Title: Brief Education Supported Treatment (BEST) for adolescent borderline personality disorder: A feasibility study of delivery of specialised, early intervention for borderline personality disorder through collaboration with education providers, incorporating a feasibility randomised controlled trial
Funder: Department of Health and Social Care

Abstract: Background: There is an urgent need for accessible interventions to address the growing prevalence of symptoms of borderline personality disorder (BPD), including self-harm, among young people. Current evidence-based interventions for adolescent BPD are not feasible within the NHS context, meaning few young people with BPD access appropriate treatment. Norfolk Youth Service’s brief treatment package for adolescent BPD, which distils key components of evidence-based treatments into 3-6 sessions, has the potential to be delivered within schools/colleges by non-specialists to meet growing demand. Aims: To refine the intervention to ensure it can be successfully delivered within schools and colleges, and to assess the feasibility of evaluating its effectiveness and cost-effectiveness in a randomised controlled trial. Intervention: BEST for adolescent BPD is a psychosocial intervention designed to decrease emotion dysregulation, by enhancing the capacity of both young people and the adults who support them to use mental state concepts to interpret and direct behaviour, and manage distress using self-care strategies. The intervention is grounded in the neurodevelopmental literature on social cognition and incorporates elements of Dialectical Behaviour Therapy for Adolescents and Mentalisation Based Treatment for Adolescents. Following a full-day preparatory workshop, education staff members co-deliver the treatment package to individual participants from their institution in partnership with a child and adolescent mental health service (CAMHS) practitioner. Through this experience, school/college staff members are equipped with the knowledge and skills to provide ongoing support. Design: Stage 1 comprises a rapid evidence synthesis of the barriers and facilitators to the implementation of interventions for clinical case level mental health problems within schools/colleges and piloting of the intervention with six participants, following which the intervention manual will be finalised. Stage 2 will be a feasibility randomised controlled trial involving six to eight schools/colleges. Eligible young people (n=60) will be randomised in a 1:1 ratio to receive either the BEST for adolescent BPD intervention plus treatment as usual or treatment as usual alone. Participants will be assessed by a blinded assessor at baseline and at 8 and 24-weeks follow-up. A parallel process evaluation will generate understanding of intervention implementation and explore how the intervention is experienced by young people and staff. Participants: Pupils aged 13-18 who score above the clinical cut-off on the Borderline Personality Features Scale for Children and report current self-harm. Referrals will be accepted from participating schools/colleges and CAMHS. After giving informed consent, pupils will be screened to ensure they meet the inclusion criteria. Outputs: The primary output of the feasibility study will be the decision whether to progress to a definitive RCT. Criteria for progression include recruitment and retention rates within 70% of target, satisfactory treatment concordance (at least 70% of those randomised to receive the intervention attend three or more treatment sessions) and limited contamination of the control arm (monitored via the process evaluation). If these are not met, alternative designs will be considered. Key interim outputs will include the finalised intervention manual, and publication of the trial protocol and rapid evidence synthesis.

Lay abstract: Borderline personality disorder (BPD) is a severe mental health problem characterised by unstable emotions, intense but difficult relationships, disturbed sense of self and impulsive behaviour such as self-harm and suicide. BPD usually begins during adolescence and continues into adulthood, often with devastating personal, social and economic consequences. The prevalence of BPD in adolescence is estimated at 3%: approximately one child in every classroom. Although there are effective treatments for BPD, few individuals are able to access these treatments, and often only after they have been experiencing distressing and disabling symptoms for many years. The aim of this study is to investigate whether it is possible to deliver early, specialised support to young people with symptoms of BPD including self-harm through working in partnership with schools and colleges. Self-harm in young people has increased alarmingly in recent years. This increase is overwhelming schools and colleges who are inadequately supported to meet the needs of pupils with the most severe mental health problems due to poor integration between education and health services. This study investigates a brief intervention that aims to equip education professionals with the knowledge and skills to support pupils with symptoms of BPD including self-harm. Staff from participating schools and colleges will take part in a training workshop in preparation for co-delivering a series of 3 – 6 sessions to individual pupils from their institution together with a CAMHS professional. Sessions are informed by existing evidence-based treatments for adolescent BPD and are designed to help young people understand the problems they are experiencing and learn to manage them better. The intervention is designed to reduce BPD symptoms by decreasing the emotional instability at the heart of the disorder, both by: (a) delivering the key elements of evidence-based interventions for adolescent BPD at an early stage, before symptoms become entrenched, and (b) reducing the confusion and anxiety that often surrounds young people with BPD who self-harm by equipping education professionals with the knowledge and skills to support pupils with BPD. In the first stage of the study, we will use the findings of existing research to refine the intervention and pilot it within schools and colleges. In the second stage, to test whether it will be possible to evaluate the effects of the intervention in a fair and unbiased way, participants will be allocated at random to either receive the study intervention or standard care. Young people aged 13-18 years with symptoms of BPD including self-harm will be invited to take part and, if they consent, will be screened to ensure the study is suitable for them. All participants will be offered an assessment of their mental health with a study research assistant on entry to the study and 8 and 24 weeks later. Participants will also be invited to take part in in-depth interviews to help us understand their experience of taking part in the study. In addition, school and college staff will be asked to log the contacts they have with participants during the study and detailed observations will be carried out at each school and college to understand how the intervention is delivered in differing institutions. The results of the study will be shared with participating schools and colleges and will be used to inform the design of a future study evaluating whether the intervention leads to improved outcomes for young people.

Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH