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Review                                                                                                                                                     Open Access

## Personality Disorder in Childhood and Adolescence comes of Age: a Review of the Current Evidence and Prospects for Future Research

Mickey T. Kongerslev 1,2* , Andrew M. Chanen 3,4 , Erik Simonsen 1,5

1 Psychiatric Research Unit, Region Zealand, Roskilde, Denmark 2 Psychiatric Clinic Roskilde, Region Zealand, Roskilde, Denmark 3 Orygyn, the National Centre of Excellence in Youth Mental Health, Melbourne, Australia 4 Centre for Youth Mental Health, the University of Melbourne, Australia

5 Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark

*Corresponding author:

psymtk@me.com

## Abstract

In this article, the authors provide a narrative review of the mounting evidence base on personality disorder in childhood and  adolescence.  Topics  covered  include  diagnostic  validity,  prevalence,  developmental  issues,  comorbidity,  risk  and protective  factors,  and  treatment.  Novel  indicated  prevention  and  early  intervention  programs  for  borderline  personality disorder in adolescence are given special priority. To conclude, directions for future research are provided.

Keywords : personality disorder; adolescence; diagnosis; early intervention; developmental psychopathology; psychotherapy; prevention

## Introduction

Until recently, personality disorder (PD) was considered separately from other mental state disorders as a special and intractable form of adult mental  disorder with a primarily  environmental aetiology and a treatment refractory course (1,2). To paraphrase the Danish philosopher Søren Kierkegaard (3), it was as if PD was a sickness unto death. Fortunately, such beliefs-together with the associated  therapeutic  nihilism-have  now  been dispelled  by  empirical  research.  In  adult  mental health,  PD  is  now  widely  recognized  as  a  major mental disorder that is associated with severe psychosocial  dysfunction  and  poor  quality  of  life. Moreover, PD has come to be considered treatable and, in some  cases, even to remit (4,5). This heightened recognition of PD is also reflected in the international proliferation of official treatment guidelines (6-9).

For decades, there has been general agreement, as reflected in the official diagnostic manuals, that PD has its onset at least by adolescence or early adulthood  (10,11).  By  implication,  this  develop- mental perspective on PD opens up the possibility of identifying PD  among  children and young people. Historically, however, PD during childhood and  adolescence has been  a neglected area of empirical  research  and  surrounded  by  controversy (12-17).  Fortunately,  research  on  PD  in  childhood and  adolescence  has  flourished  over  the  past  two decades  and  shed  light  on  many  of  the  persistent clinical controversies and myths that surround these syndromes.

Despite the remarkable scientific progress of the past two decades, skepticism, unease, and misunderstanding  with  regard  to  PD  diagnoses  in adolescence seem to continue among some clinicians (18-21).  Hence,  a  major  goal of this special  issue  of  the  Scandinavian  Journal  of  Child and  Adolescent  Psychiatry  and  Psychology  is  to increase researchers' and clinicians' awareness of the validity  and  importance  of  PD  during  adolescence so  that  it  might  be  more  readily  identified  and treated. We hope that this article, which reviews the current  evidence  base  and  offer  suggestions  for future  research,  will  help  to  ease  some  of  these concerns by highlighting key research findings.

