SPECIAL ARTICLE Borderline Disorders of Childhood: An Overview THEODORE A. PETTI, M.D., M.P.H.,

AND

RICARDO M. VELA, M.D.

Abstract. This selected review considers children classified as "borderline" and focuses on two broad categories: Borderline personality disorder/borderline spectrum and schizotypal personality disordcr/autism/schivophrcnia spectrum classifications. Clinical descriptions, biological correlates, delimitation from other disorders, outcome, family studies, hypothesized etiologies, therapeutic considerations, and response to treatment arc presented for each. Data support the subclassification of the heterogeneous groupings of borderline children into at least the two categories, and their differentiation from each other and from other clinical disorders in the population. Overlap across the borderline categories exists for individual children. The nature and shortcomings of relevant studies arc described, the need for scientifically based research championed, and a differential approach to directive treatment of borderline children advocated. Further subclassification of borderline disorders should result in more cost-effective diagnosis and treatment. 1. Am. Acad. Child Adolesc. Psychiatry. 1990,29.3:327-337. Key Words: borderline, schizotypal , classification. A body of literature describing severely disturbed children whose clinical pictures cross over several diagnostic categorics has developed. Rich clinical descriptions in terms of individual cases and large groups of borderline children have abounded (Mahler, er al., 1949; Weil, 1953; Ekstcin and Wallerstein, 1954; Gclccrd, 1958; Marcus, 1963; Rosenfeld and Sprince, 1963; Frijling-Schreuder, 1969; Pine, 1974, 1986; Chethik, 1979, 1986; Morales, 1981; Kernberg, 1983a; Robson, 1983; Bemporad, et al., 1987). There appear to be two major streams of classification. First, psychoanalytic and psychodynamic authors have created a rich, descriptive literature which contributes a psychodynamic perspective for classification and treatment. In the 1950s, child psychoanalysts began describing a group of children who were distinguishable from frankly psychotic children, yet more severely disturbed than "psychoneurotic" children. These children exhibited serious ego development disturbances, were prone to overwhelming anxiety, and manifested ego fragmentation and regression when exposed to everyday stresses. Upon removal of the stress, they were noted to regain their reality testing ability, as contrasted to the less reversible nature of the psychosis in psychotic children. Magical and grandiose thinking, responses to fantasy as real, and very disturbed relationships with others were more frequently observed in the borderline child, as compared to normal or neurotic children by the analysts (Mack, 1975). The second stream is more descriptive and has concentrated on youngsters bordering on the sehizotypallautistic/

schizophrenic spectrum of childhood disorders, Wolff and Chick (1980) comment on the similar descriptions of "borderline" youngsters from both streams: abnormal psychological defenses, intrusion of primary process thinking into their waking life, omnipotence perceived in interactions with others, a long duration of symptomatology, and poor response to interpretive psychotherapy. This review has arbitrarily divided these severely disturbed children into two sets of disorders: (I) the borderline personality disorder (SPD) (APA, 1980; 1(87) / borderline spectrum; and (2) the sehizotypaJ personality disorder (SPD) (APA, 1980; 1987) / autistic/schizophrenic spectrum. The overview will consider the historical antecedents of these categories and their overlap; discuss issues of controversy, including clinical descriptions, posited ctiologic mechanisms, biological correlates, and outcome; and consider thcrapeutic interventions. A major effort wi II be made to dcmonstrate that the general area of borderline disorders can be divided into more distinct categories which correspond to BPD/type/borderline spectrum and SPD/autism/schizophrenia spectrum disorders.

Clinical Description The clinical description is meant to delineate the association of specific clinical features in characterizing a particular disorder. Though many clinicians seem to find the concept of borderline children useful, its validity has not been establ ished. The heterogeneity of borclerline disorders

has resulted in varied clinical descriptions depending on the group under discussion and the orientation of the clinical researcher.

Accepted October 5. 1989. Dr. Petti is Professor of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School (}f Medicine. Dr. Vela is Chief of Child and Adolescent Psychiatry, Bronx-Lebanon Hospital Center and Assistant Professor ofPsychiatry, Albert Einstein College of Medicine. Reprints may be requestedfrom Dr. Petti at WPIC, 3811 O'Hara Street, Pittsburgh, PA 15213.

Borderline Personality Disorderlllorderlinc Spec/rum Freud's 1918 description of the Wolfman may have been the first retrospective psychoanalytic description or a borderline child/adolescent (Anthony, 1(83), Mahler and associates (1949) considered a variety or more' 'benign" cases of ehildhood psychosis "in which larger parts of the per-

0890-8567/90/2903-0327$02.00/0© 1990 by the American Academy of Child and Adolescent Psychiatry.

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sonality remained intact," as compared to those with frank psychosis due to their ability to employ' 'neurosis-like defense mechanisms." Wei I (1953, 1956) described "certain severe disturbances of ego development" which evolved around the areas of social adaptation, manageability, and "neurotic-like" behavior. In 1954, Ekstein and Wallerstein used the term "borderline" to describe children, analogous to the "borderline" adults depicted by Knight (1953). These children were notable for their alternation of neurotic and psychotic ego organization and fluctuations in functioning during the therapy hour. A number of psychoanalytically oriented papers followed describing characteristics and dymimics (Gclcerd , 1958; Marcus, 1963; Rosenfeld and Sprince, 1963; Frijling-Schreuder, 1969; Pine, 1974, 1986; Bradley, 1979; Chcthik , 1979, 1986; Gilpin, 1981; Morales, 1981; Bcmporad er al., 1987). An edited work (Robson, 1983) provides a comprehensive overview. In an attempt to obtain a consensus on the diagnosis of borderline disorder in children, Vela et al. (1983) analyzed the text of seven key psychoanalytically oriented works addressing this topic and "translated" the psychoanalytic terminology into descriptive terms. Reported behaviors were clustered together into groups of symptoms. Six symptoms were agreed upon by six or more of the authors: (I) disturbed (intense) interpersonal relationships, (2) disturbances in the sense of reality, (3) excessive intense anxiety, (4) impulsive behavior, (5) fleeting "neurotic-like" symptoms, and (6) uneven or distorted development. High agreement on this core group of symptoms may indicate that the authorities were describing a similar psychiatric disorder. Other schema outside DSM-flI-R (APA, 1987) have been proposed. Bemporad and associates (1982) have developed a set of diagnostic criteria based on a literature review and consideration of24 hospitalized, latency-aged children. The characteristic areas of general pathology may be summarized as follows: (I) relationships to others; (2) thought content and processes; (3) nature and extent of anxiety; (4) lack of control; (5) fluctuations in functioning; and (6) associated features which arc said to include poor social functioning, inability to learn from experience or adapt to novel situations, and poor hygiene. As can be seen, the first four symptoms correspond with Vela's consensus criteria (with fluctuations in functioning implicit throughout), especially in the manifestation of disturbance in interpersonal relationships. Developmental, instinctual, ego, and object relations deficits arc also frequently considered major features of borderline children (Chethik, 1986). Other subclassifications have been suggested for such borderline children, including "fluid" (Gilpin, 1981) and' 'highly functioning" borderline children (Chethik, 1986). Morales (1981) has tried to integrate the psychoanalytic oriented literature to define a borderline spectrum which runs from the psychotic end to the narcissistic personality disorder end. Though these sub-categories have not been validated by research, their range illustrates the hcterogenity of the clinical presentation of borderline children. Borderline disorders of childhood are not included in the section of "Disorders Usually First Evident in Infancy, 328

