Aggression and Violent Behavior 18 (2013) 644–655

Contents lists available at ScienceDirect

Aggression and Violent Behavior

The link between personality disorder and parenting behaviors: A systematic review
Sarah Laulik a,b, Shihning Chou a,⁎, Kevin D. Browne a, Jayne Allam b
a
Centre for Forensic and Family Psychology Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, United Kingdom
b
Forpsych Limited, Forensic Private Practice, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To systematically review the literature on the link between personality disorder and parenting capacity
Received 5 June 2013 from an attachment theory perspective.
Received in revised form 29 June 2013 Method: Four electronic databases were searched systematically. Those studies that met the pre-defined inclu-
Accepted 16 July 2013 sion criteria were quality assessed. Data was then extracted and synthesized from the included studies using a
Available online 31 July 2013
qualitative approach.
Results: Fifteen thousand and sixty one hits were found. A further 22 studies were identified through expert
Keywords:
Personality disorder
contact, and two from references lists. Two thousand eight hundred and eighty five duplicates were removed
Parenting capacity and a further 11,926 irrelevant studies were excluded. Of the remaining 250 articles, 229 did not meet the inclu-
Parent–child relations sion criteria and were therefore removed and two articles were unobtainable. A further 19 studies were removed
Child abuse following quality assessment, leaving a total of 11 studies to be reviewed. The majority of the findings supported
the association between a diagnosis of personality disorder, poor parent–child interactions and problematic
parenting practices.
Conclusions: Parental personality disorder was identified as a risk factor for impaired parenting behaviors and
disturbed parent–infant. More rigorous research is required in relation to how co-morbidity and personality
disorder alone influence the broad dimensions of parenting capacity for both mothers and fathers.
© 2013 Elsevier Ltd. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 644
645
1.1. Personality disorder and parenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 645
1.2. Rationale for systematic review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 646
2. Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 646
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 647
3.1. Descriptive overview of included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 647
3.2. Defining personality disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 647
3.3. Outcome measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 647
3.4. Co-morbidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 649
3.5. Direction of the results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 649
3.6. Quality of the included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 651
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 652
4.1. Clinical implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 653
4.2. Directions for future research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 653
5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 654
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 654

⁎ Corresponding author at: Floor B, Yang Fujia Building, University of Nottingham, Wollaton Road, NG8 1BB, United Kingdom. Tel.: +44 115 8466623; fax: +44 115 8466625.
E-mail address: shihning.chou@nottingham.ac.uk (S. Chou).

1359-1789/$ – see front matter © 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.avb.2013.07.017
 S. Laulik et al. / Aggression and Violent Behavior 18 (2013) 644–655 645

1. Introduction overrepresented in individuals with borderline personality disorder

According to the Fourth Edition of the Diagnostic and Statistical Man-
ual of Mental Disorders (DSM-IV; American Psychiatric Association,
1994, 2000) personality disorder is ‘an enduring pattern of inner experi-
ences and behavior that deviates markedly from the expectations of
the individual's culture’. To receive a formal diagnosis, the pattern
must be enduring and inflexible across a range of situations, be manifest
in cognitions, affective responses, impulse control or interpersonal func-
tioning, and lead to clinically significant distress as well as impairment
in social, occupation and other areas of functioning.
Personality disorder has its onset in adolescence. It is a relatively
common psychiatric disorder, affecting 4% of the general population in
the UK (Coid, Yang, Roberts et al., 2006), with prevalence rates in prima-
ry care outpatient settings rising as high as 24% (Moran et al., 2000).
Although distinguished from mental illness by its enduring and perva-
sive nature, personality disorder does commonly co-occur with other
Axis I disorders. Indeed, it is considered a predisposing factor for numer-
ous psychiatric disorders, including depression, anxiety, impulse-
control disorder and substance dependence, and is also associated
with an increased risk of suicide (Kendall, 2002).
Despite increasing attention given to the prognosis, consequences
and correlates of personality disorder, comparatively little is known
about the etiology of these disorders. Numerous factors have been im-
plicated, ranging from the genetic, social to the psychological. Like
many disorders, there exists no-one causative explanation. A consensus
among researchers exists, however, that it is the interaction between
the individual and their environment that plays the most significant
role in the development of these disorders (Paris, 1996). For this reason,
research and theory focused on individual and family processes are
amongst the most prominent.
Empirically, research consistently identifies a high degree of psycho-
logical and social dysfunction in the families of individuals who develop
personality disorder. This includes depression, alcoholism, family break-
down, as well as violence (Paris, 1996). A strong association between
abusive experience in the context of the parent–child relationship and
personality disorder in adulthood is also commonly found (Battle
et al., 2004) with childhood sexual abuse, in particular, being a particu-
larly strong predictor of the development of a variety of personality
disorders (Paris, Zweig-Frank, & Gudzer, 1994). There is also evidence
of a connection between specific personality disorders and childhood
experiences, with unpredictable and intrusive care-giving associated
with borderline personality disorder (Paris, 1996; Reich & Zanarini,
2001), ineffective parenting practices, physical abuse and parental loss
associated with antisocial personality disorder (Patterson, DeBaryshe,
& Ramsey, 1989; Reich, 1986), and parental neglect and a lack of family
cohesion implicated in the development of schizoid and dependent
personality disorder respectively (Head, Baker, & Williamson, 1991;
Leizberg, 1989). Consistent with these findings is evidence linking
personality disorder with insecure, disorganized and unresolved adult
attachment patterns (Brennan & Shaver, 1998; Crittenden & Newman,
2010; Lyddon & Sherry, 2001). Preoccupied patterns of attachment are
(Fonagy et al., 1996), whereas antisocial and avoidant personality disor-
der are more commonly associated with dismissive styles (Lyddon &
Sherry, 2001).
DSM-IV delineates ten subtypes of personality disorder (see
Table 1). These are categorized into three distinct clusters based on
their different global characteristics: Cluster A (characterized by odd
or eccentric behavior) comprises Paranoid, Schizoid and Schizotypal
Personality Disorders; Cluster B (characterized by dramatic, emotional
or erratic behavior) comprises Antisocial, Borderline, Histrionic and
Narcissistic Personality Disorders; and Cluster C (characterized by anx-
ious or fearful behavior) comprises Avoidant, Dependent and Obses-
sive–Compulsive Personality Disorders.
The specific effects of personality disorder on an individual's func-
tioning vary across the different diagnoses; thus individuals with per-
sonality disorder present very differently. Commonalties do exist,
however, with individuals with all ten personality disorders exhibiting
the following characteristics: a preoccupation with the self, perspective
taking deficits, difficulties taking accountability, limited empathy for
others, a limited and distorted perception of the self and others, unhap-
piness, and highly dysfunctional interpersonal relationships (DSM-IV,
1994, 2000). The latter, in particular, is the cardinal feature of the per-
sonality disorders.
Difficulties relating to other people and developing close and mean-
ingful intimate relationships can be seen across all 10 personality disor-
ders, albeit to varying degrees. For example, those with schizoid
personality disorder lack interest in others (Sperry & Mosak, 1996),
whereas those with dependent personality disorder are over-reliant
and compliant in their relationships (Bornstein, 1992). In contrast, the
relationships of those with narcissistic personality disorder are typically
exploitative and characterized by a lack of regard for other people
(Lyddon & Sherry, 2001; Sperry & Mosak, 1996). For those with border-
line personality disorder, relationships are highly unstable, intense and
typically characterized by extreme shifts of closeness and distance.
A significant amount of research exists linking dysfunction in intimate
and social relationships with personality disorder (Lyddon & Sherry,
2001). As well as being associated with dysfunction in marital function-
ing, such as conflict and marital dissatisfaction (South, Turkheimer, &
Oltmanns, 2008), antisocial, borderline and narcissistic personality disor-
ders have been linked with the perpetration of severe relationship
dysfunction, namely intimate partner violence (Holtzworth-Munroe,
2000; Rothschild, Dimson, Storaasli, & Clapp, 1997; White & Gondolf,
2000). Findings have also demarcated a number of personality disorders,
Cluster B disorders in particular, with an increased risk of violence to
others (Coid, Yang, Tyrer, Roberts, & Ullrich, 2006; Watzke, Ullrich, &
Marneros, 2006).
1.1. Personality disorder and parenting
To date, studies exploring the relationship between psychopathology
and parenting behaviors have overlooked the impact of personality
disorder. They have instead focused on Axis I disorders, in particular

Table 1
DSM-IV classifications of personality disorder.

