score and between T0-T1 (pre-baseline to pre-training), T1-T3 (pre- to post-training), and T1-T4 (pre- to follow-up training) [Table 3]. For the APQ, we used the normative data (Alpha coefficient and SD per subscale and gender of the child) from Dadds, Maujean, and Fraser study (30).

One participant showed improvement in Positive Parenting and one in Involvement. Deterioration in Poor Monitoring was found for one participant, and in Positive Parenting for another participant. From pre-training to post-training (T1-T3) clinically reliable RCIs were found for the following participants and measures. For the APQ subscales, clinically reliable change, indicating an improvement in parenting skills was found for Involvement (P3, P7), Positive Parenting (P7), Inconsistent Discipline (P1, P2, P4, P10), and Corporal Punishment (P4). For the APQ subscales, clinical reliable change in the opposite direction, indicating a deterioration in parenting skills (T1-T3) was found for Involvement (P10) and Poor monitoring (P2). Regarding parenting stress, NOSI-K RCIs of P1, P4, and P7 indicated clinically reliable decrease in stress levels.

From pre-training to follow-up (T1-T4), the following RCIs were found to be clinically reliable. For the APQ subscales, clinically reliable change, indicating an improvement in parenting skills, was found for Involvement (P4, P7), Positive Parenting (P4, P7, P10), Inconsistent Discipline (P1, P3, P4, P10), and Corporal Punishment (P4). For the APQ subscales, clinically reliable change in the opposite direction, indicating a deterioration in parenting skills, was found for Involvement (P10) and Poor Monitoring (P2). For the NOSI-K RCI’s, we used the normative data (clinical norms) from questionnaire manual. Further, four NOSI-K RCIs indicated clinically reliable decrease in stress levels for P1, P2, P4, and P7.

Table 3. Parenting behaviors and stress at T1-T4 and reliable change

P		Pre-baseline T0	Pre-treatment T1	Mid-treatment T2	Post-treatment T3	Follow-up T4	RCI T0-T1	RCI T1-T3	RCI T1-T4
1
	APQ Inv	27	24	29	27	29	0.94	-0.94	-1.56
	APQ PP	20	24	28	26	25	-2.29^a	-1.72	-0.57
	APQ PM	15	14	14	18	14	0.46	-1.82	0
	APQ ID	19	17	11	7	6	0.79	3.96^a	4.36^a
	APQ CP	8	7	4	4	4	0.64	1.93	1.93
	NOSI-K tot	99	94	93	61	67	0.55	3.63^a	2.97^a
2
	APQ Inv	38	33	33	39	39	1.56	-1.87	-1.87
	APQ PP	21	20	18	22	21	0.57	-1.15	-0.57
	APQ PM	19	15	22	22	21	1.82	-3.19^b	-2.73^b
	APQ ID	19	18	18	12	17	0.40	2.38^a	0.40
	APQ CP	5	6	5	5	4	-0.64	0.64	1.28
	NOSI-K tot	87	84	80	76	60	0.33	0.88	2.64^a
3
	APQ Inv	27	31	29	38	33	-1.25	-2.19^a	-0.62
	APQ PP	18	18	20	21	21	0	-1.72	-1.72
	APQ PM	13	21	21	22	20	-3.64^b	-0.46	0.46
	APQ ID	22	23	24	19	18	-0.40	1.58	1.98^a
	APQ CP	6	6	8	5	5	0	0.64	0.64
	NOSI-K tot	96	102	106	93	94	-0.66	0.99	0.88
4
	APQ Inv	32	31	31	35	38	0.31	-1.25	-2.19^a
	APQ PP	24	20	21	23	24	2.29^b	-1.72	-2.29^a
	APQ PM	22	21	19	24	24	0.46	-1.37	-1.37
	APQ ID	22	22	17	17	15	0	1.98^a	2.77^a
	APQ CP	8	8	5	4	4	0	2.57^a	2.57^a
	NOSI-K tot	112	115	76	71	72	-0.33	4.84^a	4.73^a
5
	APQ Inv	31	28	30	-	-	0.98	-	-
	APQ PP	18	18	20	-	-	0	-	-
	APQ PM	22	19	13	-	-	1.19	-	-
	APQ ID	17	19	17	-	-	-0.81	-	-
	APQ CP	7	8	5	-	-	-0.66	-	-
	NOSI-K tot	106	125	91	-	-	-2.09^b	-	-
6
	APQ Inv	37	36	-	-	-	0.32	-	-
	APQ PP	18	19	-	-	-	-0.39	-	-
	APQ PM	30	31	-	-	-	-0.56	-	-
	APQ ID	20	20	-	-	-	0	-	-
	APQ CP	10	10	-	-	-	0	-	-
	NOSI-K tot	113	88	-	-	-	2.75^a	-	-
7
	APQ Inv	22	23	39	40	47	-0.31	-5.31^a	-7.49^a
	APQ PP	17	15	21	24	27	1.15	-5.16^a	-6.88^a
	APQ PM	14	18	24	20	21	-1.82	-0.91	-1.37
	APQ ID	21	23	23	20	19	-0.79	1.19	1.58
	APQ CP	6	6	6	3	4	0	1.93	1.28
	NOSI-K tot	120	116	107	91	95	0.44	2.75^a	2.31^a
8
	APQ Inv	30	28	34	-	-	0.62	-	-
	APQ PP	15	18	16	-	-	-1.37	-	-
	APQ PM	22	14	22	-	-	4.59^a	-	-
	APQ ID	23	21	23	-	-	0.70	-	-
	APQ CP	6	5	6	-	-	0.64	-	-
	NOSI-K tot	102	103	91	-	-	-0.11	-	-
9
	APQ Inv	29	31	-	-	-	-0.65	-	-
	APQ PP	21	21	-	-	-	0	-	-
	APQ PM	10	15	-	-	-	-1.98^b	-	-
	APQ ID	18	18	-	-	-	0	-	-
	APQ CP	5	5	-	-	-	0	-	-
	NOSI-K tot	91	77	-	-	-	1.54	-	-
10
	APQ Inv	27	36	25	26	27	-2.81^a	3.12^b	2.81^b
	APQ PP	24	23	22	23	27	0.57	0	-2.29^a
	APQ PM	14	14	14	14	14	0	0	0
	APQ ID	16	19	15	9	4	-0.98	3.27^a	4.90^a
	APQ CP	5	4	5	4	4	0.64	0	0
	NOSI-K tot	92	89	103	81	97	0.33	0.88	-0.88

Note: sum score of the NOSI-K, APQ Inv= Involvement, APQ PP= Positive Parenting, APQ PM= Poor Monitoring, APQ ID= Inconsistent Discipline, APQ CP= Corporal

Punishment. Participants 1-6 location 1: baseline period = 3 weeks; 7-10 location 2: baseline period = 5 weeks.

^aImprovements in parenting skills (APQ) or parental stress (NOSI-K)

^b Deterioration in parenting skills (APQ) or parental stress (NOSI-K)

Nonoverlap of All Pairs (NAP)

In Table 4, the NAP scores for the biweekly APQ and NOSI-K idiosyncratic assessments can be found. Scores across APQ and NOSI-K items were summarized to form a total score on each questionnaire per week. For the ease of the interpretation and visualisation of the frequent data, the scores on the items from APQ subscales Poor Monitoring (PM), Inconsistent Discipline (ID), and Corporal Punishment (CP) were recoded. In response, scores on all APQ subscales and items should be interpreted as follows: higher values indicate more adequate parenting behaviour. For the NOSI-K questionnaire holds: lower values indicate lower levels of stress.

Results indicate that all ten mothers have a NAP APQ score >50%. Seven mothers have a NAP APQ score above 93% (large effect, according to Parker & Vannest (40)).

The NOSI-K NAP scores show that four mothers have a NAP score >50%, but there is only one mother with a NOSI-K NAP score above 93%. Five participants show NOSI-K NAP scores below 50%; four participants with scores slightly below chance level (between 40-50%) and one participant with a very small percentage (10%) indicative of an effect in the opposite direction as expected.

Table 4. NAP scores for frequent assessments across baseline and treatment phase

Participant	APQ	NOSI-K
1	99^a	64.9^b
2	74^a	46.9
3	99^a	46.8
4	97^a	100^b
5	93^a	84.4^b
6	97.2^a	22
7	97^a	46.7
8	64^a	41.8
9	99^a	86.5^b
10	66^a	8.3

Note. NAP = 50% is neutral percentage; >50% is indicative of an effect in the expected direction,

<50% is indicative of an effect in the opposite direction.

^aImprovements in parenting behavior in training phase as opposed to baseline phase

^b Improvements in parental stress in training phase as opposed to baseline phase

Participants 1-6 location 1: baseline period = 3 weeks; 7-10 location 2: baseline period = 5 weeks.

Figure 1 shows the individual scores on APQ and NOSI-K of the ten mothers during baseline and training phase.