Childhood or Adolescence," but the DSM-III-R specifics that the BPD "should be diagnosed in children and adolescents, rather than the corresponding childhood disorders, if the Personality Disorder criteria are met, the disturbance is pervasive and persistent, and it is unlikely that it will be limited to a developmental stage. The other Personality Disorder categories (e.g., Schizotypal Personality Disorder) may be applied to children or adolescents in those unusual instances in which particular maladaptive personality traits appear to be stable" (p. 336). In the most stinging indictment of the concept, Gualtieri ct al. (1983) report that none of the 16 children, 6 to 13 years of age, referred as "borderline" for inpatient care or comprehensive evaluation, met DSM-1I1 criteria for BPD (APA, 1980). The authors conclude that child psychiatrists seemed to use the term "more to denote a disorder characterized by disorganized cognitive faculties, but less severe or pervasive than childhood psychoses" (p. 70). No mention was made as to whether the children met criteria for SPD, though nine were diagnosed as attention deficit disorder with hyperactivity, two with adjustment reaction, and one each with "Conduct Disorder," "Conduct Disorder and ADD + H," "Childhood schizophrenia," "Adjustment reaction and ADD + H," and separation anxiety disorder. Schizotypal Personality Disorder/Autism/Schizophrenia Spectrum In 1944, Asperger described a psychiatric syndrome which he named "Autistic Psychopathy of Childhood" (AP). These children were characterized by abnormalities of gaze, poverty of expression and gesture, as well as unusual voice production. Those with high intelligence would become specialists in the natural sciences, mathcmathics, engineering and art. while those with low intelligence would function as "automata," and when of intermediate intellect as eccentrics (Wolff and Barlow, 1979). Resembling many children labelled as "borderline" or "schizotypal" today, they often displayed learning disabilities and difficulties in concentration or of being distracted from within. Similar to children with infantile autism, their social adaptation was impaired and they were unable to experience empathy, or conform to social conventions. Wolff and Barlow (1979) list the clinical features of "schizoid personality in childhood" (SPC) as: emotional detachment and being solitary; lack of adaptability or rigidity assuming obsessional proportions; sensitivity (easily hurt, touchy) marked by periodic suspiciousness and paranoid ideation; lack of empathic feelings towards others; and "odd ideation often with metaphorical use of language" (p. 30). These children with SPC were differentiated from autistic children by the presence of language, emotional responsiveness toward others, and lack of involvement in ritualistic and compulsive behavior. The clinical features were considered to be almost identical to those described by Aspcrger. Classification as a personality disorder was justified by the nature of its lifelong and unchanging patterns of deviate functioning, and persistence of the disorder into adulthood (Wolff and Chick, 1980). Aspergers (AP) description of SPD type children has l.Am. Acad. Child Adolesc. Psychiatry, 29:3, May 1990

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been repeatedly supported by the literature except that AP includes impaired nonverbal communication, while SPD of DSM-III includes abnormal perceptual experiences and ideas of reference as symptoms. Nagy and Szatmari (1986) reviewed 20 charts of children identified by pediatricians and psychiatrists as having at least one symptom related to disordered thinking and one to social isolation or oddities of behavior. Many of the 18 boys and two girls had a number of chart diagnoses including borderline autism, BPD, borderline psychosis, schizoaffective disorder, and childhood neuroses. All met three or more SPD criteria (with 18 meeting four or more) and had documented magical thinkingl bizarre preoccupations, social isolation, and social anxiety; all were considered by their parents as abnormal before age 5 years but able to relate better to adults. None could establish or maintain friendships with peers. Rarely found were ideas of reference, paranoid thinking, or illusions. However, several workers consider children meeting criteria for AP to be experiencing a variant of autism or pervasive developmental disorder (PDD) (Wing, 1981; Rutter, 1985; Pomeroy and Friedman, 1987; Bowman, 1988); while others consider SPD to be on the schizophrenic disorder spectrum (Russell et al., 1987). Pomeroy and Friedman (1987), in a retrospective chart review, selected children with chronic socialization problems (not secondary to shyness or anxiety), hallucinations, delusions and/or obsessive/compulsive symptoms, but not meeting criteria for the diagnosis of infantile autism or severe brain injury. Separating the group into early (before age 3 years) and late (after 5 to 7 years), they found the early group could be subdivided into an autistic and schizoid spectrum; while the latter group seemed to be comprised of children resembling Asperger's and the DSM-III schizoid disorder diagnoses. The neuropsychological profile of the children diagnosed as AP showed little evidence of gross deficits in language and was characterized by lateralizing features indicative of nondominant hemisphere dysfunction. Pine (1983), in his broad use of the concept' 'borderline," considers "schizoid personality" of childhood to be part of the borderline group of children. However, the nature of the interpersonal relationships differentiate borderline children from those under the schizoid/schizotypal spectrum. Borderline children are considered overdependent, possessive, overdemanding, and socially disinhibited (Vela et al., 1983), while schizoid children are considered solitary, emotionally detached, and unempathic (Wolff and Chick, 1980).