## Synopsis Research Findings

## Diagnosing personality disorder in children and adolescents

A source of controversy and misunderstanding has been  whether  PD  diagnoses can be  made  or  are permitted for  children  and  adolescents.  A  common misperception among mental health professionals is that  the  official  diagnostic  systems-the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (10) and the ICD-10 Classification of Mental and  Behavioural  Disorders (11)-do  not  permit  PD diagnoses for individuals who are younger than 18 years (21). One possible reason for this misunderstanding is the ambivalent and contradictory  phrasing  employed  in  the  DSM-5 (Section  II)  and  the  ICD-10  with  regard  to  the diagnosis  of  PD  in  this  age  group.  Despite  the conceptualization of PD as a developmental disorder that usually has its onset by adolescence or early adulthood, the DSM-5 notes that PD diagnosis for individuals who are less than 18 years old should only be considered in 'relatively unusual' circumstances (10) and ICD-10 considers the applicability  of  PD  diagnoses  in  adolescence  to  be 'highly  unlikely'  (11).  The  only  exception  to  the allowance  of  diagnosing  PD  below  age  18,  is  for antisocial  PD,  in  the  DSM-5,  Section  II,  which explicitly  requires  individuals  to  be  18  years  or older.  Hence,  despite  allowing  for  PD  diagnoses among individuals  who  are  less  than  18  years  old, the  use  of  such  wording  by  the  official  diagnostic systems effectively discourages the use of this diagnosis. The DSM-5 confuses matters further by stating  that  the  features  of  a  PD  only  need  to  be present for one year when applying PD diagnoses to individuals  who  are  less  than  18  years  old.  This seems too short a period to accurately distinguish a mental state disorder from a PD (22). The division of the diagnostic manuals into separate sections on child and adolescent disorders versus adult disorders further contributes to the confusion. PD is  not  mentioned  in  the  former  but  appears  in  the latter, with little account of its developmental origins and manifestations. The ICD-10 labeling of PDs as 'Disorders of adult personality' is a case in point. As we demonstrate later in this review, such ideas  enshrined  in  the  current  diagnostic  manuals can  no  longer  be  supported.  Section  III  of  the DSM-5  and  the  forthcoming  ICD-11  both  reflect the  progress  made  in  understanding  the  reliability and validity of PD diagnoses (22) in childhood and adolescence,  supporting  the  feasibility  of  their  use and recognizing that they are as reliable and valid in young people as they are for adults (23-33).

## Prevalence

Few studies have investigated the prevalence of PD in adolescence, and virtually none have looked at its prevalence  in  childhood.  Extant  studies  have  also used different sampling and assessment procedures. Accordingly,  the  prevalence  data  reviewed  in  this paragraph  are  at  best  tentative.  The  prevalence  of PD in adolescent community samples and primary care  settings  generally  ranges  from  6%  to  17% across studies (34). An exception to these estimates was  a  study  by  Lewinsohn  and  colleagues  (35), which found a low prevalence of PD  in the community  (1.7%  among  participants  without  and 3.8%  among  participants  with  a  history  of  other mental  disorders).  The  relatively  low  prevalence estimates in this study are probably a result of the researchers using the International Personality Disorder Examination (IPDE) (36) for assessments, which  required  PD  features  to  be  present  for  5 years, even in young people.

Prevalence  estimates  in clinical  samples  range from 41% to 64% (27,37), and from 36% to 88% in juvenile  justice  samples  (38-40).  These  prevalence estimates are similar to or slightly higher than those reported for adults (41-43). The peak prevalence for PD  is  reported  to  occur  during  early  and  middle adolescence (23,44), whereas studies that have focused  on  late  adolescence  have  obtained  lower prevalence estimates comparable to those reported for  adults  (34,45).  Consistent  with  these  findings  a community-based  longitudinal  study  of  PD  trait levels found that PD peaks in early adolescence and subsequently  declines  in  a  linear  fashion  until  the late 20s (46).

Additionally, studies have shown that, as in adult populations, the co-occurrence among specific PDs is frequent in adolescence (37,39,47,48). In terms of the DSM-5, Section II, grouping of PDs into three clusters on  the basis of descriptive similarities, Cluster  B  PDs  appear  to  be  the  most  prevalent during  adolescence  (27,46),  a  finding  that  again converges with data for adult populations (49).

## Continuity and change in personality disorder

Concerns about the temporal course of personality development are one possible source for the reticence of some clinicians to make PD diagnoses in  adolescence.  However,  contemporary  research has shown that personality development is a lifelong process,  with  no  sudden  changes  occurring  at  age 18, and that personality stability and change coexist across the life course (22). From a research perspective,  there  are  multiple  ways  to  concept- ualize  the  temporal  course,  continuity,  and  change of personality and its disorders throughout  the life span  (50-52).  Here,  we  focus  on  the  three  most common  methods  used  to  do  this:  1)  rank-order continuity, 2) mean-level change, and 3) diagnostic stability.

