Can Under 18’s be diagnosed with Borderline Personality Disorder?
A Guide to Teen BPD treatment for Parents and Carers.
Borderline Personality Disorder has long been considered a diagnosis that mental health professionals were reluctant to make. It was also a diagnosis that families and young people lived in fear of receiving.
The reluctance in confirming a diagnosis of Borderline Personality Disorder left many young people and families searching for answers. It also prevented even more young people from receiving the treatment, support, and interventions they desperately need.
Fortunately, views on early intervention are changing. Psychiatrists and Mental Health professionals agree that competent treatment in adolescence and early adulthood can significantly change treatment outcomes for young people.
Is my teen exhibiting signs of BPD?
Parents concerned about their children, teenagers and young adults may notice some of the signs and symptoms regularly associated with Borderline Personality Disorder. Parents may see intense and frequent changes in mood, mood swings, impulsivity, increased risk-taking, self-harm, intense relationships, volatile relationships with family and friends, increased anger and rage, thoughts or plans of suicide.
Borderline Personality Disorder or normal adolescent development?
The Pre-teen and Teen years are filled with major developmental changes. The changes that our children experience are physical, social and psychological. There is a shift towards building a sense of identity and developing a ‘core’. A healthy ‘core’ is rather like a steel pole that anchors us to the ground. It allows us to take on ideas, views and shape ourselves whilst remaining grounded and developing a complete sense of self. This is an evolving process throughout the tweens, teens and into the mid-’20s for most young people.
New parents are often warned about three stages of development. The New born exhaustion, The Toddler Challenge and the up’s and down’s of the teenage years.
Not all teenagers experience a tough transition, and not all parents will be worried. Like every other aspect of parenting, some times are more challenging than others. Tweens, Teens and Young Adults are likely to have times when they are more sensitive, more emotionally charged, and feel more irritable.
It’s usual to have some changes in friendships and some periods of overt sensitivity or emotional distress. It’s usual sometimes to push back, challenge or develop skills to challenge parents in a respectful way (and sometimes, without practice, challenges may not feel respectful at all). It is not usual to run away, harm others, break or destroy possessions, skip school or rely on drugs and alcohol. Open discussions relating to your family values; or the non-negotiables will help you find clarity in the behaviours which may be troublesome.
Early Signs of Borderline Personality Disorder
Early Borderline Pathology order wise described as the signs and symptoms of Borderline Personality Disorder in young people under the age of 19 have been seen in clinical research to predict disruption in functioning into adulthood.
Personality Disorders can be seen to gather pace during childhood and adolescence. A Personality Disorder does not appear suddenly or without warning. Parents, families and educators may have noticed early disruptive behaviours, disturbance in emotional regulation, extreme swings in mood, clingy behaviours alternating with dismissive behaviours, unsettled and highly charged emotional friendships. Young people are sometimes described as Emotionally Unstable (Emotionally Unstable Personality Disorder).
A high percentage of young people who demonstrate BPD Traits before age 19 will continue to exhibit BPD symptoms until mid-adulthood.
Early diagnosis, leading to earlier treatment, is a protective factor.
Children and Teens who display early signs and symptoms that may evolve to a diagnosis of BPD should be carefully monitored by Child & Adolescent Mental Health Specialists.
Teen BPD is recognised as an official diagnosis in DSM5
The most recent update to The Diagnostic and Statistical Manual of Mental Disorders, known as DSM5, has extended BPD diagnosis to those under 18. Adolescent Psychiatrists with extensive experience in the treatment and management of Borderline Personality Disorder may consider the diagnosis appropriate in circumstances where there is a pattern of behaviours that is, ‘a pervasive, persistent and unlikely to be a particular developmental stage’.
9 DSM5 Criteria for diagnosis of BPD (shortened version)
- Steps to avoid perceived or real abandonment
- Instability in interpersonal relationships, making and keeping friendships.
- Identity Disturbance/ taking on or borrowing identities/views of others
- Impulsivity and risk-taking
- Self-harm or suicidal thoughts and behaviours
- Affective instability
- feelings of emptiness (or numbness) much of the time.
- Intense anger or rage that often feels difficult to control
- Stress-related paranoid ideation or dissociation
Experiencing five out of the nine criteria is indicative of Borderline Personality Disorder.