Biological Correlates As child psychiatry begins to employ techniques useful in understanding the neurophysiological and neuropsychological correlates of psychiatric disorders, we can expect marked advances regarding the borderline disorders. To date, several rich paths to investigate childhood borderline disorders have begun to be defined. BPDIBorderline Spectrum

The association of organic brain pathology and children diagnosed as "borderline" appears repeatedly in the literl.Am.Acad. Child Adolesc. Psychiatry, 29:3, May 1990

ature. Rosenfeld and Sprince (1963) were the first to note the finding of "organicity" in some borderline children. In a follow-up of 29 subjects with infantile borderline psychosis, Wergeland (1979) found neurological signs of brain damage and pathological EEGs in 10 of them. Aarkrog (1981) reports evidence of organieity manifested by abnormal EEGs, physical signs of brain damage, or signs of brain damage in psychological testing in nine out of 29 borderline adolescents who had been evaluated in childhood. Bernporad and associates (1982) reported evidence of "organic involvement" in 22 of 24 borderline children. This was manifested by a variety of findings including abnormal (nondiagnostic) EEGs, visual-motor problems, history of early seizures, attentional disorder and hyperactivity, poor fine and gross motor coordination, speech artieulation problems, reading and mathematical disabilities, petit mal seizures, and others. However, a preliminary study revealed no significant differences in signs of minimal brain damage in children meeting borderline personality organization criteria compared to a clinic group not meeting the criteria (Liebowitz, (984). Rogeness and associates (1984) have investigated dopamine-beta-hydroxylase (DBH) in disturbed children. The deficiency of this enzyme can result in either excess dopamine or deficient norepinephrine and could be related to the dopamine hypothesis of schizophrenia or the norepinephrine hypothesis of depression. Lowered DI3I-] levels have been found in autistic children, children who arc psychotic, and children with conduct disorder, undersocialized (UCD). Twenty emotionally disturbed boys whose DBI-! values were less than or equal to 2 f.LM/min/L plasma were compared to 20 emotionally disturbed boys with DBH values greater than 15 f.LM/min/L. All had required psychiatric hospitalization. Most of the boys with the lower levels had values of zero (the zero DBH group). Forty percent of the zero DBI-I group were diagnosed as BPD. In a larger study, the UCD group of boys with near-zero DBH demonstrated more schizotypal, schizophrenic, and borderline symptoms, particularly, brief psychotic episodes, than did the conduct disorder, socialized boys with DBI-I levels greater than six (Rogeness et aI., 1986). However, the wide range of activity in normal populations for the DBH enzyme makes it unreliable as a marker or indicator of underlying neurophysiological disorder (Cohen et al., 1983). It is evident that there is no pathognomic finding or any one-to-one correlation between a spcci fie organic pathology and the development of borderline disorders in children. However, the high incidence of "organicity" in these children raises various possibilities: (I) that the presencc of organic involvement (broadly defined) predisposes to the development of borderline disorder in children; (2) there is a subgroup of borderline children with an organic etiology (which raises the question of the important differential diagnosis between borderline disorder and organic personality syndrome); and (3) the eombination of organic and environmental factors (see section on etiology) contributes to the development of borderline disorder. Additional research is needed to elucidate this issue. 329

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Si'Dt/vutismtSchizophrenia Spectrum

Significantly higher platelet levels of monoamine oxidase activity were demonstrated in boys under 13 years with SPD and schizophrenia than matched controls or boys with major depressive disorder (MDD). Whole blood serotonin levels were also significantly higher for SPD and schizophrenia groups as compared to the MDD group, but not significantly different from the control group (Rogeness et al., 1985). Nagy and Szatmari (1986) report a high frequency in SPD children of various ncurodevelopmental markers of brain dysfunction, e.g., clumsiness, EEG abnormalities, and psychometric test deficits. Such nonspecific findings have been reported in most studies of borderline and conduct disordered children and, hence, add little to validity though they may be more frequent in SPD than BPD children (Petti and Law, (982).

Delimitation from Other Disorders Exclusionary criteria arc considered by Feighner and associates (1972) as the major factor in differentiating a particular diagnosis. This has been a particular problem with the borderline diagnoses. However, studies do support the borderline classification as having unique characteristics and allowing differentiation from other disorders. Leichtman and Nathan (1983) have described the highly atypical and distinctive manner in which such children function in response to differing aspects of the testing situation. In contrast to other children, borderline children openly demonstrate their conflicts and problems during testing, without the need for specific test instruments, and in a manner which compels the examiner's attention. "They tend to be anxious, impulsive, and intolerant of frustration; they exhibit pronounced characterological and interpersonal problems; they are subject to abrupt mood swings and sharp regression; and they arc apt to interpret the world around them and to interact with others in idiosyncratic ways" (p. 124). BPD/ Borderline Spectrum

Borderline disorders in children have been differentiated from neurotic, schizotypal, psychotic, and other severe childhood disorders using different diagnostic criteria and methodologies. Petti and Law (1982) reviewed the charts of 10 children, ages 6 to 12 years of age, who were hospitalized for severe psychopathology and manifested borderline psychotic features. The symptoms described in the hospital record were matched to the DSM-Ill criteria for BPO, SPD, and PDD. An eleventh child was dropped from the study because he met criteria for all three disorders. Five of the children met criteria for BPD and five for SPD. Criteria for PDD were met by two children in both the BPD and SPD groups. Significant differences were found between the groups regarding symptoms comprising the criteria for each (with children meeting BPD criteria demonstrating greater impulsivity, unstable relationships, problems with anger, affective instability, self-damaging acts) and for the total of BPD symptom ratings. They suggest that the retrospective analysis of hospital-records methodology did 330

not allow for an even greater differentiation in symptoms between the groups. The overlap of SPD and BPD diagnoses in the child excluded from the analysis is consistent with the 20% overlap found in adults (Spitzer et al., 1979). In contrast to this, a recent study of children with SPD reports no overlap at all, although it does not appear that the BPD criteria were a specific focus of the data collection (Russell et al., 1987). Liebowitz (1984), in a preliminary report, employed modified structural criteria of Kernberg (1977) in diagnosing borderline personality organization. Of the 65 children and adolescents, ages 6 to 17, seen for comprehensive outpatient evaluation, 17 met criteria for borderline personality organization; when these youngsters were compared to the other 48, they demonstrated a statistically significant increase in frequency of all BPD symptoms except for intolerance of being alone. The borderline personality organization group also had significantly greater amounts of intense anxiety, depression and low self-esteem, omnipotent-grandiose fantasies, lack of empathy, no lasting peer-group relationships, and disorganization. Bentivegna and associates (1985) applied Bemporad's criteria in a chart review study and were able to significantly differentiate 70 borderline children from two other control groups. Adult criteria for differentiating individuals with a borderline personality disorder (Gunderson and Singer, 1975) have also been employed in children (Bradley, 1979; Greenman et al., 1986). In a retrospective study of 86 hospitalized 6- to 12-year-olds, Greenman and associates used a modified adult scale, the Diagnostic Interview for Bordelines (DIB-R) (Gunderson et al., 1981), to identify borderline children and to demonstrate the extent to which the youngsters manifested features described in the literature (i.e., the Bemporad criteria). Moderate concordance between the Bemporad criteria and modified adult criteria was documented. They concluded that the validity and utility of the term to describe youngsters meeting that set of adult (Gunderson) and Bemporad criteria are in question, since they found few significant differences between identified borderline and non-borderline children serving as controls. However, the methodology is flawed. The selection criteria lack specificity (Gualtieri and Van Bourgondien, 1987). Over 30% of the children were diagnosed as borderline using the DIB-R, of which only two (7%) were diagnosed as BDP and 15% "other personality disorder." In contrast, 5% were diagnosed as BPD in the non-borderline control group! Employing broad criteria for borderline diagnoses, Rubin and associates (1984) statistically differentiated borderline from neurotic children, with the former having more severe behavioral pathology, disturbances in ego functions and modulation of affect, as well as difficulties in directing attention. However, selection criteria overlapped considerably with the Degree of Disturbance Scale employed. Verhulst (1984) obtained 28 items from the literature, said to distinguish borderline from other children, and asked Dutch child psychiatrists to endorse those that were specific to a borderline, neurotic, and psychotic child in their practice. Scoring highest were "social isolation" (97%), I.Am.Acad. Child Adolesc. Psychiatry, 29:3, May 1990

C HILDHOOD BORDERLI NE DISO RDERS

" rnicropsychotic episodes" (93 %) , " high level of anxiety" (9 1%), and " predom ina ntly pr imitive defense mech anisms" (9 1%). Of the 28 cha rac teristics described for borderline childre n , only the presen ce of marked separation anx iety, feelings of lon eliness. and hyperactivit y failed to be significantly different between bo rderline and " neu rotic" children. Likewise , a psycho tic child was described as having significantly less " de ma ndi ng, clin gin g , and unpredictable relati onship s ," " predo minantly prim itive defen se mechani sm s ," shifting levels of ego functioning, and feelings of loneliness than a bord erl ine child . Characteristics reported signifi cantly more o ften in psychotic , compare d to borderline ch ildren , incl uded "w ithdrawn , aloof in contac t with ot hers, " need fulfillin g re lation ships , langu age and speec h pec uliarities , special interest or talent in one area, and res istance to change in the env ironment. Methodological flaws in the study include a potentially bias ed sample . SPD/Au tism/S chizop hrenia Sp ectrum

T he two studies employing DSM- l/I criteria support the different iation o f SPD children from others in the sa me clinical se tting . Co mpa red to BPD children , tho se with SPD demonstrated incr ea sed sy mpto ms of magical thinkin g, odd speech , inadequa te rap po rt, suspicio usness /paranoia, and total of SPD ratin gs (Petti and law , 1982) . Likewise , in comparing schizo typa l personali ty traits in the borderl ines , comp ared to the others , signi fica nt differenc es were found in distrust , suspiciousn es s and paranoid ideati on, hypersen sitivi ty with a trend toward sig nificance in peculi ar thoughts and bizarre fant asies , and average total number of SPD traits (Liebowi tz, 1984) . In a ca refully co ntro lled study co mparing children from 4.5 to 14 .0 ye ars of agc (mea n = 9 .5), dia gnosed as either SPD (DSM -l/I) or sc hizophre nia , Russell and associates ( 1987) repo rt that 20 met SPD and 35 schizophrenia criteria . One SPD chi ld did not meet the DSM-Il/-R rev ised criteri a ca lling for five rath er than fo ur associated symptoms. Full criter ia for SPD wer e met by 69% of the children with a schizophrenic disorder. Only soc ial anx iety/sens itivity to critic ism was found to be stati stically sig nificant mor e fre quentl y in the SPD group . Sign ificantly less hallucinations , delu sion s , and tho ught disord er were found in the SPD co mpared to the schi zophren ia co ntrols . Additional DSMIII diagn oses , but not BPD , were found in 80% of the SPD children. Th e auth ors asse rt that SPD sho uld be reclassified as sch izo typa l di sorder and adde d to the Axis I of the DSM , given its phen om en olog ieal close relation ship to the diagnosis of sehizo phrenia; or the d iagn osis and criteria sho uld he listed in the childhoo d disor der s sect ion. Thi s is much in line with Me eh l' s ( 1962) suggestion that bord erline disorders ex ist on a co ntinuu m of " schizotypy" with sc hizo phrenia (Shapiro, 1983) . SP D children do man ifest symptom s of both schizo phre nia and PDD (Nagy and Szatmari , 1986) . Wol ff and Barlow (1979) co mpared children labeled SPC with we ll-functioning auti st ic and normal children on tests of cog nitive processes, langu age , memory, and intellige nce . They report that the SP C group coo perated less on tests of memory , cog nition, and langu age and we re less motivated l .A m. Acad . Child Adolesc. Psychiatry, 29:3, May 1990

to succeed than the other two groups; inner preoccupat ion see med to hamper per formance . T he SPC gro up wa s intermedia te in sca tte r in subtest sco res bet ween the normal and autistic control gro ups . On the ' Illinois Test of Psych oli nguistic Ab ilities , the autistic and SPC groups had mainl y negati ve , while the norm al con trols had positi ve subtcst sco res on most items. Sch izoid children we re clearl y higher functioning and showe d less repetiti ve be hav ior on tests of perseveration and pattern impositions than autistic children, and co uld not be differenti ated from normal co ntrols . Overall , the SP C chil dren functioned intermed iate ly bet ween the co ntrol groups , sharing the stereotypy and tendency to impose patterns, some lingui stic hand icaps , and lack of perceptiveness for meaning with the autistic control s .