[insert Figure 1 here]

Group atmosphere

In total, 71.3% (n = 77) GSRS forms were completed. Missing data was due to drop-out or being at home with corona related problems and joining the group via a screen. Inclusion or exclusion of training dropouts in this analysis does not change the results.

Scores on all subscales (overall and per location) were above the cut-off score indicating that the participants were satisfied with the training (Table 5).

Table 5. Means and standard deviations of the GSRS subscale and total score

	Relationship	Goals and topics	Approach or method	Total score
All mothers (N=10)
Mean	9.31	8.78	9.02	9.20
SD	.83	1.58	1.25	1.08
Location 1 (N=6)
Mean	9.23	8.51	8.78	9.10
SD	.92	1.84	1.46	1.26
Location 2 (N=4)
Mean	9.45	9.26	9.42	9.35
SD	.61	.74	.55	.65

Note. Location 1 = participants 1-6 location 1: baseline period = 3 weeks; Location 2 = 7-10 location 2: baseline period = 5 weeks.

The current study evaluated the effects of a DBT parenting training in mothers with BPD using a multiple baseline single-case design. This study is, to our knowledge, the first to systematically and quantitively evaluate parenting group training based on DBT (16) for women with children under the age of six, with BPD.

In contrary to the training phase period, only for a few indices of parenting skills reliable change was found during the baseline period of the study indicating that in the absence of training only some change in client complaints was found. During the training phase, both a post-training as well as at follow-up, consistent reliable change in parenting skills was found in six mothers who completed the training.

Overall, the most prominent improvement is found in relation to inconsistent discipline parenting skill. Inconsistent discipline points to the consistent application of the rules related to setting boundaries. In this sense, this is probably also the most meaningful concept related to BPD because one of the main difficulties of patients with BPD is keeping own boundaries and setting them towards others. Finding changes in this subscale suggests that DBT parenting training may seem to tap into this concept well. Reliable change in corporal punishment scale was found only for one participant which can be potentially explained by the methodological shortcomings of this subscale (low internal consistency) or by the fact that it is probably very difficult to report objectively and honestly on this scale because some mothers may be afraid of out of home placement of their children.

While RCIs represent changes in clients in comparison to a norm group scores, analyses of the idiosyncratic, frequent, observations allow us to examine within-participant changes in symptoms between training and baseline phase. For all training completers (N= 6), improvements in overall parenting skills during training phase were found in comparison to the baseline phase. For five participants this effect was large. DBT training seemed to have a clinical benefit on parenting skills and, thus, especially in the case when mothers were allowed to choose items from APQ that tapped the most into their personal complaint. We inspected qualitatively results from the two locations on APQ and it seems that there is no difference.

Regarding parental stress, the results were somewhat less positive. Reliable decrease in stress was observed for three participants at post- and for four participants at follow-up. Results from idiosyncratic assessments indicated that four participants experienced lower levels of stress during training phase as opposed to the baseline phase. To begin with, participants entered the study with already very high levels of reported stress in comparison to a normative group of mothers without psychiatric disorders (all but one participant had a total score of > 90 at T0). Covid lockdown and home schooling might have increased the levels of stress in general. Further, newly learned behaviour during the training could have made mothers more aware of their skills and since it takes effort to act differently, which could have caused stress. Finally, it is possible that DBT parenting training does not tap sufficiently into parenting stress, as the component of mindfulness included in the training is directed more towards ‘acting in the present moment’ and ‘being aware of your actions’, and not towards decreasing levels of stress.

Individual participant characteristics that could potentially explain the effects were examined tentatively. Participants 1 and 4 seemed to have profited the most out of training; large to medium within-person effects and improvements in both parenting skills as well as stress were found. Both participants were mothers in their early thirties, each with in total two children and there were clear agreements made about the involvement of the father within the family. One of the mothers was of Dutch and the other of Turkish descent. One mother had comorbid depressive disorder and the other had no comorbidity, but they both received anti-depressants. Participants 3, 7, and 10 had a comorbid post-traumatic stress disorder. It is informative to see that, while positive changes in parenting skills are reported in these mothers, all (but one participant for one RCI) reports no effects of the training on parenting stress.

In line with the research of Renneberg and Rosenbach (16) the participants were satisfied with the training, considering the scores on the GSRS. At the same time, four participants discontinued the training preliminarily. While some explanations for the dropout can be found in the patient characteristics (e.g., reported levels of stress), the most likely explanation is the lack of commitment. In DBT, commitment from the client as well as the therapist is crucial. The intention to take specific actions, to construct a plan, and to achieve goals is needed to change behaviour. Commitment is important when executing DBT as a commitment phase is the first step in the protocol of DBT (12). The commitment phase is not yet a standard part of DBT parenting training and should be included as such.