Cluster A Paranoid Personality Disorder: marked distrust of others; belief, without reason, that others are exploiting, harming, or trying to deceive him or her; belief in
hidden meanings; unforgiving and grudge holding.
Schizoid Personality Disorder: limited range of emotion, both in expression of and experiencing; indifferent to social relationships.
Schizotypal Personality Disorder: peculiarities of thinking; odd beliefs, and eccentricities of appearance, behavior, interpersonal style, and thought.
Cluster B Antisocial Personality Disorder: violation of the rights of others and societal rules.
Borderline Personality Disorder: rapid changes in mood; intense unstable interpersonal relationships; marked impulsivity; instability in affect and in self image.
Histrionic Personality Disorder: excessive emotionality; superficiality; attention seeking behaviors.
Narcissistic Personality Disorder: grandiosity; lack of empathy; need to be admired; hypersensitive to the opinions of others.
Cluster C Avoidant Personality Disorder: marked social inhibition; feelings of inadequacy; extreme sensitivity to criticism.
Dependent Personality Disorder: submissive; extreme need of other people; fear of separation; marked lack of decisiveness and self-confidence.
Obsessive–Compulsive Personality Disorder: characterised by perfectionism and inflexibility; preoccupation with uncontrollable patterns of thought and action.
646 S. Laulik et al. / Aggression and Violent Behavior 18 (2013) 644–655
depression, anxiety and psychosis. These studies, demonstrate a signifi-
cant association between psychopathology, impaired parenting prac-
tices and fatal and non-fatal child abuse (Berg-Nielsen, Vikan, & Dahl,
2002; Cicchetti & Lynch, 1995; Reder & Duncan, 2003) and highlight
the deleterious impact that parental psychopathology can exert on the
parent–child relationship. When one considers these findings and the
negative impact that personality disorder exerts on interpersonal func-
tioning, it is, then, reasonable to assume that personality disorder
might (negatively) infiltrate the parent–child relationship.
One mechanism that is thought to influence the way in which all
parents interact and treat their children is that of attachment security.
Thus, attachment theory is relevant to the development of both person-
ality and parenting styles in adulthood (Crittenden, 2008; Lyddon &
Sherry, 2001). Central to the developmental approach of attachment is
the proposition that formative experiences with primary caregivers in-
fluence the development of the self and future close relationships. The
mechanism through which this occurs can be found in what Bowlby
(1969) termed as ‘internal working models’, internal templates for rela-
tionships which develop as a consequence of earlier patterns of interac-
tions between caregivers and their infants. According to Bowlby (1969),
the infants of parents who respond to their behavioral cues for comfort
and security in a responsive and sensitive manner are likely to develop
a secure attachment style underpinned by an internal working model
of the self as valued and others as trustworthy. By contrast, the infants
of parents who are inaccessible or inconsistently responsive to their be-
havioral cues instead develop maladaptive internal working models of
the self and others that are subsequently reflected in three forms of inse-
cure attachment: dismissive, preoccupied and disorganized. A dismissive
(avoidant) pattern of attachment is characterized by a minimization of
attachment concerns and is thought to develop as a consequence of
experiencing interactions with caregivers who are inaccessible, rejecting
and unresponsive. A preoccupied (ambivalent) pattern of attachment
is characterized by a preoccupation and maximization of attachment
concerns and is thought to develop as a consequence of inconsistencies
in parental responsiveness availability and accessibility (Ainsworth,
Blehar, Waters, & Wall, 1978). The disorganized pattern of attachment
in infancy is characterized by a lack of an organized strategy for achiev-
ing proximity to one's caregiver and is considered to be a consequence of
frightening and frightened care-giving responses (Main & Hesse, 1990).
An abundance of research has demonstrated that when adults be-
come parents, the character and quality of their care-giving is derived
from their internal working models of attachment (George & Solomon,
1996). Whereas secure parents respond to their children's needs in a
warm, sensitive and consistent manner, insecure and disorganized
parents struggle to be openly available and warmly responsive to the
demands of their progeny (Howe, Brandon, Hinings, & Schofield, 1999).
Research suggests that when adults with a dismissive attachment
style become parents, they are prone to repeating what their parents
did with them. Main (1995) asserts that when faced with their
children's distress and dependency needs, dismissive adults' anxiety
rises, which, in turn, leads to a deactivating of the attachment system.
The parenting style of these parents is thus likely to be characterized
by emotional, physical and psychological withdrawal (Crittenden,
2008; Howe et al., 1999). Those parents with a preoccupied adult attach-
ment style respond to their children's needs inconsistently and their
sensitivity and availability is dependent on parent's feelings and emo-
tional state, rather than their children's needs and behavioral cues
(Crittenden, 2008; Howe et al., 1999). Parents with a disorganized attach-
ment style remain affected by their unresolved attachment trauma
which, in turn, makes it very difficult for them to identify, respond and
empathize with their children's needs. Research suggests that for these
parents, the task of caring for infants, in particular infants who appear
vulnerable or in a state of need, may reignite unresolved feelings of
fear, anger, distress or abandonment and thus lead to abusive, hostile
and frightening care-giving responses (Crittenden & Ainsworth, 1989;
Crittenden, 2008; Reder & Duncan, 1999).
The links between personality disorder, attachment insecurity and
child maltreatment identified in the literature above goes some way
to help explain the frequently observed intergenerational transmission
of child maltreatment (Pears & Capaldi, 2001). Parents with personality
disorder may be particularly vulnerable to treating their children in the
same way that they themselves were treated. Indeed, Adshead (2003)
claims that the children of personality disordered parents may be placed
at risk of physical and emotional harm as a consequence of the emotion-
al difficulties, dysregulated affect, hostility, unusual cognitions and
preoccupation with the self that characterize aspects of personality
disorder. Cordess (2003) more specifically asserts, that different person-
ality disorder subtypes are likely to (negatively) impact on parenting in
specific ways, with parents with Cluster A and B disorders posing a risk
of physical abuse and neglect, and those with Cluster C disorders posing
a risk of emotional harm. In a review specifically relating to the children
of mothers with Borderline Personality Disorder, Lamont (2006)
identifies these children as disadvantaged and at high risk of future
psychopathology as a direct consequence of their mothers' borderline
symptomatology.
1.2. Rationale for systematic review
The above research on personality disorder, attachment insecurity
and that linking Axis I psychopathology to abusive and impaired parent-
ing practices, would suggest it important to understand if, and how, Axis
II disorders impact upon parenting. Identifying this information could
aid clinicians in risk assessment as well as helping identify appropriate
intervention strategies. The purpose of the current review was, there-
fore, to assess the links between parental personality disorder and par-
enting behaviors. By systematically reviewing the available literature,
this paper aims to determine if parental personality disorder is associat-
ed with impaired parenting practices and poor quality of parent–child
interactions. If a relationship is identified then a secondary aim is to pro-
vide directions for future research.
2. Method
The following databases were searched for eligible studies:
PsychINFO; Medline; Embase; and Web of Science. The same search