Outcome Deter mining the course of a disorder assists in ruling out whether the disorder co uld be attributed to anot her d isord er or illness, and the extent to whi ch the original diagn osis describes a hom ogen eou s gro up . Ava ilable studies p rovide some interestin g informa tion co nce rn ing the course of the disord er. Most studies , how ev er , are poorl y co ntro lled , employ loose definition s o f childre n defin ed as bord erl ine , and co nsider the psychod ynamically defined bord erline child . BPD /Borderline Sp ectru m

No sys tema tic stud ies have been repo rted on the co urse of children dia gn osed as BP D . However , a numb er of studies have exa mi ned gro ups of childre n falling within the spectrum. Kestenb aum (198 3) , employ ing the co nse nsus criteria (Vela et al., 1983), reviewed seven cases, retro spec tive ly dia gn osed as borderl ine , which had been in treatment. After 14 to 30 ye ars, one of the seven was diagnosed as BPD , one as SPD , one as schizo id , two as sc hizophrenia, one as bipo lar disord er , and one as anx iety disorder. Th ese results sugges t that the co nse nsus criteria, as a reflec tion of early ' 'l umping " efforts o f nosologists, may lack predi ctiv e validi ty except to predict ex ten sive psychopathology. Etemad and Szurek ( 1973) rev iew ed the ch arts of 84 children, 27 diagnosed as " bor de rline , " usin g Eks tein and Wallerstein 's definition of the disorder. The fo llow-up period ex tended from 5 to 23 years, and the age ran ge o f the patient s at the tim e of the last foll ow -up was from 10 to 34 yea rs . Out come was limit ed to the need for rehospitali zation and no data were provided abo ut the d iagnosis at foll owup . Abo ut 4 1% of the sample was not hospit ali zed after disch arge, while the rest requ ired different degrees of co ntinued hospit alization . No co nclusion about outco me ca n be made fro m this stud y ex cept that the majority of the cases appeared to ha ve a serious disturbance req uiring prolon ged intensive treatment. In ano ther study , Wcrgcl and ( 1979) fol lowed up 29 " borderlin e psych otic " chi ldren who had been hospital ized for observa tion in a psychi atric unit. Th e children we re di agnosed usin g Ekstein and Waller stein 's, Pin e ' s , and Brasks definitions of bord erline childre n. The follow-up peri od was 4 to 19 years and the age range at foll ow -up was 12 to 30 years . About one-third of the patients were still bord erline or' ' manife st psychotic " at the time of follow-up , regardless

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of whether they received treatment or not. The rest were either symptom free or had varying degrees of neurotic symptomology. This study points toward a better prognosis for these children than would be expected. However, there was a selection bias in the study: the more disturbed children were the ones who were assigned for treatment. Aarkrog ( 1981) studied 50 borderline adolescents referred for adolescent psychiatric ward hospitalization. She used the Danish classification for borderline states, comprising three main types: infantile borderline psychosis (with four subtypes), pseudoncurotic , and pseudopsychopathic borderline states. The study consisted of two parts: a followback study and a 5-year real time prospective study. Of the 50 adolescents, 29 had been evaluated in childhood, II of them diagnosed as "infantile borderline psychosis" following the Danish classification. At the time of the follow-up, 70% of the borderline adolescents were still borderline. The II children diagnosed as "borderline infantile psychosis" in childhood continued to be borderline through adolescence and early adulthood. (Aarkrog, 1981; personal communication) In conclusion, even though most clinicians seem to assume that borderline children grow into borderline adults and that borderline psychopathology has its developmental roots in early childhood, there is some supportive but no conclusive evidence that this is the case. Additional research involving controlled follow-up studies, with adequate samples, definite, inclusive diagnostic criteria, and standardized methods of measuring outcome into adulthood arc needed in order to establish predictive validity. Possible guides for future studies arc available from those with young adults (McGlashan, 1986a, b). .'lPn/Autism/Schizophrenia Spectrum

Asperger reported that only one of the 200 boys he identified later developed a schizophrenic disorder. Wolff and Chick (1980) carefully followed the schizoid borderlines and have confirmed the earlier findings of Asperger. Matched to a control group of children with other psychiatric disorders referred to the same child psychiatric department, 22 boys with schizoid disorder were followed about 10 years later. Schizoid disorder was diagnosed in 18 of the SPC boys and one control. On follow-up, the schizoids were "clearly deficient in their interpersonal relationships"; with most showing impaired empathy and odd style of communication. In a related work, Cull et al. (1984) report a 12-year follow-up of 23 SPC boys demonstrating significant correlation and continuity of the SPC disorder over time. Preliminary results of a later study with schizoid and control subjects at a mean age of 28 years, confirms that a majority of the schizoid children arc indistinguishable from SPD adults, with 19 of 25 schizoid children diagnosed as SPD; four controls were later diagnosed as SPD. Three "schizoids" and no controls were identified as borderline using a scaled score of 7 or greater on the DIE. In addition, only one definite and one doubtful case of schizophrenia were identified at the follow-ups of the SPC youngsters at mean ages of 22 and 28 years, respectively (Wolff, 1989).

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Family Studies No controlled family or genetic studies have been conducted for the borderline disorders of childhood. Asperger's early description noted that some of the boys had mothers with the disorder. He later reported a family member with features of the disorder for all the boys that he studied (Nagy and Szatmari, 1986). Bowman (1988) describes a father and his four sons who present symptoms along the autism/ Asperger spectrum in terms of clinical psychological and psycholinguistic profiles. Separating familial from genetic factors is of critical importance, since familial contributions have been strongly suggested as a major factor in adolescent (Shapiro, 1978) and adult (Gunderson et aI., 1980) borderlines and BPD (Torgersen, 1984), while genetic factors seem to influence the development of SPD diagnosed in adults (Torgersen, 1984).