Rank-order continuity or differential continuity refers to the  consistency  of  the  relative  order  of  individuals on  a  given  PD  dimension  or  symptom  over  time, typically  expressed  as  a  test-retest  correlation.  The rank-order stability of PD symptoms in adolescence and  early  adulthood  has  typically  ranged  from  .42 to .65 in longitudinal studies, thus indicating moderate  to  high  stability  (53,54).  A  longitudinal study  that  focused  specifically  on  borderline  PD features in childhood (in fourth through sixth graders)  also  reported  moderate  stability  (55).  A recent  meta-analysis  broadened  these  findings  by showing that the rank-order stability of maladaptive personality  traits  and  PD  symptoms  is  moderately stable across childhood, increases in stability during early  adolescence,  and  peaks  in  stability  at  around the age of 30 years (56).

Mean-level change addresses the increase or decrease in  the  average  trait  level  of  the  population  as  a whole.  Studies  of  mean-level  change  indicate  that mean  levels  of  PD  symptoms  peaks  during  early adolescence  and  then  decline  throughout  middle adolescence, reaching levels comparable with those of  adults  in  late  adolescence  or  early  adulthood (34,46,54).  Prospective  studies  also  show  that  the deviation of maladaptive personality traits increases from late adolescence to early adulthood (53,57,58). This  could  indicate  that  the  significance  of  PD symptoms  changes  over  time  in  relation  to  salient life  tasks  and  environmental  demands  (53,58-60). Data  from  large  community  samples  suggest  that specifically for borderline PD, mean  levels of severity  scores  remain relatively  stable  for  the  ages of 14 through 17 (61,62).

Diagnostic stability concerns the continuity of categorical PD diagnoses over time. Studies estimating the diagnostic stability of specific PDs in childhood and adolescence have generally reported low to moderate stability over time (23,24,34, 61,63,64); this could be conservatively interpreted as indicating modest diagnostic stability during adolescence (65).

How can we reconcile these research findings? To be  sure,  the  issues  surrounding  the  continuity  and stability of PD are complex and unlikely to be easily resolved,  for  a  number  of  reasons  (66).  First,  we contextualize the results. Although diagnostic stability  is  low  to  moderate  in  adolescent  populations,  this  is  also  the  case  in  adulthood.  A  major finding from prospective follow-up studies of adult patients diagnosed with PDs  is that diagnostic continuity is low to moderate, and that  some patients even 'remit' (22,51,67,68). However, diagnostic remission does  not necessarily imply functional recovery (69). Indeed, most adult patients with  PD  who  have  been  followed  up  for  years remain  significantly  functionally  impaired  (5,67,7073).  Persons  displaying  PD  symptoms  below  the threshold for a categorical diagnosis are considered to have  remitted  diagnostically,  but  they  might continue to have clinically significant levels of subthreshold personality pathology. Accordingly studies show that individuals diagnosed with PD in adolescence  often  still  have  elevated  PD  traits  in adulthood (46,74). Also, individuals with  persistent impairments  might  change  from  one  diagnostic category to another over time (74), perhaps indicating 'heterotypic continuity' -that the underlying developmental and pathological processes  remains  the  same  despite  changes  in phenotypic presentation (16,75-77). Overall, the bulk  of  current  research  converges  on  demonstrating that persons diagnosed with PD in adolescence  continue  to  have  serious  functional impairments well into adulthood (23,53,78,79).

Second, the framework of developmental psychopathology (80,81) implies the findings can be interpreted in light of results from normal personality development. Research has convincingly demonstrated that normal and abnormal personality are part of the same spectrum, and display a similar higher-order factor structure across age groups (22,82-87). However, Western folk psychology generally  views  children  and  adolescents  as  having personalities that are unstable or 'under construction' whereas adult personalities are perceived as relatively unchanging (51,88). Research into normal personality development has challenged these  assumptions  by  demonstrating  that  normal personality traits in  childhood  and  adolescence, despite fluctuations within certain lower-order domains, are more stable than would commonly be expected, and also more stable than PD symptoms (87,89-92). Furthermore, contrary to common expectations,  research  reveals  that  normal  personality  undergoes  normative  changes  throughout  the entire lifespan (93). Hence, some degree of development  and  change  in  personality  is  to  be expected  throughout  the  life  course,  as  a  result  of the complex interactions between heritable dispositions and the environment (94-99).

