Carolyn Ha

Borderline personality disorder in adolescents: evidence in support of the Childhood Interview for DSM-IV Borderline Personality Disorder in a sample of adolescent inpatients

Empirical evidence is increasing in support of the validity of the construct of borderline personality disorder (BPD) in adolescence. There is growing consensus that the early identification and treatment of emerging borderline traits may be an important focus. However, few diagnostic (questionnaire- or interview-based) measures specifically developed or adapted for adolescents and children exist. The Childhood Interview for DSM-IV Borderline Personality Disorder (CI-BPD) [Zanarini, 2003] is a promising interview-based measure of adolescent BPD. Currently, no studies have explicitly been designed to examine the psychometric properties of the CI-BPD. The aim of the current study was to examine various psychometric properties of the CI-BPD in an inpatient sample of adolescents (n = 245). A confirmatory factor analytic approach was used to examine the internal factor structure of the 9 CI-BPD items. In addition, internal consistency, interrater reliability, convergent validity (with clinician diagnosis and 2 questionnaire-based measures of BPD), and concurrent validity (with Axis I psychopathology and deliberate self-harm) were examined. Similar to several adult studies, the confirmatory factor analytic results supported a unidimensional factor structure for the CI-BPD, indicating that the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria on which the CI-BPD is based constitute a coherent combination of traits and symptoms even in adolescents. In addition, other validity criteria were excellent. Taken together, the current study provides strong evidence for the validity of the CI-BPD for use in adolescents.

The criTerion validiTy of The Borderline PersonaliTy feaTures scale for children in an adolescenT inPaTienT seTTing

The purpose of the current study was to examine the criterion validity of the Borderline Personality Features Scale for Children (BPFS-C) by assessing the performance of the self-report and a newly developed parent report version of the measure (BPFS-P) in detecting a borderline personality disorder (BPD) diagnosis in adolescent inpatients. This study also examined parent-child agreement and the internal consistency of the BPFS subscales. An inpatient sample of adolescents (n = 51) ranging from ages 12-18 completed the BPFS and were administered the Child Interview for DSM-IV Borderline Personality Disorder (CI-BPD) by trained clinical research staff. ROC analyses revealed that the BPFS-C has high accuracy (AUC = .931; Se = .856; Sp = .840) in discriminating adolescents with a diagnosis of BPD, as measured by the CI-BPD, while the BPFS-P has moderate accuracy (AUC = .795; Se = .733; Sp = .720). Parent-child agreement on total scores was significant (r = .687; p < .005). Cronbachs alphas suggested internal consistency for the four subscales of the BPFS. These findings support the criterion validity of this measure, particularly the self-report version, in adolescent inpatient settings.

The measurement of reflective function in adolescents with and without borderline traits

Reflective function refers to the capacity to reflect on the mind of self and others in the context of the attachment relationship. Reflective function (and its conceptual neighbor, mentalizing) has been shown to be an important correlate of a variety of disorders, including borderline personality disorder (BPD). The current study examined the construct validity of the Reflective Function Questionnaire for Youths (RFQY) in an inpatient sample of adolescents. Adequate internal consistency was established for the RFQY. Significant positive associations with an interview-based measure of reflective function and an experimental-based assessment of mentalization were found for the RFQY. Strong negative relations with BPD features were found and adolescent patients who scored above clinical cut-off for BPD symptoms demonstrated significantly poorer reflective function compared to patients without the disorder. These findings provide preliminary support for the notion that reflective function can be validly and reliably assessed in adolescent populations.

The development of a mentalization-based outcomes and research protocol for an adolescent inpatient unit.

The authors describe the development of a theory-driven assessment and research protocol at the Adolescent Treatment Program of The Menninger Clinic. First, the theoretical framework behind a mentalization-based model for assessment and treatment is described. Next, the process whereby measures were selected to operationalize key components of the mentalization-based model is discussed, including a brief discussion of each measure and assessment procedure. The next section describes the clinical and research use of the data collected. Here, the authors describe how outcomes assessment information is integrated into the clinical decision-making process, and they outline the research questions they aim to answer through the assessment protocol. The authors conclude with a section on the challenges, pitfalls, and future directions of the project.