Etiologies Proposed for the Borderline Disorders A panoply of etiologies have been proposed for the development and maintenance of thc borderline child. Psychoanalysts have posited irregularities in the early mother-child relationship and disturbances in ego development (Geleerd, 1958; Rosenfeld and Sprincc, 1963; Mahler, 1971; Masterson, 1972; Masterson and Rinsley, 1975; Rinsley, 1980; Chethik, 1986). Support for the theoretical role of disruption of the early infant-mother bond in borderline pathology has been provided by the findings of Bradley (1979). History of maternal separation before the age of 5 years was statistically greater in a group of 14 children and adolescent borderline patients than in control groups of psychotic, nonpsychotic, and delinquent children. Minimal brain dysfunction, severe developmental or sensory deficits (e.g., deafness or blindness), or developmental lags possibly interacting with psychodynamic factors (Kern berg , 1983a) may be considered causal or associated conditions. Bemporad and associates (1982), besides noting the increasing frequency of organic impairment in their borderline sample when compared to siblings or to children with other forms of psychopathology, report histories of abuse, neglect, and inconsistent care. Mothers were noted to be frequently unstable, easily frustrated, and unable to sustain empathic relationships; the fathers showed difficulty in selfcontrol and instability in relationships. One or both parents often participated in or encouraged the unrealistic fantasies of the child. Pine (1986) offers an integrative psychoanalytic model that assumes neurophysiological handicaps and/or toxic environmental conditions that impact on failure to develop core aspects of higher functioning and result in maladaptive coping mechanisms, thus leading to the development of the borderline child.

Therapeutic Considerations Given the heterogeneous nature of borderline children, therapeutic treatment becomes a major challenge. The entire armament of child psychiatry has been focused and advocated for borderline children, including education and appropriate behavioral management (Wing, 1981), psychoanalytically oriented psychotherapy (Rinsley, 1980; Gilpin, J. Am. Acad. Child Adolesc. Psychiatry, 29:3 , May 1990

C H I L D I IO O I) BO RD ERLI N E D ISOR D ER S

1981 ; Kernberg , 1983b) , co llabora tive therapy (Weger et al., 1981) , partial hospitalization (Stambler and Mutter , 1981; Han son et al. , 1983) , intens ive residenti al treatment (Lew is and Brown, 1979 , 1980; Masterson and Rinslcy , 1975) , family interventions (Weger et al. , 1981 ; Combrinck-Graham , 1986) and psychoph arm acology (Petti and Unis , 1981 ; Petti, 1983) . Th e differential diagno sis is cr itica l in treatment planning for this group of children. As Kern berg (l983b ) notes , the organ ic and psychological factors must be assessed in bor derl ine children in ord er to appro pria tely plan for and implement effective treat ment.

Bl'Dlllorderlinc Sp ectrum Psychotherapy for borderline ch ildren evolve d from the classical psychoanalytic prin cipl es used with reported success in the treatment of neu roti c adults and ch ildren . In recent years , the trend has been to emphasize mod ifications in psyc hothe rapeutic technique required to divert psychotic functioning and stren gth en defen se mechanisms. Ekstein and Wall erstein ( 1956) exami ned the techni cal probl em s of the usc o f psych oanal ytic interpretation s in therapy and reco mme nded the usc of " interpretation with in the regression , " thu s supporti ng the therapi st' s prim ary ai m of mainta inin g the relat ion sh ip and prevent ing the disrup tion of co ntac t. Interpretati ons ai ming at insig ht were to be made on ly afte r lessening regressive tendencies . Commun ication was to rem ain within prim ary process fantasy and modes of ex press ion, un til the ch ild had acqu ired the "strengt h" to move to a more mature posi tion. Exa mples used to illustrate this techn ique reveal that the therapi st would not co nfro nt the child with cog nitive di storti ons and maladaptive psychoti c thinking , but rathe r wo uld ag ree with the child's false belie fs during what wou ld appear to be mini-p sychot ic

episodes. Rosenfeld and Sprince ( 1965) later pro posed modi fications to fac ilitate repression and disp lacement rather than mak ing unconscious mat erial co nscious . They em ph asized that ch ildren had to be help ed to build up defenses , and that therapists should prov ide a function similar to the " aux iliary ego," help the child becom e awa re tha t tens ion can be contained , and facili tate the use of displ acement as a defen se mech anism . Th ey asserted that the affect, tone, or facia l ex press ion of the therapist is of greater imp ortance than the ver bal co ntent of an interpre tation, and quest ioned the usefulness of interpret ing agg ress ive impulses . Gilp in ( 1976) reviewed the literature that emphas izes the critica l importance in dev elopin g sta ble introjects and details an illu str ative case where in the thera pist serves as an auxil iary ego in ass isting with verba liza tio ns ove r makin g decisions , in sorting out complex ities , and in differentiating causa l relatio nships. T he pivotal role of interpreting transference is stressed. In contrast to th is, Lewis and Brown ( 1979) em phas ize fostering the development o f rea lity testin g throu gh help ing the child reco gnize and under stand his/her reactions to var ious events occ urring in daily life , and clarifyin g distinction s bet ween rea lity and fanta sy . Provi di ng a consistent object (interpersonal) relationship and helping the child to de velop mas tery mechanisms and to maint ain contro l during the l .Am .A cad . Child Adol esc.Psychiatry , 29:3 , May 1990