Third, it should be recognized that most longitudinal  data  on  PD  from  childhood  through adulthood  stem  from  only  one  large  prospective follow-up  study,  the  Children  in  the  Community (CIC)  Study  (53),  and  needs  to  be  replicated  (98). However,  the  findings  of  the  CIC  are  consistent with cross-sectional prevalence studies of  PDs during  early  adolescence;  results  from  studies  of normal  personality  reporting  age-related  decreases in  negative  traits  (51,100,101);  and  with  findings from large-scale epidemiological studies which indicate  that  the  onset  for  many  common  mental health  disorders  peaks  during  adolescence  (102104). Given the continuity between PD criteria and normal personality traits, the research findings also beg the question of whether developmental changes in  PD  symptoms  are  part  and  parcel  of  the  same process  as  the  one  that  drives  normal  personality changes.  Finally,  it  should  be  noted  that  other methodological issues relevant to understanding the PD  continuity and change across the lifespan include the use of different assessment instruments and measurement error (56,98,105-109).

To  summarize,  the  current  evidence  shows  a predictable  pattern  of  stability  and  change  in  PD across  the  life  course.  PD  seems  to  change  from childhood  through  adulthood  in  similar  ways  to normal-range personality (22). In adolescence, as in adulthood, the rank order stability of PD  is moderate  to  high,  whereas  diagnostic  stability  is low. The stability of functional impairments associated  with  PD  is  high  across  the  lifespan. There is no sudden increase in trait stability in the transition from the second to third decade of life.

## Co-occurrence

Research on PD in adults has consistently demonstrated  that  these  conditions  frequently  cooccur  concurrently  and  prospectively  with  a  wide range  of  other  mental  state  disorders  (110-112). This co-occurrence accounts for increases in impairment  and  treatment  needs,  higher  rates  of treatment  seeking,  poorer  prognosis,  and  greater chronicity (113-117).

Studies  examining  patterns  of  co-occurence  in adolescent samples reveal that PD co-occur frequently  with  other  mental  disorders,  such  as affective  and  disruptive  behavior  disorders,  posttraumatic  stress  disorder  (PTSD),  eating  disorders, substance  abuse,  anxiety  disorders,  and  psychosis spectrum  disorders  (37,53,114,118-122).  Research also  suggests  that  adolescent  in-  and  outpatients with co-occurring PD and mental state disorders are substantially  more  impaired  than  those  with  only mental state disorders (28,118), and tend to display the  most  complex  patterns  of  comorbidity  (120). Moreover, PD co-occuring with other mental disorders  in  adolescence  has  been  prospectively linked with elevated mental health service use, and elevated use of prescribed psychotropic drugs during  early  adulthood  (123).  The  presence  of  PD together with other  mental disorders is also a significant predictor of poor quality of life (124).

Data  from  the  CIC  Study  have  revealed  that adolescents with co-occurring PD and other mental disorders have worse long-term prognoses for academic, occupational, and interpersonal functioning  when  followed  for  a  period  of  more than  20  years  (53,65,74).  With  regard  to  mental health outcomes, the CIC Study found that adolescents with co-occurring PD and mental state disorders had more severe current psychopathology and  an  almost  nine-fold  increase  in  the  risk  for future development of psychiatric disorders as compared  with  individuals  with  no  disorders  or those  with  only  PDs  or  other  mental  disorders respectively  (114).  Additionally,  reviews  of  major longitudinal  studies  suggest  that  PD  co-occurring with other mental/behavioral disorders in adolescence increases the likelihood of PD continuing or worsening during young adulthood by up  to  19  times  and  that  it  is  more  likely  that improvement in PD leads to improvement in other co-occurring disorders than vice versa (51,53,57,65).