Following limitations of our study can be mentioned. Firstly, we planned a third group but were not able to find enough participants because of the Covid-related lockdown (mothers were home schooling their children at that time) in combinations with underutilisation of staff. The lack of a third group limits the power and generalizability of the study findings. In the two groups included in this study the mothers occasionally needed to stay in quarantine and could not attend the group sessions live. We arranged a video call, so they could participate from home, but in our opinion, it affected the quality of the training as well as the commitment to practice new behaviour and it possibly let to additional missing data. Nevertheless, positive results on parenting skills and stress found in our study indicate that the training was beneficial to mothers who probably had even higher stress levels due to Covid lockdowns and home schooling.

Secondly, our method of using self-report questionnaires, measuring parenting behaviour and parental stress could be seen as a shortcoming. We assume that the participating mothers felt judged or stigmatized frequently because of their severe psychiatric problems (43). Based on clinical experience we predicted that asking relatives about the parenting skills of the participants or observing them with their child would make the mothers feel insecure. However, one might argue that because motherhood is such a sensitive issue, socially desirable answers lie in wait. Furthermore, by using self-report questionnaires we measured perceived stress and parenting skills rather than externally validated parenting skills, and stress levels.

Future studies should consider assessing the severity of BPD symptoms as this could have moderated the training outcomes. In addition, systematic reviews published in recent years (6,8) advocated children to come along with their mothers to therapy to attend mother-child sessions. The mother child interaction could then be trained, observed, and assessed more objectively. Clinically, results from our study indicated that even more attention to parental stress could be given during the training although it remains unknown (especially because this is the first study to assess parental stress) whether such high levels of parental stress are characteristic of mothers with BPD or influenced by covid context at that time. Enhancing commitment to DBT should be included as a standard first phase of this parenting training. Given the potential fluctuations in the complaints of patients with BPD, heterogeneity, and results from individualized assessments in our study, investigation of within-patient changes in training outcomes remains an important focus of research.

DBT parenting training has a great clinical value for mothers with BPD struggling with raising their children. We found empirical evidence to confirm this clinical impression. Most prominent improvement was found in relation to mothers disciplining their children in a more consistent manner. The complexity and heterogeneity of the participants requires a more idiosyncratic approach. One would suggest that mothers with BPD could profit more from the DBT parenting training if commitment to participate would increase by addressing commitment thoroughly in advance (pre-treatment) as well as more focus on stress management. Despite limitations, this study contributes to the treatment of mothers struggling with severe interpersonal problems and thereby the wellbeing of their family. To prevent intergenerational problems further research is needed to promote focus on parenting for mothers with a borderline personality disorder.

BPD: borderline personality disorder

DBT: dialectical behaviour therapy

APQ: Alabama parenting questionnaire
NOSI-K: Nijmeegse Ouderlijke Stress Index Kort

GSRS: Group session rating scale

SRS: session rating scale

IA: idiosyncratic assessment

RCI: reliable change index

NAP: nonoverlap of all pairs

RCT: randomised controlled trial

Ethical approval and consent to participate

The study was approved by Medisch ethische commissie VUMc (ref: 2020-473 NLno74201.029.20). All participants gave written, informed consent for data collection and analyzation. The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008.

Consent of publication

All participants gave written, informed consent for publication.

Availability of data and materials

The dataset generated and analysed during the current study is not publicly available due to privacy, but is available from the corresponding author on reasonable request.

Competing Interest

The authors declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author’s contributions:

DV: conceptualization, data-analysis, writing original draft

MM: supervision, writing and reviewing

PO: statistical analysis and advice, reviewing

MH: introduction of the protocol, translating the protocol, treatment implementation and training of the participating coaches and therapists

All authors read and approved the final manuscript.

Acknowledgements:

We would like to thank the all the participating mothers who volunteered in this study. We are also grateful to Jessica Apeldoorn for assisting with the data collection.

Author’s information

Correspondence concerning this article should be addressed to D.E. Vigeveno, MSc, Healthcare psychologist, Clinical specialist in training. GGZ Noord-Holland-Noord, Stationsplein 138 1703 WC Heerhugopwaard, The Netherlands.Email: [email protected]

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No competing interests reported.

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Effectiveness of parenting training in mothers with a borderline personality disorder: A multiple baseline single-case experimental design study

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