therapy hou r, in orde r to limit regressi ve , sex ua lized, and aggressive beh avior to manageable level s , we re co nside red to be critical. Chethik ( 1979) si mila rly suggests that interpretations in therapy with borderline children sho uld be ego suppor tive , helping the chi ld to build up defen ses and to stre ng then and develop coping sk ills . Sm ith et a!. ( 1982) advocate the use of four maj or moda lities: psych oth erapy , med icat ion, fami ly therapy , and enviro nmental support. Th ey di vide the treatm ent of borderlin e children into three stages : ( I) allay ing anx iety and makin g an allianc e , (2) prom otin g ego de ve lopment , and (3) internaliza tion . Anxie ty is seen as an obstacle in the formation of a ther apeuti c allia nce . During the first phase of trea tmen t, exploration o f anx iety is avo ided as this may escalate into panic. Th e therapist curta ils the elaboratio n o f sexual and aggressive fanta sy material, avoids dynamic exploration and may need to restrain the child ph ysically if' he or she becomes aggressive . Durin g the second stage, the therapist helps stren gthen every area of the child' s devel opme nt and defensive structure . T he dan gers of reg ressio n, panic , and loss of contro l are mon itored and the therap ist talks with the child about events occurri ng in his/her real life in orde r to avoid isolation from the therapist. T he last phase is see n as some what ope n-e nde d, analogo us to ther apy wi th neurotic ch ildren , and frequently ext end ing into yo ung adulthoo d . The importa nce of reso lving separation- individuatio n issues in borderl ine children is stressed by Kern berg ( 1983b), as she enu merates the assoc iate d "mirroring" function s and their relevance to the thera pis t in he lpin g to reso lve the pathological clinging, shadow ing, and darting. For the young bord erl ine chi ld , she advoca tes wo rking wi th the moth er child diad in mak ing mani fest the an xieti es and fe ars o r abandonment , total loss, or annih ilation. Sh e present s a se t of 12 co nsideratio ns for the psychodynamic therapist to address . Vela and Pett i (1988) have sugg ested a more dir ecti ve mode l of therapy for bo rderlin e disorde rs of' childhood . Non direc tive therapy is seen as counterproductive in the treatment of bord erline chi ldren. Vela ( 198 8) argu es that psyc ho the rap y fo r borde rl in e c hildre n mu st invo lve th e clarificati on of limi ts fro m the beginning, monitor ing the expressi on of fee lings, providin g structure whe n necessary , clarifying the difference betw een reality and fanta sy , di sco urag ing regressed , withdraw n and psychotic beh avior, and directly co nfro nting ma ladap tive be hav ior. Cognitive mis perceptions sho uld be mod ified and co rrec ted.

SPD/AutismlSchizophrenia Spectrum In speaki ng o f Asperger' s sy ndro me, Win g ( 198 1) asserts that the hand icap s ca n be addressed thro ugh app rop riate managem ent and educat ion. She cites the importan ce 1'01' both parent s and teach ers in recognizing the di fficulties , so metimes subtl e , in co mprehe ns ion o f' ab str act langu age which can mak e co mmunic atio n di fficu lt. Win g sugges ts that the repetitive speec h and motor habi ts cannot be ex tinguished , but ca n be modified to mak e them mor e soci al ly useful and acceptable ove r tim e. The goal of ed ucati on is to develop the child ' s spec ial interes ts and ge ne ral co m-

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potence to the extent that will allow inde pende nce in later life . Most descr iption s of psych od ynami cally orient ed therapeuti c interventions focus on the BP D spectrum child where the techni ques arc co nsonant with the theoretical and etiologic co nstructs . Bau er and Moda rressi (1977) prov ide a theoret ical basis for wo rking with SP D spectru m chi ldren from objec t relationsh ip theory and developmental ego psychology perspect ives . T he strategies to allow " jo ining " thera pist and child arc nicely illustrated .

treatment and with receiving so me residenti al treatment. A case study (Petti and Unis, 1981 ) and anecdotal case reports sugges t that BPD borderline childre n respond to imipramine treatment. If researchers in the field would accept operation al definitions of the disorder, c .g . , those for SPD and BPD , dev elop ratin g sca les , and usc them in sound single case design or , opt imall y , in mult isite co llaborative studies, then we should be able to better support the ex iste nce of subgro ups of " borde rline" childre n and their di fferential response to treatment.

Psychopharruacotherapy

Discussion

Psychop har macolog ical inter venti on s are bein g used with increasi ng frequency in controlling the sy mptoms of the bord erline disorders, partic ularly those ass oc iated with BPD (Petti, 1983; Petti and Law, 1982; Rogeness et a!., 1984). Rin sley ( 1980) has suggested that psychotropic medi cations for bord erlin e children be targeted to spec ific symptoms, e.g ., stimulants for hyperacti vity and imipramine for depression. A biological mech anism has been pos ited by Rogeness and associates ( 1984) who noted that significantly mo re of their zero DBH boys were treated with psychotrop ics than the co mparison gro up . T hey report that 25% required a combination of neuroleptic drugs and methylphenidate, which allowe d successful placement outside the hosp ital setting, and sugges t that the combination may redress neurotransmitter imbalances throu gh multiple channels , as may imip-

Issues related to bord erlin e disorders for both children and adults co ntinue to enge nde r much dis cussion . BPD has been used as a descriptor of a clin ica l picture of an unstable personality and psychodynamically as both a descriptor of personalit y organization and as an indicator of se verity or degree of impa irment. Th e que stion of whether the dia gnostic criteria should include a history of tran sient , but se lflimited , deficits in rea lity testin g persis ts (Wi diger et al. , 1988) . Th e same may be said for the BPD diagnosis in children and adolescent s , Alt ern atively , tran sien t psyc hotic episodes may indi cate degre e of severity of eve n a un ique subgro up of both BPD and SPD spec tru m children . Like wise, SPD /SP C and schizoi d personality disorders (APA, 1987) have bee n con sidered as separate disorders, as well as either var iants along a schizo phrenia spec trum or a single personality d isorder in adults (W idiger et al. , 1988). Th e recent report and rev iew by Wol ff ( 1989) offers further support for this view . The mod ification of DSM lll-R allowing SPD and schizoid person ality disord er to be d iagnosed in the same perso n and not to be exclusio nary, redefine Wolff' s group eve n mor e into the SPD classification . Th is in turn sugge sts that the maj or d ifferenti al for th is group will be SPD, PDD , and schizo phrenic disorder and that such youngsters can be rem oved from the class ification of borderl ine disord ers . Current wisdom suggests that the amount of spac e required to present a topic area is inversely proportional to the deg ree of scient ific certainty assoc iated with it. The borderline disorder s of childhoo d support thi s rul e . Thi s review has attempted to present material represent ati ve of the literature . At this point an atte mpt will be made to summa rize the curre nt state of the field: 1. The ge neric term ' 'b ord erl ine" whe n applied to chi ldren ca n reasonably be divi ded into two broad sy ndrom es: the BPD /bord erlin e spectru m and SPD/schizoty pal spectrum syndro mes with som e over lap in individual cases . Children mee ting criteria for either clu ster can be differentiated from children from general or clini cal populations . 2. The BPD gro up remains a heterogeneou s am algam of wide ranging psyc hopatho logy with repeated efforts by clini cians to class ify and subclassify the very disturbed chi ldre n falling within its purv iew . However, there is a co re group of psychopath olo gical symptoms with whic h most elin icians see m to agree . (a) The co-mor bid ity with other psychi atri c disord ers (e .g ., UC D, ADHD, specific and mixed devel-

rarnine.