The cross-informant concordance and concurrent validity of the Borderline Personality Features Scale for Children in a community sample of boys

The Borderline Personality Disorder Features Scale for Children (BPFSC) is currently the only dimensional measure specifically developed to assess borderline features in children and adolescents. Few studies have investigated this measure for its concurrent validity and concordance between youth self-report and parent-report versions. To this end, the current study had two aims: (1) to investigate the cross-informant concordance (youth self-report vs. parent-report) of the BPFSC; and (2) to examine the concurrent validity of the BPFSC by showing that youth scoring high on the BPFSC also show poor clinical and psychosocial functioning, as measured by a standard Axis I scale. A community sample (N = 171) of boys between the ages of 8 and 18 completed the BPFSC and a self-report measure of Axis I psychopathology. Parents completed a newly developed parent-report version of the BPFSC (BPFSP) and a standard measure of Axis I psychopathology to index clinical and psychosocial functioning. Findings confirmed expectations. Modest concordance between parent- and self-report ratings were found. In addition, youth with borderline features showed poorer clinical and psychosocial functioning in all domains, especially where externalizing problems were concerned. Concurrent validity and modest parent—child concordance were demonstrated for the BPFSC. The BPFSC and BPFSP show promise as dimensional measures to assess borderline features in boys. However, a criterion validity study is needed before the measure can be used.

Psychiatric Comorbidity in Hospitalized Adolescents With Borderline Personality Disorder

OBJECTIVE The goal of this study was to carry out the first comprehensive assessment of psychiatric comorbidity in adolescents (aged 12-17 years) with DSM-IV criteria for borderline personality disorder (BPD) compared to a psychiatric comparison group without BPD. Complex comorbidity (a hallmark feature of adult BPD and defined as having any mood or anxiety disorder plus a disorder of impulsivity) was also examined as a distinguishing feature of adolescent BPD. METHOD Consecutively admitted patients (October 2008 to October 2012) to an inpatient psychiatric hospital received parental consent and gave assent for participation in the study (N = 418), with the final sample after exclusions consisting of 335 adolescent inpatients. A comprehensive, multimethod approach to determining psychiatric comorbidity was used, including both an interview-based (categorical) and a questionnaire-based (dimensional) assessment as well as both parent and adolescent self-report. Measures included the Diagnostic Interview Schedule for Children (NIMH-DISC-IV), Child Behavior Checklist (CBCL), Youth Self-Report (YSR), Car, Relax Alone, Forget, Friends, Trouble (CRAFFT), and the Childhood Interview for DSM-IV Borderline Personality Disorder (CI-BPD). RESULTS Thirty-three percent of the final sample met criteria for BPD. Adolescent inpatients with BPD showed significantly higher rates of psychiatric comorbidity compared to non-BPD psychiatric subjects for both internalizing (χ²₁ = 27.40, P < .001) and externalizing (χ²₁ = 19.02, P < .001) diagnosis. Similarly, using dimensional scores for self-reported symptoms, adolescent inpatients with BPD had significantly higher rates of psychiatric comorbidity compared to non-BPD subjects for internalizing (t₃₂₉ = -6.63, P < .001) and externalizing (t₃₂₉ = -7.14, P < .001) problems. Parent-reported symptoms were significantly higher in the BPD group only when using a dimensional approach (internalizing: t₃₂₁ = -3.42, P < .001; externalizing: t₃₂₁ = -3.32, P < .001). Furthermore, significantly higher rates of complex comorbidity were found for adolescents with BPD (χ²₁ = 26.60, P < .001). Moreover, externalizing and internalizing problems interacted in association with borderline traits (B = .25; P < .001). CONCLUSIONS Similar to findings in adult studies of BPD, adolescents with BPD demonstrate significantly more complex comorbidity compared to psychiatric subjects without BPD.

