Q. I would very much like to ask for your opinion and advice about what to do with a child with suspected innate BPD predisposition.

My son, who just turned 4, has been very sensitive to emotional/bodily stress right from birth. Incidentally, we happen to have a videotape showing how he screams, persistently and horrified quite unlike most other newborn when the nurse gently brushes his hair, washes him etc. half on hour after his birth.

He was a very cute and charming baby. However, he would cry relentlessly on the rare occasions when I was away from him for a few hours. He also had a colic and we were not able to soothe him no matter what we did.

For your background information, his father is a borderline (undiagnosed, in denial). Since I came across the definition of BPD on the Internet some 1 ½ years ago, I have been actively surfing the web collecting all the information I can find. (The problem is that in our country very little is known about the disorder even among professionals.) I have also read the books "Stop Walking on Eggshells", "Love and Loathing", "Hope for Parents", and "Biological Unhappiness". On the basis of all this information, I am 100 % certain that he is a BP. A very difficult partner, but a great and devoted father, when not raging or suicidal. Luckily, his BPD behavior has to a very large extent took place out of sight of the kids. Children love him and get the very best out of him. There are three children in our family: a 10-year-old daughter from my previous relationship, this son and a one year younger daughter.

At the moment my deepest concern is my son. He is a sweet boy and I love him dearly, but he tends to loose his temper all too easily. The big question is, how to respond in a right manner to the child's emotional outbursts and temper tantrums in order to prevent him from developing BPD? According to the theory of Dr. Marsha Linehan about BPD, the role of validating environment is critical. "The personal experiences and responses of the growing child should not be disqualified or invalidated by the significant others in his or her life, i.e. individual behaviors and communications should not be rejected as invalid. The child's personal communications should be accepted as an accurate indication of his/her true feelings and a valid response to circumstances. Emotional displays and painful behaviors should not be met with punishment that is erratically administered and intermittently reinforcing. Not too high a value should be placed on self-control and self-reliance. Possible difficulties in these areas should be acknowledged. The family should not have an oversimplified idea of how to solve life's difficulties and to meet needs. Negative feelings should be tolerated. "

How to do this in practice? A few examples: -It is morning. We ought to get up, I ought to go to work and the children to the kindergarten. My son demands, crying, angry and distressed, that I lie in bed beside him. He won't accept any explanations. -In the evening when bedtime is already overdue, he insists that I must still play with him. He erupts, bursts into tears and tries to hit me when I say no, no matter how emphatically. - We have come home from playground. He lies on the floor and insists, screaming, that I should take off his outwear, even though I know he is very well capable of doing it himself and I am busy helping his little sister. He gets very upset and screams and threatens me if I no matter how gently suggest that he try and do it himself. -He asks where a certain toy is. I tell him that it is on the floor. His sister, eager to please her brother, runs to pick it up and gives it to him. He hits his sister in the face because he would have wanted me to come and give it to him. When I scold him for what he did he gets very angry and upset and a tantrum follows.

Now, was I invalidating him when I expressed my disapproval of his bad behavior?

Very often it seems to be a matter of life and death whether he can have his way with me or not. He has a very intense and demanding, even frenzy, relation to me. He seems to need to have total control over me at times. He may explode even in situations where I cannot agree with him on something without having to bend the truth, e.g. he claims (wrongly) that it is Sunday. When I suggest, very cautiously, that "you would probably wish that it were Sunday, but Sunday is after three days, today it is Wednesday", he becomes furious and shouts that "I don't wish that it were Sunday, I know it is Sunday!"

We have tried to be understanding, encouraging, compassionate and empathetic to the best we can, shown him love and appreciation. I have tried to validate his feelings by saying that "mother understands how you are feeling, " "mother knows that you would like to …., but we can't…" This only seems to trigger a more furious tantrum, as if he had come to learn that when I start with a sentence like that it means that his demand is going to be turned down.

I feel that deep down there seems to be often sadness and worry in that little boy. He is feeling bad about himself after tantrums and I am afraid that it is beginning to impair his self-image. Likewise, he is about to be labeled as a troublemaker in the kindergarten among other children because he is so easily irritated. I am of course concerned that this will erode his self-esteem.

I am known as a relatively calm and rational person, but in situations like these I feel clueless. If I comply with his demands, I become his puppet-on-a-string. If I don't, his reaction escalates and he gets more and more upset, sometimes to the point of hysteria. He is very much in stress, I can feel his heart beating rapidly. This brings me to another problematic aspect. Dr. Larry Siever, i.a., writes in one of his articles that trauma may sensitize or alter the activity of the stress system in brain or actually cause structural changes in the hippocampus, which is involved in emotional memories. Now, repetitive experience of emotional stress equals with trauma, doesn't it? Consequently, shouldn't we try to minimize the child's exposure to emotional stress (which is frequent with such kids!) so as not to cause damage to the brain? Should we do this by medicating the child (with SSRIs?) so as to raise his low threshold to negative environmental stimuli and for negative emotional reaction, i.e. to prevent his autonomic nervous system from reacting excessively (leading to emotional stress and trauma, leading in turn perhaps to brain damage)?!

Do you think that adverse environmental factors in a child's life are necessarily required to produce full BPD? If so, could physical pain be such a factor? Both my son and his father suffered from colic during 2 months as an infant - long-lasting, repetitive experience of pain that the parents failed to alleviate, certainly involving also a lot of emotional stress. Or could it be that a BPD-prone child interprets perfectly normal treatment from parents who are only trying to teach them, like their sisters and brothers, what is right and what is wrong as unempathetic, even abusive? Is progress into BPD actually inevitable in a child with biological predisposition? If not, what to do to prevent it?

I am pretty certain that neither was my partner in any way abused during his childhood. His mother, who stayed at home taking care of him, is one the most empathetic, kind, unselfish and caring persons I know. His father, on the other hand, was much away from home and represented mainly an authoritative, disciplinatory figure. He resembles his son in impulsivity and irritability, but is more contained. There is also substance abuse in the family. My partner's sister is also sort of impulsive, but in a cheerful and constructive, not hostile way.

I feel that I need very much guidance and advice as to how to treat my little son. As I stated earlier, in my country, the knowledge and know-how about BPD, in particular when it comes to children, is virtually non-existent and there are no BPD-qualified psychiatrists or therapists to turn to. I know that there are Therapy groups do you think that my child would benefit from those?

The overall attitude towards giving drugs to children with mental problems seems to be very negative in Finland. There is one open-minded child psychiatrist who has started treating AD(H)D children with Ritalin. He is my only hope, but I am afraid that in the absence of sufficient knowledge of BPD, he might diagnose my son as AD(H)D and prescribe him wrong medication.

In summary: How to respond to intense anger outbursts and avoid "intermittent reinforcement"? Could the child benefit from medication during the critical childhood years in order to prevent him from developing a full-blown BPD? Can you give me any (Internet) references about (childhood) BDP and medication to show to child psychiatrists in my country so as to update them and to be able to obtain the best possible treatment for my son?

I know that you must be very busy but I hope that you can find some time to share your thoughts with me or, if this is not possible, pass my letter on to one of your colleagues for reply. You can also, if you like, refer me to another expert to whom I can turn to with my questions. The situation with my son is getting worse and worse and I don't know what to do.

  A. Your letter is poignant and your heartfelt concern is clear. There are, unfortunately, very few facts known about what causes BPD and how to prevent it in children. For example, while the incidence of trauma is high in children that develop BPD, not all children that develop BPD were exposed to trauma. Also, not all trauma results in BPD. Perhaps the trauma comes about because the same chemistry that causes BPD also causes rage and aggression. If the parents have this (or their friends) the child can either inherit the gene from Mom and/or Dad, and look like they were exposed to trauma from parents or friends of parents. The trauma will be an epiphenomenona. It looks related to the BPD, but is not. If occurs because the environment will expose the child to a higher rate of abuse, but the abuse does not cause the BPD. That said, all of this is theory. In fact, all of Siever's and Linnehan's work is theory, too.

You really need to get your child to a good psychiatrist for an evaluation. University programs are the best. Set up a program that makes sense. Your child could have social phobia or obsessive compulsive disorder or bipolar disorder or a host of other problems that need to be worked up before labeling the child BPD.

Ultimately, you do the best job you can do as a parent. Since kids tend to avoid pain, if they do things that are painful to themselves, it is probably a genetic thing, and needs to be addressed medically. That is where the psychiatrist comes in.