Th e wo rk of Schulz and ass oc iates ( 1988) highl igh ts the hetero gen eous responses of bord erl ine patients to psychotropic age nts as ea rlier describe d by Klein ( 1975) for adults and Petti ( 1983) for children . Diverse groups of med ications , ranging from anxiolytic agents , tricyclic antidepressants , psyc homo tor stimulants , ncurolepti cs , and lithium have been described as helping ameliorate sy mptoms in bord erlin e disord ered chi ldre n . Sel ect antico nvulsants (e .g ., carbamazcpine and valproic acid) may assume an even greater role in the future as child ren with an orga nic component arc better de lineated . Th e psychopharmacological treatment of bord erlin e paticnt s may call for greater cli nical ski ll than for any ot her childhoo d d isord er or syndro me as re lated to ex pec tations , fea rs, fantasies, co nflicts, ctc . , of children and their families regard ing medic ation (Petti and Sallee, 1986). Psychotherapcutic support is often vital in successful pharmacotherapy of childhood borde rline co nd itio ns (Petti , 1989). Speci fic guide lines for medi cat ion of children with the bord erline disord ers have not developed .

Response to Treatment Cant well ( 1985) suggested that response to tre atm ent is a critical co mpo nent of the validation process. The" medical model ' hold s that outco me with regard to co urse or response to therapeu tic interve ntion is rea lly the test of the diagnosis as an hypothesis . Unfort unately , no well-co ntro lled group studies exis t to whic h we can turn . Of 62 trea ted borderl ine cas es review ed by Bent ivegna and asso ciates (1985) , 32 improved , 25 showed no change , and five beca me wor se. The better treatmen t ou tco me co rre lated with the length of 334

J. Am.Acad . Child Adol esc .Psychiatry , 29: 3 , May 1990

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opmental disabilit ies) obsc ures the gro up 's definition . (b) Co ntinuity with the adult forms of BPD spec trum disord ers has been demon strated in some studies . Poo r out come and pe rsistent psyc hopatho logy is expec ted for most chi ldren falling within this spec tru m of d isorders . Ret rospective studies sugges t that the related adult disorders begin during childhoo d . (c) Fam ilial load ing for the d isorde r is prob abl y the result of a neuro-dcvelopmental pred ispositi on interactin g with ina deq ua te , insufficiently nurtu ring parenting fig ures in a co nflictua l or abusive environment. (d) Psychotropic age nts do have a beneficial effe ct on ameliorating distressing assoc iated symptoms and seem to assist these children to better organize their thinking and to increase aspects of sel f-control , while de cre asing the disablin g panic exp erienced during co nfl ict. Well co ntrolled, doubleblind group studies for this gro up have not been reported . (e) Dyna mic , structure d, long-term psych oth erapies can be very effec tive in ass isting BPD spec trum children to develop the requisite ski lls, con tro ls, and interre latedness with peers required to function in the mainstre am . Educa tiona l and/or resi denti al progr ams (w hen need ed) playa critical role in the overall care for such children as do edu cation and suppor tive work with the fam ilies . The trad itional role of intensive psych oanalytic psychotherapy and psyc hotherapeutic intervention has been qu estion ed . Co ntro lled studies ha ve not been co nducted . 3. The SPD group appears to be more hom ogeneous in the clinical present ation of childre n so diagnosed ; but the range and sev erity of psyc hopathology is extensive . However, the following conclusions can be drawn: (a) Predictive validity has been demonstrated for the non-DSM IlI-R S PC (equivalent to SPD of the DSM [II-R ) subgro up. T he children who fit into this cla ssific ation sho uld be treated and studi ed as a syndrome , dist inct fro m the genera l classification of borderl ine childre n and co mprise d of spec ific disord ers . (b) Th e SPD gro ups falls within the less severe pathology reg ion of the schizo phrenia spec trum , but the evo lut ion of the clini cal picture into full sc hizophrenic or autistic disorders is infre quent. The findin g by Ru ssell and associates (19 87) of significantly more se ns itivity to criticism in SPD , as co mpared to children with a schizo phre nia disorde r, also suggests a higher level of relatedn ess in the SPD gro up. (c) The reported famili al loadin g for SPD is prob ably ge netically based and manifested throu gh the differ ential expression of bioc hemical and neur opsychological mech anism s. (d) Currently availab le psychotropic agents do not J . A m. A cad. Child Adolesc . P sy chiatry , 29:3, May 1990

serve a major ro le in S PD spec trum childre n except possib ly .t~ ame liorate. targete? sy mp toms, e.g ., hyperactivity , depression , anx iety, or transient psyc ho tic decom pensati on . Educa tio na lly oriented and directiv e psych oth erapeuti c intervention s with em phas is on learning theory based therapies offer the greatest benefit to SPD spec trum children at this time .

Conclusion In co ncl usion, we must avoid prem ature closure o r c lassific ations of children who fail to meet our curre nt diagn ostic categories . Th ere appea r to be a number of borderl ine disorders with differin g etio logies, phen omenology , assoc iated feature s, and required treatm ent s. Assuming the pr em ise or this overview that bord erl ine co nditions in children can be roughly divided into BPD and SPD spectrum classification s with little overlap, then the task for present and future resea rch involves (1) dev elopment o f reliable, valid rating sca les , and trait mark er s and; (2) the further delineation of the subtypes , with attent ion devo ted to their clin ical , neurophysiological , and neu rop sych ological features, etiolog ies, and spec ific therapeu tic interve ntions . We mu st accept the fact that our classificat ion of disorders affec ting childre n is still ea rly in its development and that " borelerline" rep rese nts a sy ndrome about which we have a number of path s to exp lore, subtypes to deli neate , and interve ntion strategies to test. Thus , we must build upon the ex isting rich data base and insights which astute cli nic ians and rese archers have provided .

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