On approval to conduct this study from the local institutional review board (IRB), the postdoctoral study coordinator/therapist initiated contact with families from an existing waiting list of families who had initiated contact with the research program, requesting to remain on a waiting list for future treatment studies. Due to a lengthy delay in receiving IRB approval, the therapist was only able to enroll the first two eligible families seeking treatment as his postdoctoral training was nearly complete. They were administered a brief phone screening interview to determine potential study eligibility (the family had to be willing to participate in the assessment and treatment protocol, the child had to be between the ages of 8 and 12 and have a high probability of being diagnosed with BPD if enrolled). Parents provided written informed consent and children provided assent to participate in a clinical trial prior to study entry. Treatment was provided at no charge and parking passes were provided at each assessment and treatment session. Names, ages, and other identifying information have been altered slightly to protect the families' identity. Children included an 11-year-old White girl ("Jane") and a 10-year-old White boy ("John"). Each was living with their biological parents and a sibling. Their clinical histories are summarized here.
Jane presented with significant mood lability and was excessively guarded. She appeared unkempt, with uncombed, mangled hair, a soiled jacket, dirty pants, and severely chapped hands. Her mother reported the latter was due to Jane's excessive washing of and picking on her skin. Jane's parents had experienced significant marital conflict and a brief divorce, followed by remarriage. During this time, Jane reportedly changed from a "vibrant and popular child" to one who could not keep friends. Once, Jane had to be picked up from school as she was lying in a fetal position crying inconsolably. Recently, Jane had been verbally and physically aggressive toward her parents, displaying rapid, tangential, and incoherent speech; exhibiting disruptive behaviors at school; engaging in socially inappropriate interactions; and participating in risky behaviors that had required medical attention. On one occasion, Jane became so upset her mother was leaving home on an errand that she ran barefooted after her mother's car. After being let into the car, Jane attempted to jump out the window. Once back home, she ran from her family and tried to jump out of a second-story loft yelling, "I can fly, I'm going to jump!" When family members attempted to calm her, she accused them of trying to kill her and hit them with a bar. She then fled to her bedroom and moved a large dresser in front of the door. Jane's parents were unable to enter her bedroom or persuade her to come out. Out of desperation, they called the police and emergency medical technician (EMT), who forcibly removed her door and convinced Jane to take her medications to prevent hospitalization. Jane's mother reported Jane's mood episodes fluctuated throughout the day, with sad moods "on and off" all day, accompanied by irritability, restlessness, excessive fatigue, and negative views of self. At other times during the day, Jane experienced an elevated activity level, rapid thoughts and speech, overestimation of her abilities, hypersexuality, and dangerous behaviors. Duration could vary from minutes to hours, frequency ranged from a few times a day to several times a week. Jane's mood disturbance had been present for 2 years without full remission, despite short durations of more stable functioning. Family history included mother's past anorexia, bulimia, panic disorder, and posttraumatic stress disorder and father's current BPD and symptoms of obsessive-compulsive disorder.
Jane had been treated for mood dysregulation for the past year. A behavior analyst worked with Jane at school; Jane refused to engage in outpatient therapy. Jane's mother received outpatient parent guidance. Regarding medication, Jane received a 3-month trial of sertraline at age 8. This resulted in akathesia, elevated moods, and excessively dangerous behaviors. Between ages 9 and 10, Jane had trials of divalproex sodium and clonidine, neither of which produced significant improvement. Jane then started quetiapine, from which she was being tapered due to lack of efficacy at the time of her evaluation. For the past year, Jane had been prescribed fluvoxamine and clonazepam to manage compulsive behavior and to decrease agitation.
John presented as restless with excessively distorted thoughts and limited insight. At times during the interview, John stared blankly and was unresponsive to verbal requests. At other times, he would become very animated and overly active. On several occasions, John began to hit and choke himself but could be redirected. John's mother reported a long-standing history of engaging in dangerous behaviors, including trying to eat a light bulb and hitting and biting himself and others. These behaviors intensified on preschool entry. John's mother reported his mood symptoms could "be stable or flare up." For example, John would have "good and bad times" throughout his preschool day, and some weeks were worse than others. Additionally, in the last few months of preschool, staff required his mother remain on-site to assist in managing his disruptive behaviors. As John got older, his mood and accompanying symptoms occasionally remained relatively stable for 4 to 5 months at a time then would flare up for 4 to 5 months. John's mother attributed this to his medications working for a little while then being less effective, seemingly due to physical development. For 4 years, John had not gone for more than 6 months without needing a medication readjustment. During mood episodes, John frequently displayed severe behavioral and emotional outbursts, thought impairment, rapid speech, and sexually inappropriate behaviors. At these times, John attempted to touch his mother's genital and breast areas, commented repeatedly on her private anatomy, and joked about breast-feeding. In the third grade, John began receiving educational services through a school designed for children with behavioral and emotional disorders. There is a family history of paternal depression and manic symptoms.