Borderline Personality Disorder in Children: Signs, Diagnosis, & Treatment

What Is Borderline Personality Disorder?

Borderline personality disorder (BPD) is a mental health condition characterized by pervasive patterns of instability in interpersonal relationships, self-image, and emotions. Individuals with BPD experience intense episodes of anger, depression, and anxiety that can last from a few hours to days.² They struggle with fear of abandonment and may engage in risky behaviors, showing a marked pattern of impulsivity and mood swings.

The complexity of BPD lies in its overlapping symptoms with other mental health disorders, such as depression, anxiety, and bipolar disorder, making diagnosis challenging.³ It frequently co-occurs with other conditions, adding layers of complexity to treatment and management. This overlap can complicate the clinical picture, requiring comprehensive assessments to ensure accurate diagnosis and appropriate intervention strategies. The disorder’s impact on personal and professional relationships further complicates individuals’ lives, necessitating a multifaceted treatment approach.¹

Signs of Borderline Personality Disorder in Children

Signs of BPD  in children follow similar criteria for adults and are defined as a 1-year pattern of immature personality development with disturbances in at least five of the following domains: efforts to avoid abandonment, unstable interpersonal relationships, identity disturbance, impulsivity, suicidal and self-mutilating behaviors, affective instability, chronic feelings of emptiness, inappropriate intense anger, and stress-related paranoid ideation.^{1, 2}

Ten signs of BPD in children include:

1. Intense emotional sensitivity: Children with BPD may react to situations with heightened emotional intensity compared with their peers, showing extreme responses to perceived criticisms or rejections.
2. Fear of abandonment: Even minor separations or changes in routine can provoke significant anxiety and fear of being left alone or uncared for.
3. Unstable relationships: They might have tumultuous relationships, swinging between idealization (intensely liking someone) and devaluation (intensely disliking someone), often without a clear cause.
4. Impulsive behaviors: This could include reckless behavior without consideration for consequences, such as running away from home or engaging in risky play.
5. Frequent mood swings: Their emotions can change very quickly, showing intense happiness, irritability, or anger within a few hours or days.
6. Chronic feelings of emptiness: A persistent feeling of emptiness or boredom that they can’t seem to fill with activities or relationships.
7. Explosive anger: Borderline rage involves difficulty controlling anger and can lead to explosive outbursts, often over relatively minor issues, followed by shame or guilt.
8. Self-harm or suicidal behavior: Engaging in self-harm behavior, like cutting or hitting themselves or talking about suicide, even if they don’t intend to act on these thoughts.
9. Identity disturbance: They might show significant uncertainty about their identity, including self-image, sexual orientation, long-term goals, and values.
10. Paranoid thoughts or severe dissociation: In times of stress, they may experience paranoid thoughts about others’ intentions or have episodes of dissociation, feeling detached from themselves or reality.^{1, 2}

How to Know the Difference Between Typical Child Behavior & BPD in Children

Distinguishing between typical child behavior and symptoms indicative of BPD in children can be challenging, as many characteristics of BPD, such as mood swings and impulsivity, are also common in healthy developmental stages. However, the intensity, frequency, and impact of these behaviors on a child’s functioning are key differentiators.⁴ Typical behaviors are generally transient and less disruptive, whereas BPD-related behaviors are persistent, extreme, and significantly impair social, academic, and familial relationships.

Another important factor is the context and triggers of behaviors. While typical child behavior can often be linked to immediate causes or developmental phases (e.g., tantrums in toddlers over boundaries), behaviors associated with BPD are more complex, reflecting deeper issues with emotional regulation and identity.⁴ These behaviors are not just reactions to specific events but are part of a consistent pattern that affects all areas of life. Professional evaluation is crucial, as mental health experts can discern the subtleties between typical development and disorders like BPD.

What Causes BPD in Children?

The causes of BPD in children are multifaceted, involving a complex interplay of genetic, environmental, and psychological factors.¹ Genetics may predispose an individual to BPD, while environmental factors, such as trauma, abuse, or neglect in early childhood, significantly increase the risk. Psychological factors, including early attachment issues and disruptions in family relationships, also contribute to the development of BPD in children. These elements combined can affect a child’s emotional regulation and coping mechanisms, laying the groundwork for BPD.