Source; APA, 2013
Is there a difference between Teen and Adult Diagnosis?
Whilst the criteria remain the same, your mental health practitioner will be particularly cautious in assessing those under the age of eighteen.
Children and Teenagers can demonstrate higher emotional instability levels and sensitivity, which will be considered in assessments and treatment planning.
Borderline Personality Disorder in Children under 13
Whilst it is technically possible to present with symptoms of BPD in children under 13, it is incredibly unusual and almost unheard of to receive a diagnosis at this age.
Research in community-based studies has shown that ‘BPD-type behaviours’ have been accurately assessed in children as young as 11, which indicates a possibility of the later development and diagnosis of BPD. The research further details that preventative measures, active intervention and behaviour modification, family therapy and a supportive and nurturing treatment plan can significantly reduce the impact.
Parents of Children under 13 with concerns such as those described above should reach out for support and a thorough evaluation of their situation. In the event that a child under 13 self-harms or has suicidal thoughts or actions, urgent help should be obtained from your nearest Child and Adolescent Psychiatrist or Emergency Departments.
Thoughts or demonstrations of suicidal or self-harming behaviour are never ‘for attention and should always be taken seriously.
How common is BPD in Teens and Young Adults?
Borderline Personality Disorder affects approx 3.5% of the general population.
A recent study in Hong Kong estimates a prevalence of 3-11%of the population.
Borderline Personality Disorder is associated with approximately 30% of those seeking treatment in mental health services. The figure that is higher still at around 50% in dedicated adolescent mental health programs.
Those diagnosed with BPD have a 50-fold increase in suicidal behaviours. (Chanen et al, 2008b). 78% of teenagers and adolescents attending the emergency department for suicidal behaviours meet the diagnostic criteria for Borderline Personality Disorder.
Non Suicidal Self Injury or Self – harm is seen in approximately 58% of those diagnosed with BPD.
Source; Greenfield B, Henry M, Lis E, et al. Correlates, stability and predictors or Borderline Personality Disorder among previously suicidal youth. Eur Child Adolescent Psychiatry. 2015 Pubmed.
BPD & Bipolar Disorder
Borderline Personality Disorder and Bipolar Disorder in young people and adolescents are sometimes difficult to distinguish in this age group. Both BPD and Bipolar maybe consider as working diagnosis by your treatment team.
BPD and Bipolar share many similar presentations in young adults and may result in increased instability and self-harming behaviours. This is turn, may impair friendship groups and severely disrupt family and school life. Your clinical team may further investigate mood changes, from elevated to depressed and the young person’s presentation overall.
There has been some promising research into sleep study cycles, with changes noted between the shorter patterns in those diagnosed with BPD and longer sleep periods in those diagnosed with depressed mood and Bipolar.
Complex Trauma and BPD
Complex Trauma or cPTSD, together with PTSD, are often seen in young people who present with BPD traits. Many children and teenagers presenting for treatment have suffered from childhood trauma experiences.
The relationship between cPTSD and BPD continues to be the subject of research. Whilst there are links and similarities, for example, is dissociation, researchers are uncertain on the extent of the relationship between complex and developmental trauma and a later diagnosis of BPD.
Trauma-focused care is essential for young people in all settings.
Teens and BPD. A voice to be heard.
The Wave is a specialist program dedicated to the treatment of Teenagers and families who experience BPD themselves or within the wider family system. Ou young people are keen to be seen and heard. BPD does not define them. BPD does not stand in the way of education, volunteering, nor making friends.
‘As my coping skills go up, my self-harm goes down. For ages, it was the only way I had to show how sad and angry I felt.’
‘I am so scared of losing people. When I make friends, it feels like they are my whole world; it’s more than scary to think I will lose them and be on my own again.’
‘I somehow believed that I would always be on the outside. I hated myself; that’s one of the reasons that I cut. I am learning to be part of a group. It is nice being part of something.’
‘My mum says that my temper scares her. To be honest, it scares me too. I feel red inside my head and say and do things without thinking. I am learning that ‘I’m not my emotions’
‘Depression and anxiety are hard for me. I seem to feel things much more strongly than others’
‘Sometimes I feel like if I lose control, I will lose everything. It has made me a bit bossy and angry at home, especially with my sisters’
Teenagers who have been diagnosed with BPD need to be heard and validated, like every other teenager.
Specialist BPD Treatment Programs for Teens
Young people demonstrating traits of BPD are notoriously difficult to engage in treatment. Treatment services need to be tailored to their increased needs and risk profiles. Adolescents and young adults (even those over 18) tend to do poorly in adult treatment programs. Young adults and teenagers need specific adolescent interventions and therapy that meets their needs emotionally and developmentally.
The Wave is home to a specialist BPD program. The clinical expertise therapies that are evidence-based for the management of BPD greatly improves the rate of positive treatment outcomes. DBT, EMDR, IPT and Trauma-focused practice together with social skills training are recommended in the treatment of BPD. Group therapy and the ability to process big emotions in a community setting are essential in treating BPD. Positive interpersonal relationships and the ability to resolve conflict without escalation are often a treatment goal in managing BPD in Teens and Young Adults.
Treatment Programs and admissions relating to BPD and co-occurring conditions can be predicted to belong to terms of admissions. Successful admissions into treatment programs often follow situations that have led to crisis intervention or Emergency Department interventions.
Disengagement or dropout rates recorded for young people diagnosed with BPD in outpatient and residential treatment approach 60-70%. This is both dangerous and costly, as untreated BPD accounts for repeated Emergency room attendance and social care interventions. In contrast, specialist treatment programs and in particular, The Wave Programs in Kuala Lumpur, have a 100% completion rate across BPD programs.
Adolescents diagnosed with BPD often experience periods of lifelong change when they benefit from a great treatment experience.
The Family and BPD. How can families help?
Read, read and read some more. It is great to keep yourself informed from reliable sources. There are many excellent books offering support for parents in all stages of diagnosis and treatment. Join BPD for Families support group and networks. It great to listen and share.
Helping Your Troubled Teen: Learn to Recognise, Understand, and Address the destructive behaviours of Today’s Teens. Kaplan Cynthia. PhD Blaise A Aguirre MD and Michael Rayer MD Fair winds 2007
Consistency and collaboration in parenting are key. Address problems as they occur, calmly and directly. Look at the patterns that may have appeared within the family. Does one parent defer decisions to the other? Are there times when you change or reverse decisions involving your child? Do you respond to threats by giving in or altering the decision-making process? Do you feel disempowered in parenting? Working as a family will help you feel supported and heard and provide the foundations for building better family relationships.
Seek family therapy or couples counselling to support you and your partner. Parenting under stress can leave cracks appearing in relationships.
Look at any inconsistencies and work together to provide unified parenting. If your partner (ex-partner) or the other parent does not share full-time parenting, seek help early on to establish clear, achievable boundaries for both parents. Take extra care to support each other and leave no room for the young adults to ‘divide and rule’. Keep your opinions of the ‘other’ parent as material for your own therapy; your child cannot process Mum or Dad’s perceived shortcomings. Discussing adult business can feed the fear of rejection and abandonment in young people.
Be clear and be Direct, loving, firm and fair. Only set boundaries and implement changes that you are sure that you can follow through with. Changing the goalposts can be destabilising and is particularly difficult for this group of young people.
Do not tolerate verbal or physical abuse: blackmail, threats and unpleasant behaviour. Remove yourself from the situation. Encourage regulation by not responding to threats or demands.
Encourage routines. Schedules and clear instructions are key.
Encourage long term engagement in treatment with realistic goals and tackle each new challenge in small steps.
Experience is key. Engage professionals who have extensive experience and specific training in BPD and who able to use a variety of approaches in treatment. Finding a treatment team who you connect with is incredibly important. Treatment can be a long and rocky road; you need a team that you feel will support you on all terrains.
Borderline Personality Disorder is complex, and diagnosis is simply one of the steps in a journey that, if navigated correctly, can be the beginning of more understanding, connected and loving family relationships.
Fiona Yassin is the International Clinical Director at The Wave Clinic in Kuala Lumpur, working with teens, young adults and their families. Fiona is a UK registered Psychotherapist and Supervisor of Clinicians. EMDR trained and a member of EMDRIA, Fiona recognises the role of complex trauma in eating disorders and is currently developing Trauma-Focused Eating Disorder Services in Asia and the Middle East. Fiona is an International Chapter member of IAEDP, CBT-E, and RO-DBT trained. Fiona is also a Fellow of APPCH, and she loves her cats 🙂