terms were applied to all databases but were modified to meet the re-
quirements of each individual database. Terms were mapped to subject
headings and keywords, abstracts and titles were searched to minimize
the amount of studies lost due to incorrect coding. In addition, trunca-
tion and wildcard options were used to accommodate for the variation
in terms used by authors. The search strategy employed combined
terms covering the following concepts: personality disorder, parenting
capacity, parenting efficacy, parenting behaviors, parent–child interac-
tions, child abuse and neglect. The reference lists of this material and
narrative reviews were hand-searched for studies matching the search
criteria, and seven experts in the area were contacted for any other rel-
evant papers.
The inclusion criteria were: (1) parents aged 18 years or over;
(2) diagnosis of any personality disorder using a structured assessment
procedure or presence of significant features associated with any per-
sonality disorder; (3) assessment of parenting behaviors to include:
the quality of observed parent–infant interactions, self-reported parent-
ing behaviors and recorded incidents of child abuse or maltreatment;
(4) cohort, case control studies, case-series or cross-sectional studies;
(5) all languages.
Studies were excluded if they met the following criteria: (1) parents
below the age of 18; (2) mothers and fathers who are not the child's
primary caregiver; (3) personality disorders diagnosed on the basis of
behavioral observations or outcomes (e.g.: history of antisocial acts
being seen to reflect antisocial personality disorder); (4) personality
disorders diagnosed with non-standardized measures; (5) narrative
reviews, commentaries or other types of opinion papers.
 S. Laulik et al. / Aggression and Violent Behavior 18 (2013) 644–655
To assess the quality of eligible studies, a set of quality assessment
criteria for each study design was formulated based on the Critical
Appraisal Skills Programmes (CASP, 2004) and included information
to highlight a number of key variables and potential methodological
limitations (i.e.: selection methods, sampling methods, detection/
measurement, attrition rates and statistical analysis) which could
impact on the validity and outcomes of the study. To ensure consistency
in the quality of the studies assessed, 20% of the studies were verified by
a second independent reviewer assessed. Only studies deemed to be of a
moderate to high quality (i.e.: with a quality assessment score of 70% or
above) were included in the review. A flow diagram to illustrate the
study selection process can be seen in Fig. 1.
Data from the reviewed studies were independently extracted using
a pre-defined extraction form devised for the purpose of the study. The
extraction form listed the following general and specific details in
order to compare each study: study design, population characteristics,
measurement of personality disorder, measurement of child maltreat-
ment/parenting behaviors/parent–child interactions, the validity of
measurement tools, attrition rates (if applicable), confounding factors
and analysis of data, including appropriateness of particular statistical
tests. Information which was unclear was recorded as unknown.
3. Results
Following a systematic search of electronic databases, 15,039 hits
were found. A further 22 were identified through experts, and two
from references lists. Two thousand eight hundred and eighty five du-
plicates were removed and a further 11,926 irrelevant studies were ex-
cluded. Of the remaining 250 articles, 229 were removed in accordance
to the inclusion/exclusion criteria. One primary study was unobtainable.
Further one unpublished dissertation could not be located.
PsycINFO 5,645
MEDLINE 4,236
Embase 3,638
Web of Science 1,518
Experts 22
Reference Lists 2
TOTAL HITS 15,061
2,885 duplicate publications excluded
11,926 irrelevant publications excluded
1 unobtainable article
1 unobtainable thesis
229 publications which did not meet the
inclusion criteria excluded
19 studies (out of 15061 publications)
met the inclusion criteria
esults 8 studies excluded after quality
assessment
11 studies included in the final analysis
Fig. 1. Flowchart of study selection process and search results.
647
After all excluded studies were omitted from the review the
remaining 19 studies were quality assessed. Of the 19 studies reviewed,
eight were deemed to be of poor quality, ten of moderate quality and
one of high quality. Only those studies achieving a score of 70% and
above (moderate quality and above) were included in the final analysis,
thus leaving 11 primary studies to be included in this review. From the
11 studies entering the review, the follow data was tabulated: (Table 2)
author, aims of the study; and procedure, (Table 3) author and findings.
3.1. Descriptive overview of included studies
Of the 11 studies that were retrieved, seven used a control or com-
parison group design and four used a single group design. The methods
employed included: two case–control studies, four cohort studies and
five cross-sectional studies. Six studies were conducted in the USA and
four in the UK. The remaining study was conducted in Australia. The
total sample size of the 11 included studies was 1155. The mean sample
size of the studies was 105 and the number of participants ranged from
20 and 377. Six of the studies reported convenience sampling as a
means to recruit their participants, two studies relied on a volunteer
sampling method, one study utilized a sample from a larger longitudinal
study using convenience sampling and two studies utilized data from
a prospective longitudinal study whose original participants were
recruited using a stratified random sampling procedure (Johnson,
Cohen, Kasen, Ehrensaft, & Crawford, 2006; Johnson, Cohen, Kasen, &
Brook, 2008).
3.2. Defining personality disorder
A combination of questionnaires and interview schedules were used
to establish personality disorder prevalence in five studies; the question-
naires included: Structured Clinical Interview Screening Questionnaire
(SCID) (Crandell, Patrick, & Hobson, 2003; Hobson, Patrick, Crandell,
Garcia-Perez, & Lee, 2005; Hobson et al., 2009; Johnson, Cohen, Kasen,
Ehrensaft, & Crawford, 2006; Johnson et al., 2008); Standardized Assess-
ment of Personality-Abbreviated Scale (SAPAS) (Conroy, Marks, Schacht,
Davies, & Moran, 2010) followed by the Structured Clinical Interview for
DSM-III or DSM-IV. Famularo, Kinscherff, and Fenton (1992) employed
the Structured Clinical Interview for DSM-III only; one study employed
the Personality Disorder Examination (DeMulder, Tarullo, Klimes-
Dougan, Free, & Radke-Yarrow, 1995) and Wiehe's (2003) study,
which focused specifically on narcissistic personality disorder features,
employed two questionnaire to screen for these features, namely the
Narcissistic Personality Inventory and Hypersensitivity and Narcissism
Scale. A diagnosis of personality disorder was not made, however. In
Hans, Bernstein, and Henson's (1999) study, the presence of Axis II
disorders were assessed using the Current Past and Psychopathology
Scale and DSM-III criteria. The final study relied on case notes detailing
previous clinical diagnosis of personality disorder based on DSM-IV
criteria and a score above eight on the Revised Diagnostic Interview for
Borderlines (Newman, Stevenson, Bergman, & Boyce, 2007).
3.3. Outcome measures
Within the review, four studies focused specifically on the quality
of interaction patterns between mothers and their infants/children.
DeMulder et al. (1995), Crandell et al. (2003), Hobson et al. (2005)
and Hobson et al. (2009) utilized videotaped footage of mother and
their infants which was subsequently rated, analyzed and classified
based on a predefined criteria. Crandell et al. (2003) employed a rating
scale devised by Murray et al. (1996) called The Global Ratings Scales of
Mother–Infant Interaction, which rated maternal sensitivity, responsive-
ness and acceptance and enabled overall quality of mother–infant inter-
actions to be assessed. A modified version of this scale was employed in
Hobson et al.'s (2005) study. The Atypical Maternal Behavior Instrument
for Assessment and Classification (AMBIANCE), a measure used to code
 648
Table 2
Study characteristics.