Causes and risk factors for BPD in children include:

• Genetics: Research suggests a hereditary component to BPD, indicating that children with a family history of BPD or other personality disorders are at a higher risk of developing the condition themselves. This genetic predisposition likely interacts with environmental factors to influence the development of BPD.
• Environment: Environmental factors play a crucial role in the development of BPD in children. Exposure to traumatic experiences, such as physical, emotional, or sexual abuse, neglect, or loss during critical developmental periods, can significantly increase the risk.
• Biology: Biological factors, including abnormalities in brain structure and function, particularly in areas responsible for emotion regulation and impulse control, are associated with BPD. Neurotransmitter imbalances, affecting mood regulation and stress response, also contribute to the disorder’s pathology.
• Other relevant causes: Early attachment trauma, including disrupted bonding with primary caregivers, can lead to difficulties in relationships and self-image, which are central to BPD. Social factors, such as bullying and cultural or societal expectations, can exacerbate feelings of isolation or inadequacy, further increasing the risk of developing BPD in susceptible children.

How Does BPD Impact Children

BPD significantly impacts a child’s development, particularly in emotional regulation.⁵ Children with BPD experience intense emotions, which they find hard to control or understand, leading to frequent emotional outbursts and difficulties in coping with stress. This instability can strain their relationships with peers and family, complicating social interactions and leading to feelings of isolation or misunderstanding.

Academically, the impulsivity and mood swings associated with BPD can disrupt focus and consistency in schoolwork, affecting performance and engagement. Furthermore, the disorder’s impact on self-image can be profound, with children struggling with a coherent sense of identity, leading to low self-esteem and, in some cases, self-harmful behaviors. If not managed effectively, these challenges can persist into adulthood, potentially leading to more severe mental health issues, relationship difficulties, and impaired social functioning.

Diagnosis of Borderline Personality Disorder in Children

Diagnosing BPD in children presents unique challenges, primarily due to the overlap between typical childhood behaviors and symptoms of the disorder.^{1, 3, 4, 5} Children naturally undergo rapid developmental changes, which can mimic or mask signs of BPD, such as mood swings and identity exploration. Distinguishing these normal variations from the more persistent and disruptive patterns characteristic of BPD requires careful observation and professional judgment.

Moreover, symptoms of BPD can closely resemble those of other developmental disorders, such as ADHD, autism spectrum disorders, and anxiety disorders, complicating the diagnostic process. It necessitates a comprehensive evaluation by mental health professionals who can differentiate between these conditions. This often involves detailed interviews, behavioral observations, and collaboration with parents, teachers, and caregivers to gather a full picture of the child’s behavior across different settings and situations.

The DSM-5-TR (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision) does not provide separate diagnostic criteria for BPD in children versus adults.² The criteria are applied universally, regardless of age, but with consideration given to the individual’s developmental stage.

For a child to be diagnosed with BPD, they must exhibit  five (or more) of the following criteria:

• Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
• A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
• Identity disturbance: markedly and persistently unstable self-image or sense of self.
• Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)
• Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
• Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
• Chronic feelings of emptiness.
• Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
• Transient, stress-related paranoid ideation or severe dissociative symptoms.²

Other Conditions That Look Like BPD in Children

In children, several conditions can present symptoms that closely resemble those of BPD, making accurate diagnosis challenging. Mood disorders, such as major depressive disorder in children and bipolar disorder in children, share similar features with BPD, including intense emotional swings, irritability, and periods of intense sadness or elevated mood.² The key difference often lies in the duration and consistency of mood states; mood disorders typically present more episodic symptoms, whereas BPD features a more persistent pattern of emotional instability and interpersonal difficulties.^{1, 4}

Attention-deficit/hyperactivity disorder (ADHD) is another condition that can mimic BPD in children, particularly due to overlapping symptoms of impulsivity and difficulties in maintaining attention. Children with ADHD may also struggle with maintaining stable relationships due to impulsiveness and hyperactivity, which can be mistaken for BPD’s relational turbulence. However, ADHD primarily affects attention and executive functioning without the characteristic intense fear of abandonment and identity disturbance seen in BPD.

Treatment for BPD in Children

Seeking professional support is essential for a child with BPD to navigate the complex symptoms and prevent the progression of the disorder.¹ A comprehensive treatment plan for BPD typically involves a multidisciplinary team approach, including mental health professionals, educators, and pediatricians, to address the psychological, social, and academic needs of the child.