The Relationship Between the Youth Psychopathic Traits Inventory and Psychopathology in a U.S. Community Sample of Male Youth

The Youth Psychopathic Traits Inventory (YPI) is a self-report measure of juvenile psychopathic traits. Validity data for this measure are limited, especially for nonreferred samples. This report investigated the concurrent validity of the YPI by assessing 171 nonreferred male youth (M age = 12.96 years) with a battery of self-, parent-, and peer-report measures including the Child Behavior Checklist (CBCL), the Reactive-Proactive Aggression Questionnaire (RPQ), the Antisocial Process Screening Device (APSD), and a peer-sociometric measure of aggression. Results confirmed the expected correlations between the YPI and measures of proactive aggression, other externalizing and internalizing behavior, and parent-report psychopathic-like traits. In addition, cluster analyses of YPI scores revealed 2 groups of youth (low vs. high) who scored differently on measures of externalizing behavior. This study supports the utility of the YPI as a research tool for assessing juvenile psychopathic traits.

First empirical evaluation of the link between attachment, social cognition and borderline features in adolescents.

OBJECTIVE Several developmental models of borderline personality disorder (BPD) emphasize the role of disrupted interpersonal relationships or insecure attachment. As yet, attachment quality and the mechanisms by which insecure attachment relates to borderline features in adolescents have not been investigated. In this study, we used a multiple mediational approach to examine the cross-sectional interplay between attachment, social cognition (in particular hypermentalizing), emotion dysregulation, and borderline features in adolescence, controlling for internalizing and externalizing symptoms. METHODS The sample included 259 consecutive admissions to an adolescent inpatient unit (Mage=15.42, SD=1.43; 63.1% female). The Child Attachment Interview (CAI) was used to obtain a dimensional index of overall coherence of the attachment narrative. An experimental task was used to assess hypermentalizing, alongside self-report measures of emotion dyregulation and BPD. RESULTS Our findings suggested that, in a multiple mediation model, hypermentalizing and emotion dysregulation together mediated the relation between attachment coherence and borderline features, but that this effect was driven by hypermentalizing; that is, emotion dysregulation failed to mediate the link between attachment coherence and borderline features while hypermentalizing demonstrated mediational effects. CONCLUSIONS The study provides the first empirical evidence of well-established theoretical approaches to the development of BPD.

A Mentalization-Based Treatment Approach to Caring for Youth in Foster Care

Children and adolescents in foster care settings are at risk for development of emotional and behavioral problems due to a history of traumatic experiences combined with constant changes in their living environment with frequent shifts in caregivers, creating challenges in forming secure attachments. There has been a wealth of research evidence highlighting the importance of secure attachments in promoting the development of healthy mentalization abilities (Fonagy et al., 1991; Fonagy & Target, 2006), which facilitate the processing of traumatic experiences (Sharp, Fonagy, & Allen, 2013). Mentalization is the ability to think about and interpret self and others in terms of mental states (Luyten & Fonagy, 2009). Given the established link between traumatic experiences including child maltreatment with impaired mentalization abilities (Allen, 2013; Fonagy & Luyten, 2009; Ensink et al., 2014a; Ensink et al., 2014b), a mentalization-based approach to the treatment and care of youth is important to implement in foster care settings. This paper provides an outline and description of a mentalization-based treatment approach along with several clinical tools for caregivers and staff members to implement in the treatment and care of youth in foster care settings.

Predictors of Length of Stay in a Psychiatric Adolescent Treatment Program

Understanding predictors of adolescent inpatient length of stay (LOS) is important in informing treatment outcomes for this age group. The current literature on adolescent LOS remains limited and has been characterized by methodological limitations. In the study described here, we examined a wide range of predictors for LOS in a psychiatric unit for adolescents (N=285), including severity of disorder (previous hospitalizations, self-harm, cognitive impairment and thought disorder, severe depression, history of trauma), types of psychotropic medication, and diagnoses. Our results indicated that LOS is associated with predictors that reflect psychiatric severity—most notably prescription of mood stabilizers and youth-reported internalizing symptoms.