Author (year) Study design Location Sample Objective Procedure

size

Famularo et al. Case–control USA 91 To specify the DSM-III diagnoses prevalent in maltreating and non-maltreating mothers 54 maltreating and 37 non-maltreating mothers were administered the SCID for
(1992) DSM-III to assess past and current Axis I and Axis II diagnoses
DeMulder et al. Retrospective USA 89 To assess relations between depression and PDs and assess how these disorder impact 89 mothers (and their toddlers) who met the diagnostic criteria for either: unipolar
(1995) cohort on maternal caretaking behavior depression; bipolar illness or no current psychiatric diagnosis were recruited for the study.
Psychiatric and behavioral measures were obtained at 3 time periods: (1) when the child
was a toddler; (2) early school; and (3) preadolescence.
PD diagnosis of all three groups of mothers was made at the third time period using
the PDE
Hans et al. (1999) Cohort USA 69 To explore the contribution of psychopathology amongst opioid dependent and non- The children of 32 opioid dependent mothers and 37 non drug dependent mothers
drug using mothers were followed from birth to middle childhood. Both groups were administered SADS-L
and CPPS. When the children were 1, 4, 12, and 24 months of age, mothers and children

S. Laulik et al. / Aggression and Violent Behavior 18 (2013) 644–655

were videotaped together. Children's perception of their mothers' parenting behaviors
was gleaned at age 10.
Wiehe (2003) Case–control USA 152 To study the prevalence of narcissistic traits (and empathy) in a sample of child abuse 52 abusive parents and 101 foster parents were administered three personality
perpetrators and foster parents measures, two of which—PDE and HSNS—were related to a diagnosis of NPD
Crandell et al. Cross-sectional UK 20 To investigate mother–infant relations in mothers with BPD 8 mothers with BPD and 12 without psychiatric disorders were videotaped interacting
(2003) with their 2 month old infants in three successive interactions: face to face play; an
episode where their mother adopted a ‘still face’ and a period when play interactions
were resumed
Hobson et al. Cross-sectional UK 32 To test the prediction that mothers with a diagnosis of BPD would show “intrusive 10 mother–infant dyads with a mother with BPD and 22 dyads with mothers free of
(2005)a insensitivity” towards their 12 month old infants in a semi-structured episode of play psychopathology were videotaped in three different settings: the Ainsworth Strange
Situation technique; (Ainsworth et al., 1978) a modified Strange Situation Technique;
and play/teaching task
Johnson, Cohen, Cross-sectional USA 377 To investigate the associations between parental Axis I and Axis II disorders and self- 377 parents, who were part of a larger community-based prospective longitudinal
Kasen & study from a reported child rearing behaviors cohort, completed a psychiatric assessment (to assess for Axis I and Axis II disorders)
Crawford (2006)b prospective cohort and an assessment of child rearing behavior
Newman et al. Cross-sectional Australia 35 To assess the interaction patterns and perceptions of parents' with BPD The mother–infant interaction patterns and maternal self-perceptions of parenting
(2007) were obtained for two groups of mother–infant dyads: mothers with BPD and their
infants and mothers without BPD and their infants. To be included in the study, BPD
mothers had to: (i) have an independent clinical diagnosis of BPD; (ii) meet DSM-IV
criteria for BPD; (iii) score ≥8 on the Revised Diagnostic Interview
Johnson et al. Prospective cohort USA 377 To assess any associations between parental Axis I and Axis II disorders evident during 377 parents, who were part of a larger community-based prospective longitudinal
(2008)b adolescence or early adulthood and subsequent parenting behaviors in adulthood cohort, completed the SCID-IV NP, SCID-II screening questionnaire (over the telephone)
and then the SCID-II interview and an assessment of child rearing behavior
Hobson et al. Cross-sectional UK 90 To assess how mothers with BPD engage with their 12 to 18 month infants in separation The mother–infant interactions of BPD and non BPD Mothers in separation–reunions of
(2009)a reunion episodes the Strange Situation Test were videotaped and maternal behavior was rated and
analyzed. Cohort 1—PD diagnosed following administration of the SCID-II questionnaire.
Those that met the criteria for BPD were administered the SCID-II interview.
Cohort 2—mothers screened for BPD using SCID-II
Conroy et al. Cohort UK 200 To examine the independent and combined effects of maternal depression and PD on Newly delivered mothers were recruited and screened at 6 weeks postpartum for PD
(2010) infant care and current depression. Those with PD, depression and either or both conditions were
assessed again at 8 weeks postpartum, when measures to assess infant care,
mother–infant interactions and the home environment were administered.

Key: DSM-III—Diagnostic and Statistical Manual of Mental Disorders—Third Edition; EPDS

SCID—Structured Clinical Interview for DSM-III or DSM-IV:SAPAS—Standardised Assessment of Personality-Abbreviated Scale—SAPAS (Crandell et al., 2003) followed by the Structured Clinical Interview for DSM-III or DSM-IV; SCID-IV-NP—Non-Patient
Version of the Structured Clinical Interview for DSM-IV; SCL-90R—PD: Personality disorder; BPD: Borderline personality disorder; NPD—Narcissistic Personality Disorder; PDE—Personality Disorder Examination; NPI—Narcissistic Personality
Inventory; HSNS—Hypersensitivity Narcissism Scale; SADS-L—Schedule for Affective Disorders and Schizophrenia—Lifetime Version; CPPS—Current and Past Psychopathology Scales.
a
Studies utilise the same set of data.
b
Studies utilise the same sample.
 S. Laulik et al. / Aggression and Violent Behavior 18 (2013) 644–655
maternal responsiveness and affective communication with an infant,
was employed by Hobson et al. in their 2009 study exploring how
mothers with BPD relates to their 12 month old infants. DeMulder
et al. (1995) devised their own behavioral rating measure of maternal
communication, affect and control with their infant.
In Newman et al. (2007) study, video-recorded free play interactions
between mothers and their infants were assessed using the Emotional
Availability Scale (Biringen, Robinson, & Emde, 1998); a measure which
assesses parents' sensitivity, structuring, non-intrusiveness, and non-
hostility to their child and children's responsivity to their caregiver. The
Parenting Stress Index (Abidin, 1995), which rates self-reported stress
in the parent–child relationship and pinpoints whether this relates to
parents' affective functioning and subjective feelings related to parenting,
or the child's personal characteristics, was also administered. As was the
Parenting Sense of Competence Scale, a 17-item scale that assesses
parenting self-efficacy and satisfaction.
Conroy et al. (2010) utilized a structured interview to assess 15 as-
pects of infant care and a battery of standardized questionnaires
comprising: 1) Infant-Toddler Version of the Home Observation for the
Measurement of the Environment and Supplement to the Home Scale
for Impoverished Families, which rely on a combination of observation
and interview to provide a systematic assessment of the home-
environment; 2) The Parent/Caregiver Involvement Scale, which
provides a global assessment of the quality of mother and infant
interactions; 3) Care-Index, which assesses the quality of videotaped
mother–infant interactions using three parental dimensions (sensitivity,
controlling and unresponsive) and four infant dimensions (co-
operative, compulsive–compliant, difficult, passive); and 4) Neonatal
Behavioral Assessment Scale, which assesses infant irritability.
Parenting behavior was assessed in Hans et al. (1999) study when
children were aged 4, 12 and 24 months of age using 40 min of
videotaped footage in a laboratory ‘living room’ during a series of struc-
tured and unstructured activities. The Parent Child Observation Guides
for Program Planning, an instrument which assesses sensitive responsive-
ness (maternal timing, pacing, emotional engagement and flexibility) and
encouragement/guidance (maternal structuring, time-setting and active
role in teaching), was administered in order to assess global aspects of
mother–child interactions. At age 10, children completed a modification
of the Parent Behavior Inventory, a 42 item instrument designed to assess
children perceptions of their parents' parenting behavior which incorpo-
rates two scales: parental acceptance and parental rejection.
In the remaining two studies (Johnson et al., 2006, 2008), a measure
composed of items from other validated measures of child-rearing
behaviors (Disorganizing Poverty Interview and the Children's Report
of Parental Behavior Inventory) and findings within the literature
was used to assess inadvisable/problematic parenting behaviors. These
behaviors comprised: parental affection; parental communication; pa-
rental disciplinary consistency; parental physical punishment; parental
rejection; and parental supervision.
3.4. Co-morbidity
Three of the 11 studies did not control for co-morbidity between Axis I
and Axis II disorders in their analysis (Famularo et al., 1992; Newman
et al., 2007; Wiehe, 2003). In Crandell et al. (2003), Hobson et al.
(2005) and Hobson et al. (2009) studies, the authors excluded mothers
with co-morbid Axis I disorders from their clinical and control groups
such that these groups contained mothers with and without personality
disorder only. Of the eight studies that did refer to co-morbidity, two
(Conroy et al., 2010; DeMulder et al., 1995) specifically assessed co-
morbidity between personality disorder and depression. Hans et al.
(1999) controlled for a number of co-morbid disorders which included
personality disorder and affective disorders (major depression, atypical
bipolar, atypical depression, dysthymic disorder, anxiety disorders
(atypical anxiety, agoraphobia, social phobia, simple phobia) and adjust-
ment disorder with depressed mood. The two studies by Johnson et al.
649
(2006, 2008) included co-morbidity with anxiety, depressive, disruptive
and substance use disorders with cluster A, B and C personality disorders.
3.5. Direction of the results
Owing to the clinical heterogeneity of the included studies, meta-
analysis can produce misleading results, especially when applied to ob-
servational studies (Egger, Schneider, & Davey-Smith, 1998). The obser-
vational data in this review were subjected to a qualitative rather than
quantitative data synthesis. In reaching conclusions, the heterogenic
features and commonalities among the 11 studies were examined. Con-
sideration as to whether the studies fell in a positive, negative or neutral
direction was also conducted.
Of the 11 studies identified, two assessed the prevalence of person-
ality disorder diagnoses and or/features amongst abusive and non-
abusive parents (Famularo et al., 1992; Wiehe, 2003); four explored
the quality of mother–infant dyads with and without borderline per-
sonality disorder (Crandell et al., 2003; Hobson et al., 2005, 2009); one
study explored parenting behaviors and parenting perceptions amongst
borderline personality disordered mothers (Newman et al., 2007); two
studies assessed the relation and differences between Axis I and Axis-II
disorders and maternal caretaking behaviors (Conroy et al., 2010;
DeMulder et al., 1995); one study (Hans et al., 1999) explored the role
of psychopathology (including personality disorder) in the parenting
of drug-dependent women; and two studies provided a prospective
account of the child rearing behaviors of parents' with personality disor-
ders (Johnson et al., 2006, 2008).
Nine out of the 11 studies found a positive association between per-
sonality disorder and impaired parenting practices and/or incidents of
child maltreatment (Crandell et al., 2003; Famularo et al., 1992; Hans
et al., 1999; Hobson et al., 2005, 2009; Johnson et al., 2006, 2008;
Newman et al., 2007; Wiehe, 2003) and two found neutral and inconsis-
tent results (Conroy et al., 2010; DeMulder et al., 1995). In relation to
the studies which fell in a positive direction, Famularo et al. (1992)
found that parents who, in their recent history had substantiated re-
ports of child abuse filed with Social Services, were significantly more
likely to present with DSM-III diagnoses of personality disorder than
non-abusive controls (P = .001, Fisher's exact test). Wiehe's (2003)
study found that abusive caretakers demonstrated significantly higher
levels of narcissistic hypersensitivity on the Hypersensitivity Narcissism
Scale than their non-abusive counterparts. There were also statistically
significant differences between the two groups on four scales of the Nar-
cissistic Personality Inventory subscales: superiority (t = 3.08, p b .05),
exhibitionism (t = 2.68, p b .05), authority (t = −2.38, p b 0.5) and
entitlement (t = 2.31, p b 0.5), which remained significant, after con-
trolling for gender, race, education and age. Three of the four studies
that explored the interactions between mother–infant dyads of border-
line personality disordered mothers also found that the presence of per-
sonality disordered features was positively associated with impaired
mother–infant interactions. In the UK samples from the studies by
Crandell et al. (2003), Hobson et al. (2005) and Hobson et al. (2009), a
significantly higher proportion of women with than without borderline
personality disorder evidenced: disrupted communication with their in-
fants (Hobson et al., 2009); a higher prevalence of frightened/disoriented
behaviors in interactions with their infants (Hobson et al., 2009); less
sensitivity to their infants (Crandell et al., 2003); more intrusive behav-
iors (Hobson et al., 2005); and less satisfying/engaged quality of interac-
tions with their infants (Crandell et al., 2003).
Compared to controls, Newman et al.'s (2007) study found that
mothers with a diagnosis of borderline personality disorder (n = 14)
reported significantly lower levels of satisfaction (p b 0.001) and paren-
tal competence (p b 0.001) during interactions with their infants and
reported higher levels of stress in their parenting role (M = 84.57,
SD = 19.50) than did control mothers (M = 66.20, SD = 12.74),
t = 3.33, p = b0.001.
650 S. Laulik et al. / Aggression and Violent Behavior 18 (2013) 644–655