Dialectical behavior therapy (DBT) shows promise in teaching children coping skills to manage emotions, reduce self-harm behaviors, and improve relationships. Family therapy is also crucial, providing support and education for family members to understand better the disorder and how to respond to the child’s behaviors effectively. While medication for BPD is not the primary treatment, it may be considered to manage co-occurring conditions or specific symptoms, such as mood swings or anxiety, under careful medical supervision.⁶

Effective treatment options for children with BPD include:

• Dialectical behavior therapy (DBT): DBT for BPD is a form of cognitive-behavioral therapy specifically designed to help people with BPD. It focuses on teaching skills in four key areas: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. For children, DBT can be adapted for children to be age-appropriate. It often includes both individual therapy and skills group sessions, where children learn to manage their emotions and improve their relationships. DBT has been found to be particularly effective in reducing self-harm behaviors and emotional dysregulation in adolescents with BPD.
• Cognitive behavioral therapy (CBT): CBT can help individuals with BPD to identify and change negative thought patterns and behaviors. CBT can be adapted to teach children how to deal with challenging situations more effectively by breaking down overwhelming problems into smaller, more manageable parts. CBT’s effectiveness for BPD in children includes improving emotional regulation and reducing impulsivity. Therapists tailor the approach to be engaging and understandable for children, often incorporating games and activities that teach coping skills.
• Family therapy: Family therapy involves family members in the treatment process to improve communication, resolve conflicts, and understand the dynamics that may contribute to the child’s BPD symptoms. It’s essential for creating a supportive home environment that can help reinforce the skills learned in individual therapy.
• Psychoeducation: Educating the child and family about BPD is crucial. It helps demystify the disorder and provides essential information on managing symptoms, understanding triggers, and knowing when to seek additional help. Psychoeducation fosters a supportive environment that encourages open communication and shared problem-solving.
• Medication: While no medication specifically treats BPD, certain medications may be prescribed to address comorbid conditions or specific symptoms, such as anxiety or depression. The decision to use medication is based on a careful assessment of the child’s overall mental health needs and is typically considered as a supplement to therapy rather than a standalone treatment.

How to Support a Child with Borderline Personality Disorder

Supporting a child with BPD requires patience, understanding, and consistent communication. Parents and families can foster a supportive environment by educating themselves about BPD, recognizing the child’s emotional needs, and reinforcing positive behaviors. Establishing a routine, setting clear and achievable boundaries, and encouraging open dialogue about emotions are crucial. Additionally, seeking professional guidance and participating in family therapy can equip families with effective strategies to manage challenges and support the child’s journey toward recovery.

Here are some ways to support a child with BPD.

Educate Yourself

Educating oneself about BPD is a critical step in providing effective support for a child with the condition. Understanding the disorder’s complex symptoms, causes, and treatments enables caregivers to better interpret their child’s behaviors and emotional needs. Knowledge about BPD not only demystifies the child’s experiences but also helps caregivers avoid personalizing challenging behaviors, instead responding with empathy and informed strategies.

Moreover, being well-informed about BPD empowers caregivers to advocate for their child’s needs effectively, whether in educational settings, within healthcare systems, or when seeking out appropriate therapeutic resources. It also equips them to engage in meaningful dialogues with professionals, ensuring that interventions are tailored to the child’s unique situation. Ultimately, an educated approach to BPD can significantly enhance the quality of support provided, contributing to more positive outcomes for the child and strengthening the family unit.

The following are some resources that can help you educate yourself:

Books

–The Borderline Personality Disorder Survival Guide by Alexander L. Chapman & Kim L. Gratz: This book provides an in-depth understanding of BPD, offering practical strategies for managing symptoms and improving the quality of life.

– Parenting a Child Who Has Intense Emotions: Dialectical Behavior Therapy Skills to Help Your Child Regulate Emotional Outbursts and Aggressive Behaviors by Pat Harvey & Jeanine Penzo: Tailored for parents, this book applies DBT principles to parenting strategies, helping to navigate the intense emotions of children with BPD.

Reputable Online Sources

–National Institute of Mental Health (NIMH) – Borderline Personality Disorder: Offers a comprehensive overview of BPD, including the latest research, symptoms, treatments, and strategies for support.

–Borderline Personality Disorder Resource Center (BPDRC): Provides a wealth of resources, including articles, treatment options, and advice for families dealing with BPD.

Support Groups

–Family Connections: Offered by the National Education Alliance for Borderline Personality Disorder (NEABPD), this is a free program that provides education, skills training, and support for families of individuals with BPD.

Create a Supportive Environment

Creating a supportive and stable home environment is vital for a child with BPD, as it can significantly contribute to their sense of security and emotional well-being. One effective strategy is maintaining a consistent daily routine, which helps minimize uncertainty and anxiety. Routines around meals, homework, and bedtime provide structure and predictability, making the child feel more grounded. Additionally, engaging the child in the planning of these routines can foster a sense of control and cooperation.

Setting clear and consistent boundaries is equally important in nurturing a supportive environment. These boundaries should be established with empathy and explained in a way that the child understands, focusing on safety and respect for all family members. Consistency in applying these rules and the consequences for breaking them teaches the child about responsibility and the expectations of their behavior. Creating a calm and safe space at home where the child can retreat and manage overwhelming emotions enhances their ability to cope with stress.

Model Healthy Relationships

Modeling healthy relationships is crucial for a child with BPD, as it provides them with a tangible framework for understanding how to interact positively with others. Caregivers can demonstrate effective communication by actively listening, expressing their thoughts and feelings clearly and respectfully, and encouraging the child to do the same. This open dialogue fosters an environment where emotions and thoughts can be shared safely, teaching the child the value of transparency and empathy in relationships.

Showing how conflicts can be resolved constructively is vital. Caregivers can exemplify this by remaining calm during disagreements, using problem-solving skills, and seeking compromises that respect everyone’s needs. By observing these strategies, a child with BPD learns that conflicts are a normal part of relationships and can be managed healthily without resorting to extreme reactions. Additionally, demonstrating emotional regulation through managing one’s reactions to stress, frustration, and anger in a controlled manner teaches the child effective coping mechanisms for their intense emotions, further guiding them towards healthier interpersonal interactions.

Validate Their Feelings

Validating the feelings of a child with BPD is crucial in helping them feel understood and supported. Validation involves acknowledging their emotions without judgment, showing them that it’s okay to feel a certain way. This does not mean agreeing with any negative behaviors that may arise from those feelings but rather recognizing the emotion itself as valid and real. By doing so, caregivers help the child learn that their feelings are important and of respect and understanding, which can significantly improve their self-esteem and emotional regulation.

Further, validation can be a powerful tool in diffusing intense emotional situations. When children feel heard and understood, they are more likely to be receptive to guidance and support in managing their emotions constructively. It teaches them that they can express themselves and seek help in healthier ways, laying the foundation for stronger, more open communication between the child and caregiver. This approach fosters a trusting relationship where the child feels safe to navigate their complex emotions, which is essential for their emotional growth and stability.

Advocate for Them at School

Advocating for a child with BPD at school is essential to ensure they receive the support needed for their learning and social interactions. Caregivers can play a pivotal role by actively communicating with teachers and school counselors about the child’s condition and specific needs. This involves sharing insights into the child’s emotional triggers, effective coping strategies, and any accommodations that might facilitate a better learning environment.

Collaboration between caregivers and school staff can lead to the development of tailored strategies or individualized education plans (IEPs) that support the child’s academic and social success. This might include adjustments in teaching methods, additional time for assignments, or a quiet space for the child to regroup during overwhelming moments. Establishing regular check-ins with teachers and counselors also allows for ongoing dialogue and adjustments to strategies as needed, ensuring that the child’s evolving needs are met.

Encourage Healthy Coping Mechanisms

Teach and model healthy coping strategies for dealing with stress and intense emotions. This can include mindfulness exercises, physical activities, creative outlets like art or music, and deep breathing techniques. Encouraging the child to identify activities that help them feel calm and grounded can empower them to manage their emotions more effectively.

Foster Social Skills

Children with BPD may struggle with social interactions. Engage them in activities that promote social skills, such as group sports, clubs, or group therapy sessions designed for young people. Role-playing scenarios at home can also be a valuable tool for practicing conversation, empathy, and conflict-resolution skills in a safe environment.

Set Realistic Goals

Work with the child to set achievable goals related to their behavior, academic achievements, or personal projects. This process should involve breaking down larger goals into smaller, manageable steps, providing a sense of accomplishment and progress. Celebrate these achievements, no matter how small, to boost the child’s self-esteem and motivation.

Prioritize Self-Care for Caregivers

Supporting a child with BPD can be emotionally taxing for caregivers. It’s essential to prioritize your own mental and physical health through different types of self-care practices, seeking support from peers or support groups, and, if necessary, professional counseling. Taking care of yourself ensures you have the energy and emotional resilience to provide the best support for your child.

How to Find Professional Support

A child with BPD may require professional help when symptoms significantly interfere with their daily life, education, or relationships. Instances such as intense emotional outbursts, persistent feelings of emptiness, self-harm behaviors, or chronic interpersonal conflicts are clear indicators that additional support is needed.¹ Online therapist directories or online therapy platforms can be incredibly helpful in these situations, as they provide access to a wide range of professionals specialized in BPD and its management. These platforms offer the convenience of finding support from home, making it easier to start and continue therapy, which is essential for managing BPD symptoms over time.

Seeing a psychiatrist becomes necessary when there’s a need to consider medication as part of the treatment plan for BPD symptoms. Psychiatrists can evaluate the child’s mental health condition comprehensively and prescribe medication to manage specific symptoms, such as mood swings or depression, which often accompany BPD. Online psychiatry options offer a flexible and accessible means to consult with a psychiatrist, especially in areas with limited access to mental health services.