Consistent with the above, bivariate analyses revealed that parents
with personality disorder were more than three times as likely as
those without personality disorder to report having engaged in ≥5
types of problematic child rearing behaviors (Adjusted Odds Ratio =
3.85; 95% confidence interval: 1.63–9.10) (Johnson et al., 2006). Positive
prospective associations between personality disorders evident by mean
age 22 and maladaptive parenting behaviors in adulthood, including:
inconsistent parental discipline; and low parental affection, praise and
encouragement, were also identified in Johnson et al.'s 2008 study.
Specifically, antisocial, borderline, dependent, paranoid and passive–
aggressive personality disorder symptoms were predictive of 3 or more
problematic child-rearing behaviors, which remained significant when

Table 3
Study results.

Author Main findings

Famularo et al. (1992) ▪Significantly higher rates of current PD in maltreating compared to non-maltreating mothers.
DeMulder et al. (1995) ▪54% of unipolar mothers, 70% of bipolar mothers and 19% of well mothers reported PD symptoms
▪Differences in levels of maternal engagement and maternal criticism between well, bipolar and unipolar mothers were observed
▪Maternal engagement
Well mothers—Lack of engagement with children at Time 2 related to schizotypal traits
Bipolar mothers—Significant positive correlations found between Cluster C PDs and engaged behavior at Time 1 (dependent) and Time 2 (obsessive
compulsive). BPD and DPD symptoms associated with significantly greater engagement at all three time periods
Unipolar mothers—Lack of engagement related to schizoid and schizotypal symptoms at Time 1, 2 and 3. ANPD traits and PPD symptoms related to lack of
engagement at Time 1
▪Maternal criticism
Well mothers—Critical/irritable behavior related to higher paranoid and schizoid PD scores at Time 1 but not Time 2 or 3
Bipolar mothers—No associations
Unipolar mothers—Critical/irritable behavior at Time 1 related to antisocial symptoms but related to fewer paranoid symptoms at Time 3
Hans et al. (1999) ▪53% of opioid dependent mothers met the diagnostic criteria for PD, compared to 8% of non drug dependent mothers
▪Opioid mothers reported significantly more symptoms of PD than non-drug dependent mothers
▪Maternal PD explained a significant amount of variance between maternal substance abuse and three parenting outcomes: observations of maternal sensitive
responsiveness during infancy; observations of maternal harsh negativity during infancy; children's perception of maternal rejection during childhood
▪Cluster B features significantly related to: insensitive, unresponsive and harsh maternal behaviors and perceived maternal rejection by mother's first
child at aged 10
Wiehe (2003) ▪Abusive parents obtained significantly higher scores on the HSNS and four of the six subscales of the NPI (authority, exhibitionism, superiority, entitlement),
when age and education were controlled for statistically
▪Abusive parenting status was the only variable that was significantly predictive of HSNS and NPI subscale scores
Crandell et al. (2003) ▪Pre-still face phase—Significant difference between BPD and control mothers on maternal non-intrusive sensitivity (Mean: BPD, 7.3; control group, 12.6 U =
22.5; p b 0.05)
▪Post-still face phase—Mothers with BPD achieved significantly lower scores for non-intrusive sensitivity (e.g.: withdrawn and insensitive but in a non
intrusive manner) than control mothers (Mean: BPD, 6.8; control group, 13.0 U = 18.5; p b 0.025). Dyads comprising BPD mothers manifested interactions
of a less satisfying/engaged quality (Mean rank of dyads: BPD, 7.8; Control group, 12.3, U = 26.5; P b 0.05)
⁎Hobson et al. (2005) ▪Mothers with BPD significantly more intrusively insensitive with their 12 months old infants than mothers without BPD.
⁎⁎Johnson, Cohen, ▪PD diagnosis associated with: high parental possessiveness and rejection; inconsistent discipline; low parental affection, assistance, communication,
Kasen, Ehrensaft, & praise/encouragement, supervision, and time spent with the child.
Crawford (2006) ▪Parental PD significantly associated with number of problematic child rearing behaviors both before (r = .31, p b .001) and after (r = .26; p b .001) Axis-I
disorders were controlled for.
▪Parents with PD more than 3 times as likely as those without PDs to report having engaged in ≥ 5 types of problematic child rearing behavior.
▪Significant associations between: Cluster A: paranoid (F = 13.01; df = 5, 371; p b .0004); schizotypal (F = 15.49; df = 5, 371; p b .0001);
Cluster B: antisocial (F = 16.96; df = 5, 371; p b .02); histrionic (F = 9.34; df = 5, 371; p b .002); narcissistic (F = 4.82; df = 5, 371; p b .03); Cluster C:
avoidant (F = 5.78; df = 5, 371; p b .02); dependent (F = 8.13; df = 5, 371; p b .005) and the total number of reported problematic child rearing behaviors.
Newman et al. (2007) Mothers with BPD:
▪reported higher levels of depression on EPDS and higher levels of overall psychopathology on SCL-90R
▪achieved lower scores on the EAS revealing that mother were less sensitive in their interactions with their infants, less effective in structuring their infant's
activities and more likely to display slight to covert hostility in their interactions with their infants.
▪achieved high scores on the PSCS indicating lower levels of self-efficacy and parental satisfaction
▪reported higher levels of stress, parent–child dysfunctional interactions and a greater perception of their child as “difficult” on the PSI
⁎⁎Johnson et al. (2008) ▪Bivariate analyses revealed that diagnosis of PD evident by mean age 22 was independently significantly associated with: inconsistent parental discipline;
low parental affection, assistance and praise and encouragement; and having more than three types of problematic child-rearing behavior at mean age 33.
▪Logistic regression analyses revealed that PD traits between mean ages 14–22 were significantly associated with the total number of problematic child-
rearing behaviors reported by parents at mean age 33.
▪Parental OCPD traits were not significantly associated with a composite index of child rearing difficulties
⁎Hobson et al. (2009) ▪85% of mothers with BPD manifested disputed affective communication with their infants, compared to 47% of depressed mothers and 42% of mothers
without any psychiatric disorder
▪Univariate analysis of variance revealed main effects for BPD mothers and frightened/disoriented behaviors towards their infants.
▪Frightened/disoriented behaviors were more frequent in the BPD mothers than either comparison groups.
▪Frightened/disoriented behaviors were rare among women who did not have the diagnosis of BPD, even among those whose communication was judged to
be disrupted.
Conroy et al. (2010) ▪PD and depression exerted detrimental effects on a mother's involvement with their infant, however, depression was only associated with poorer infant care
practices when women had a PD
▪Depressed mothers were significantly less likely to use recommended infant care practices but only when Cluster A and Cluster C PDs were present.
However, presence of Cluster B PDs inhibited these scores whether or not depression was present.
▪Cluster A and C PDs were associated with significantly poorer scores on maternal involvement and sensitivity as measured by the Care-Index.
▪Depression only exerted an effect on maternal sensitivity when the mother also had a Cluster A PD.
▪No main effects found between Cluster B personality disorders on maternal sensitivity and involvement scores.
▪PDs exerted no significant effect on home environment scores.

Key: PD: Personality disorder; ANPD—Antisocial Personality Disorder; AVPD—Avoidant Personality Disorder; BPD: Borderline personality disorder; NPD—Narcissistic Personality Disorder;
DPD—Dependent Personality Disorder; PDE—Personality Disorder Examination; NPI—Narcissistic Personality Inventory; HNS—Hypersensitivity and Narcissism Scale; EAS—Emotional
Availability Scale; EPDS—Edinburgh Postnatal Depression Scale; PSCS—Parenting Sense of Competence Scale; PSI-SF—Parenting Stress Index Short-Form; SCL—90 Revised—Symptom
Checklist 90-Revised.
⁎ Studies utilise the same set of data.
⁎⁎ Studies utilise the same sample.
 S. Laulik et al. / Aggression and Violent Behavior 18 (2013) 644–655
controlling for parent and offspring age and sex and co-occurring Axis I
disorders. Finally, Hans et al.'s (1999) paper revealed that whilst mater-
nal drug dependence was related to unresponsive and negative parent-
ing behaviors, this relation was largely accounted for by underlying
personality disorder, specifically Cluster B personality disorders. As
with the studies reported above, those with Cluster B personality disor-
ders were found to interact with their infants in an insensitive,
unresponsive and harsh manner. This interaction remained even after
Axis I disorders were controlled for. Maternal antisocial personality dis-
order was also significantly related to children's perceptions of their
mothers as rejecting, at age 10.
The findings of two studies were varied and did not produce a con-
sistent positive direction between personality disorder and impaired
parenting practices. In DeMulder et al.'s (1995) study, relationship be-
tween personality disorder and parenting practices differed dependent
on the mental health diagnosis of the mother and the time that the mea-
sures were taken. For example, amongst mothers with bipolar disorder,
significant positive correlations were found between: dependent per-
sonality symptoms (.49, .43 and .46, p b .10); borderline personality
symptoms (.36, .44 and .59, p b .10); and greater maternal engagement
at all three time periods. However, for unipolar mothers, strong nega-
tive correlations were found between Cluster A personality disordered
traits, avoidant and antisocial traits. Personality disordered traits were
also related to critical irritable behaviors amongst well and unipolar
mothers, although these correlations were not consistent across all 3
time periods. No relationship was found between borderline personality
disorder symptoms and irritability or criticalness for either bipolar or
depressed mothers. Findings reported by Conroy et al. (2010) were
also varied. All three personality disorder clusters were found to exert
a detrimental main effect on infant care practices such that mothers
with these disorders were less likely to employ recommended care
practices than other mothers. There was also evidence of a significant
positive relationship between Cluster A (F = 4.19, P b 0.05) personality
disorders and maternal insensitivity. However, a lack of positive associ-
ation was found between Cluster B and C status and maternal sensitivity
observations, and whilst Cluster A and C personality disorders were
positively associated with a lack of maternal involvement; Cluster B
personality disorders exerted no effect.
3.6. Quality of the included studies
There are a number of features of the studies included in this review
which might impact on their overall quality and the reliability of their
findings. The measures of personality disorder employed and interpre-
tation of these measures is the first issue to be considered. Whilst the
questionnaire and interview schedules used were standardized, which
increases the reliability of the studies' findings, the studies do not always
differentiate between specific personality disorders diagnoses in their
results and some refer to personality disorder traits and features rather
than diagnosis. Not only does this variance affect the ability to compare
the 11 studies results, but it also has implications for the generalizability
of the studies' findings as it is possible that it is specific features of spe-
cific personality disorders, rather than a diagnosis of personality disor-
der per se that are predictive of problems with parenting and parents'
interactions with their infants. Further, in Hobson et al.'s (2009) study,
it was inferred that mothers with a diagnosis of personality disorder in
the present (when their children were 20 years of age) would have
met the diagnostic criteria for this disorder 20 years previously (when
their children were infants). Although personality is a stable feature,
the validity and reliability of such inferences are questionable in the
absence of other confirmatory information.
The measures to assess child-rearing behaviors and/or parent–infant
interactions also need to be considered. Out of the 11 studies, only five
studies assessing child-rearing behaviors used standardized measures
(Conroy et al., 2010; Crandell et al., 2003; Hans et al., 1999; Hobson
et al., 2009; Newman et al., 2007). The behavioral measures used by
651
DeMulder et al. (1995) was based on ratings of communication, affect
and control measures using a pre-defined criterion devised for the pur-
poses of the study. This measure is thus neither validated nor standard-
ized. The measure used by Hobson et al. (2005) was adapted from a
standardized measure by Murray et al. (1996); no information is given
about the manner in which this was adapted. The longitudinal studies
by Johnson et al. (2006, 2008) also utilized a measure of parenting be-
haviors composed of items from other standardized measures. Whilst
data relating to the internal consistency of this measure is reported,
no other information pertaining to the measures' psychometric proper-
ties is provided. On closer inspection it is also apparent that the child-
rearing behaviors alluded to in the questionnaire are each assessed by
only two or three questions. It is thus possible that these questions
may not be representative of the variable that they are intending to
measure. The above means that the reliability of the measures used in
these studies are questionable.
Caution also needs to be exerted with regards to the validity of the
findings extrapolated from the measures employed. Only three out of
the 11 studies combined multi-methods of collecting data i.e.: observa-
tion and self-report (Conroy et al., 2010; Hans et al., 1999; Newman
et al., 2007), with the remaining eight studies utilizing observational
methods or, in the case of the longitudinal studies, (Johnson et al.,
2006, 2008) relying solely on self-report data from a questionnaire
in order to assess parenting skills. In the absence of an additional or
encompassed validity scale it is possible that findings from self-report
measures may underestimate the prevalence of any problematic par-
enting behavior, either as a result of parents' desire to present them-
selves favorably or due to a lack of insight into their own capabilities
(Gudjonsson & Haward, 1998). As such, the findings of these studies
should be reviewed with some caution.
Criticisms may also be directed towards the observational methods
that were employed in studies that assessed the quality of parent–infant
interactions. While there is no doubt that the minutia and transactional
nature of parent–infant interactions can glean very useful information
about the quality of parent–infant relations and underlying patterns of
relational behavior, in the studies included in this review observations
were brief, limited, and not always undertaken in naturalistic settings.
Further, the parent was conscious that they were being filmed. With
this in mind it is possible that the observed parent–infant interactions
referred to in studies in this review is not representative of the interac-
tional styles normally occurring at home (Gardner, 1997).
The size of the samples comprising a number of the cross-sectional
(Famularo et al., 1992; Hobson et al., 2005, 2009; Newman et al.,
2007) and one of the cohort studies (DeMulder et al., 1995) are rather
small. Thus this is a methodological weakness for eight out of the 11
studies. This was, however, not applicable for the remaining cohort
(Conroy et al., 2010; Johnson et al., 2006) and cross-sectional studies
(Johnson et al., 2006) which comprised sample sizes of 200, 377 and
377 respectively. A further consideration is the fact that the majority
of the studies, and all of the parent–infant observations, featured
mothers, with only three studies including males in the analysis. The
reasons for this are unclear. It could be that the preponderance of stud-
ies which explored borderline personality disorder led to a gender bias,
as this personality disorder is more frequently diagnosed in women
(Maier, Lichtermann, Klinger, & Heun, 1992). Alternatively, the settings
from which the populations were recruited, for example: hospitals and
antenatal clinics, may have precluded males being recruited. Whatever
the reasons, it is possible that the findings of the included studies may
be specific to maternal, rather than parental psychopathology on
parenting.
In the two case control studies, foster parents (Wiehe, 2003) and
parents of children with no recorded histories of abuse (Famularo
et al., 1992) were selected as non-abusive comparison groups. As
there is no guarantee that these parents have not engaged in abusive be-
haviors, the selection of comparison groups represents an additional
limitation. The majority of the studies (10 out of the 11) sought to
652 S. Laulik et al. / Aggression and Violent Behavior 18 (2013) 644–655
control for confounding variables relating to parental characteristics,
which included: socio-economic status; maternal education level;
gender; age and ethnicity. In addition, four studies controlled for rela-
tionship status (Conroy et al., 2010; Hans et al., 1999; Hobson et al.,
2005; Newman et al., 2007). Three studies controlled for infant age
and two controlled for infant sex. Aside from these variables, only two
out of the 11 studies considered additional infant characteristics, namely
birth order (Hobson et al., 2009) and infant irritability (Crandell et al.,
2003). It is evident then, that whilst the majority of the studies
attempted to control for some confounding variables, parental charac-
teristics were considered more frequently that infant characteristics,
the number and nature of the confounding variables considered was
highly variable, and specific variables, such as number of children
were not considered in the analyses.
Whilst Johnson et al. (2006, 2008) and Hans et al. (1999) controlled
for the presence of additional psychiatric disorders, two studies did not
consider the issue of co-morbidity. Whilst Newman et al. (2007) ac-
knowledged co-morbidity in the decision to include mothers with co-
morbid depression and personality disorder in their group of borderline
personality disordered mothers, it is possible that depression rather than
personality per se may have contributed to the observed out comes.
In all but two of the studies, typically, participants were recruited
through convenience or volunteer sampling procedures. The absence
of a randomized sampling procedure, which relates to the difficulty in
locating suitable parents and securing their collaboration in any re-
search endeavors, thus restricts the generalization of these findings as
it is unknown whether the sample utilized in these studies are repre-
sentative of all parents with a diagnosis of personality disorder.
Features which impact on the validity and generalizability of the
findings also relate to the design of the study. Firstly, it is unclear as to
whether blinding of the interviewer was used in the Famularo et al.
(1992) study, in order to minimize bias. Secondly, in the cohort and
cross-sectional studies, on the basis of brief, limited mother–infant
observations conclusions are made about the overall concurrent and fu-
ture parenting abilities of parents. No one study prospectively assessed
the long-term relationship between a diagnosis of personality disorder
and parenting capacities over the course of an infant's life. Finally,
cross-sectional studies make it very difficult to ascertain with reliability
whether the infant–parent observations are determined by characteris-
tics to the mother (i.e.: personality disorder features) or whether infant
characteristics, or a combination of the two shape the quality of the
mother–infant interactions. Thus causality cannot be established in
these studies.
4. Discussion
The aim of this review was to examine whether parental personality
disorder is associated with problematic parenting behaviors or impaired
parent–child interactions. Eleven studies were deemed eligible for in-
clusion. Of these studies, nine found evidence to support the existence
of a positive association between a diagnosis of personality disorder
and personality disordered features and impaired parenting behaviors
(Crandell et al., 2003; Famularo et al., 1992; Hans et al., 1999; Hobson
et al., 2005, 2009; Johnson, Cohen, Brown, Smailes, & Bernstein, 1999;
Johnson et al., 2006; Newman et al., 2007; Wiehe, 2003) and these asso-
ciations remained when controlling for other confounding variables.
In these studies, the presence of personality disorder was related to:
the use of inadvisable and problematic parental practices (Conroy et al.,
2010; Johnson et al., 2006, 2008); inconsistent parental discipline,
low parental affection, assistance, praise and encouragement (Johnson
et al., 2006, 2008) less satisfaction and reported competence in the
parenting role (Newman et al., 2007); insensitive, intrusive, poorly
attuned and disrupted parent–infant interactions (Crandell et al.,
2003; DeMulder et al., 1995; Hans et al., 1999; Hobson et al., 2005,
2009; Newman et al., 2007); harsh behavior (Hans et al., 1999); fright-
ening/disoriented parental behavior (Hobson et al., 2009); status as an
abusive parent (Famularo et al., 1992; Wiehe, 2003). Cluster B disorders
were found to exert a negative effect on parenting in eight of the studies
and Clusters A and C were featured in three of the studies. Borderline
Personality Disorder was the specific focus of four out of the 11 studies.
Findings from two studies were varied, with one study reporting
differing associations between specific clusters of personality disorder
features and parenting behaviors dependent on the age of the child
(DeMulder et al., 1995) and another (Conroy et al., 2010) reporting:
positive associations between the three clusters of personality disorder
and impaired infant care practices; positive associations between Clus-
ter A and C personality disorder and maternal involvement; and a lack
of positive associations between Cluster B and C status and maternal
sensitivity observations.
The majority (n = 9) of the 11 studies included in this review
provide evidence to suggest that personality disorder amongst mothers
exerts a negative impact on parenting. However, the presence of con-
founding variables does not allow for causal inferences to be made
and as the review comprised only a small number of studies of varied
quality, findings must be interpreted with caution. There are also limita-
tions in the studies reported that require consideration. There are many
variables which could influence the quality of parents' interactions with
their infant, for example: stressors in the parent's life; the quality of a
parent's relationship with a partner; the ongoing family environment;
the quality of a parent's social support; life events; and infant character-
istics such as age, health, temperament etc. Unfortunately, the informa-
tion provided in the included studies did not allow for confident
conclusions to be drawn regarding the strength of the association
between personality disorder and parenting in the context of these
risk factors, as they were either not included or were included but not
explored in sufficient detail.
Four out of the 11 studies in this review specifically examined the ef-
fect of Borderline Personality Disorder on parenting variables. While one
study (Conroy et al., 2010) provided contradictory results with no posi-
tive association being found between maternal sensitivity and Cluster B
status, the majority of the studies in this review (Hans et al., 1999;
Hobson et al., 2005, 2009) found that mothers with borderline personal-
ity disorder had difficulties taking their infant's perspective, interpreting
their infant's affective states and responding to their infant's needs.
While this review is unable to clarify whether these difficulties are
specific to borderline personality disorder or generalizable to other per-
sonality disorders, the disturbance in mother–infant interactions has
implications for ongoing disturbed relationships between these mothers
and their children. There is also a risk that such maternal behavior could
preclude the development of secure attachment with their children; a
development that could affect a child's immediate and long term emo-
tional, psychological and behavioral development (Crittenden, 2008).
The findings of frightening/disoriented behavior in one study (Hobson
et al., 2009) and the results of Famularo et al.'s (1992) study, which re-
vealed that a significant proportion of the personality disordered mothers
in their sample presented with past diagnoses of post-traumatic stress
disorder, also suggests, perhaps, that it may be unresolved trauma, rath-
er than personality organization per se, that is contributing to observed
difficulties in the parent–infant interactions in these studies.
The majority of the above studies explored infant–parent interac-
tions, and only three out of the 11 studies considered the impact of
paternal personality disorder, with no studies specifically examining
father–infant interactions. With this in mind and, given the disparity
and quality of the studies methodologies included in this review, before
one can generalize from these studies, these studies require replication
including father and child interaction.
A further issue to consider is the fact that the majority of the study
populations assessed in this review comprised of mothers with only
three studies considering fathers and including these in their analysis.
As a result, the findings of this review, particularly those studies focusing
on borderline personality disorder, may not be generalizable to fathers
with personality disorder. Finally, in the mother–child interactional
 S. Laulik et al. / Aggression and Violent Behavior 18 (2013) 644–655
studies, infants were the primary focus with only one study exploring
interactions between older children and their mothers. Because of this,
caution should be exerted before generalizing these findings to older
children.
4.1. Clinical implications
Findings from the current review, whilst tentative, have implications
for clinical practice. Firstly, a proportion of abusive parents may present
with personality disordered features. Hence, it is important that psy-
chologists routinely screen for personality disorder amongst parents
known to child protection services. Structured interview procedures
should be employed wherever possible and information should be col-
lated from a variety of sources to corroborate self-report.
Secondly, given the disturbed parent–child interactions noted
amongst mothers, with personality disorder and the close link between
personality disorder, negative childhood experiences and insecure
attachment reported in the literature, it is suggested that assessment
of parents in the course of care proceedings should, wherever possible,
include a formal assessment of adult and child attachment status.
Assessment of a child's attachment status is particularly important as
an insecure attachment provides strong indications to the nature of
the parental care a child has received, irrespective of parent's self-
reported parenting behaviors.
Thirdly, if personality disorder is diagnosed then treatment to target
parents' underlying personality organization is warranted. At present,
the literature suggests that treatment for personality disorder can be ef-
fective. However, as personality is a stable feature and those individuals
with personality disorder tend to view their difficulties as egosyntonic
(meaning that the disorder is considered an integral part of the self,
and does not elicit concern or emotional distress on the part of the suf-
ferer), motivation to engage is often rather poor (McMurran, Huband, &
Overton, 2010) and treatment is likely to be longstanding (Sperry,
1995). Currently, the heterogeneity of individuals with personality dis-
order taken together with a paucity of evidence as to what kind of treat-
ment works for each personality disorder cluster (McMurran et al.,
2010) and a lack of understanding as to how personality disorder affects
parenting over the life-course, means that on the basis of this review, no
single model of treatment can be offered at this time. However, if, as
suggested by this review, personality disorder does adversely affect par-
enting capacity then treating professionals should ensure that any ther-
apeutic endeavor considers the transactional nature of the parent–child
relationship, rather than directing treatment efforts to the parent alone.
Finally, the findings of this review have implications for the mode of
treatment to be employed with parents with personality disorder. Cur-
rently, it is not yet known whether treatment targeted at an individual's
maladaptive personality style will improve parenting skills per se. It is
therefore suggested that treatment should seek to address parents' un-
derlying personality organization in tandem with specific parent–child
interventions. Approaches which increase reflective functioning or
mentalization, the capacity to understand one's own and others mental
states and behaviors, are likely to be of particular importance here
(Fonagy, Gergely, Jurist, & Target, 2002; Newman & Stevenson, 2005).
As are interventions focused on addressing parents' past experience of
trauma and interventions focused specifically on improving dyadic in-
teractions by increasing parent's sensitivity and ability to understand
their infant's needs, attachment behaviors and communications. Im-
provement in the quality of parent–child interactions is likely to improve
the overall dyadic relationship and, importantly, promote security of
attachment, itself a protective factor against the development of psycho-
pathology. It is hoped that a move from adverse to ‘good enough’ parent-
ing (Winnicott, 1953) could help to protect against the intergenerational
transmission of attachment insecurity and abuse that is commonly
reported in the literature (Crittenden, 2008; Crittenden & Ainsworth,
1989).
653
4.2. Directions for future research
This review strongly suggests that further research is merited and
especially highlights the need for more methodologically rigorous
studies to be applied to this field. Prospective longitudinal studies over
longer time periods need to be conducted, to include children of differ-
ing ages, and other factors which may affect parenting efficacy such as:
social supports and quality of the relationship with spouse. It is particu-
larly important that the psychological functioning of primary caregivers'
partners is considered in future research, as any negative parenting
practices as a result of personality disorder could, potentially, be moder-
ated by the functioning of the second parent (Reder & Duncan, 2003).
Future research should also seek to explore the parenting behaviors of
personality disordered fathers in their own right, as this was neglected
in the studies included in this review.
As the current review makes links between borderline personality
disorder and insensitive parenting, it may also be important for re-
searchers to investigate whether parents with other personality disor-
der diagnoses experience similar difficulties responding appropriately
and sensitively to their infant's cues.
Evidence of ongoing trauma in mothers with borderline personality
disorder also lends support to the need for future research to explore
the relative contribution of unresolved trauma to borderline and other
personality disordered parents' interactional style with their infants.
This is particularly pertinent as there is a good deal of research which
suggests that those parents who have experienced childhood abuse, ne-
glect or rejection and have been unable to resolve these traumatic expe-
riences, are more likely to experience difficulties in responding to their
own child in ways that promote secure attachment (Crittenden, 2008).
For these parents, the task of caring for children, in particular those who
appear vulnerable or in a state of need, may reignite unresolved feelings
of fear, anger, distress or abandonment. These feelings may, in turn,
lead to adverse care-giving response (Crittenden & Ainsworth, 1989;
Crittenden, 2008; Reder & Duncan, 1999). These findings are commonly
observed in the literature on maltreating parents who are often de-
scribed as seeking to meet their own (unmet) needs for dependency,
care and love in the parent–child relationship. When these needs are in-
evitably unmet, anger and hostility is a common occurrence (Garbarino,
Guttmann, & Seeley, 1986; Reder & Duncan, 2003). In cases of fatal abuse,
underlying feelings of rejection, fear of abandonment and helplessness
are frequently cited as precipitants (Krugman, 1985; Korbin, 1987).
If unresolved about aspects of their own childhood, parents with
personality disorder might, then, be at particular risk of re-enacting
trauma, both psychologically and physically with their own children,
thus placing their children at risk of maltreatment. Given that there is
significant evidence for the intergenerational cycle of abuse (Browne
& Herbert, 1997), a greater understanding of the relative contribution
that personality disorder plays in this cycle is essential.
It is important that future research exploring the quality of parenting
behaviors and/or parent–child interactions is assessed using a combina-
tion of self-report data and observational research so as to avoid bias. It
may also be helpful to examine different dimensions of parenting behav-
iors and consider the impact on children of their parents' behaviors by
utilizing data from a variety of sources, including: psychometric assess-
ment of parents and children; information pertaining to children's
adjustment by teachers, nursery workers etc.; children's self-reported
perceptions of their parent's behavior; as well as parents self-reported
views of their parenting. This would provide a more comprehensive
account of the quality of parenting behaviors of parents and, importantly,
illuminate children's experiences of being parented by a parent with per-
sonality disorder. Given the reciprocal nature of the parenting task, there
is also a need for studies to assess the interaction of parents and children's
characteristics, as children's characteristics, independent of the parent–
child relationship, will influence a parent's behavior. Knowledge of how
these variables operate together might aid in the assessment of risk and
protective factors amongst parents with personality disorder.
654 S. Laulik et al. / Aggression and Violent Behavior 18 (2013) 644–655
Finally, whilst links have been made between particular personality
disorder clusters and risk of general and violent offending behavior
(Esbec & Echeburúa, 2010), on the basis of this review, it is not yet
possible to state with confidence whether associations exist between
specific clusters of personality disorder and risk of engaging in particu-
lar problematic and/or abusive parenting practices. By drawing on a
wider, larger and more representative sample of personality disordered
parents it may be possible to identify specific subgroups of parents who
are vulnerable to engaging in neglectful or abusive parenting practices.
With time, it is possible that such knowledge could help to develop a
model of parenting disturbance specific to personality disorder, delin-
eating the relative impact of different personality disorders to parent-
ing, relative to other forms of psychopathology.
5. Conclusions
This systematic review suggests that personality disorder represents
a risk factor for impaired parent–child relations and problematic par-
enting practices. However, before one can generalize from the results
reported in this review, further research to clarify and extend the cur-
rent findings is needed. A broader approach to the study of the parent-
ing capabilities of personality disordered parents would also be of value,
including (a) how co-morbidity and personality disorder alone influ-
ence the broad dimensions of parenting capacity for both mothers and
fathers, (b) how parenting is affected over time, and (c) how children's
individual characteristics may serve to exacerbate or mitigate any risk in
the parent–child relationship. Over time, such valuable information will
assist with the assessment of risk and identification of suitable treat-
ment interventions in families with parents with personality disorder
in ways that maximize treatment effectiveness and, safeguard children
from potential harm.
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