## Adverse outcomes and adaptive functioning

Consistent with the literature on PD in adults (125127), the presence of PD in adolescents is concurrently  and  prospectively  associated  with  an elevated risk for suicidal ideation and suicide attempts in early adulthood (128-130). Psychological autopsy studies of completed suicides among adolescents support these findings. One  study found  that PDs-especially  those  belonging to Cluster  B  and  Cluster  C-were  more  common among  suicide  victims  than  community  controls (131). This is consistent with another psychological autopsy study, which also reported a large proportion of PDs among suicide completers; notably the investigators found that borderline PD was present in 33% of the cases (132). PD during adolescence is also associated with non-suicidal selfinjurious behavior such as cutting and burning (133135).

PD  in  adolescence  predicts  conflictual  romantic relationships  (136),  problems  in  friendships,  poor educational achievements, problems at work (23,74,114,137,138), and problems with family members in early adulthood (34). PD in adolescence is  also  associated  with  high-risk  sexual  behaviors and a high number of sexual partners (139). Cluster A  and  Cluster  B  PDs  in  particular  have  been prospectively linked with an increased risk of violent  and  criminal  behaviors  in  the  community, during both adolescence and early adulthood (140,141).  Cluster  A  PDs-most  notably  schizotypal PD-in  childhood have been found to increase  the  risk  for  more  severe  schizophrenia spectrum disorders in adulthood (64), thereby reinforcing the view that Cluster A PDs, at least in some  cases,  may  represent  developmental  precursors  or  prodromes  to  psychosis  and  schizophrenia spectrum disorders (53).

Studies find that adolescents with borderline PD report  significantly  more  mental  health  service  use as compared with healthy controls (142). Borderline PD in early adolescence also prospectively predicts low  social  functioning  and  life  satisfaction,  fewer attained adult developmental milestones, and lower academic and occupational attainment, independent of other psychiatric disorders and  despite agerelated  borderline  PD  symptom  decline  over  time (74). Finally, PD in adolescence significantly reduces concurrent and future quality of life (124,143), and increases  the  risk  of  unnatural  and  violent  death amongst offenders (144).

## Risk and protective factors

Until the last 15 years, most developmental studies of PD focused on early childhood experiences and how they affect later adult psychopathology. Although early childhood experiences are important, their effects on future development and outcomes are likely to be mediated or even reversed by later experiences (22,145), and there are currently only limited data to inform us about these processes. With regard to 'distal' risk factors, most data come from the CIC Study. Low socioeconomic status in the family of origin, being raised by a single parent,  receiving  family  welfare  support,  frequent parental conflicts, and parental illness or death have been identified as prospective risk factors for future development  of  PD  (53,65).  Maladaptive  family functioning and parenting, including low emotional closeness  between  parent  and  child,  use  of  harsh punishment during childhood, maternal overcontrol,  and  parental  psychopathology,  have  also been found to precede the later development of PD (53,65,146-148). Childhood  sexual,  physical,  and verbal abuse and childhood neglect increase the risk for development of PD in adolescence and adulthood (65,147,149-152).

Early disruptive behavior disorders-especially conduct  disorder  but  also  attention-deficit/hyperactivity  disorder  (ADHD)  and  oppositional  defiant disorder-are strong long-term predictors for most types of PDs (35,65,153-158). The available research  evidence  indicates  a  link  between  ADHD in childhood and heightened risk of borderline PD in adolescence and early adulthood (158-160). Such findings might  suggest that similar or identical phenomena  (e.g.,  impulsivity  and  aggression)  may be misleadingly characterized as mental state pathology  in  children  and  then  later  relabeled  as personality pathology in adolescence and adulthood (161).

With regard to antisocial PD, the DSM-5, Section II, requires evidence of conduct disorder with onset before age of 15 years, in order for this diagnosis to be considered applicable to persons aged 18 years or older.  The  available  research  evidence  supports  to some  extend  this  notion  of  conduct  disorder  in childhood and adolescence as a developmental precursor to antisocial PD (162-164). Yet, it should be noted that conduct disorder is also prospectively associated with a wide range of other mental disorders, including other specific PDs. Hence, the predictive value of conduct disorder does not appear to be limited to antisocial PD, but rather to a broad  range  of  psychopathology  including  other specific PDs, primarily from Cluster B PDs (153,154,156,162).  Within  the  externalizing  spectrum of disorders, substance use disorders (particularly alcohol abuse) have also been identified as  predictors  of  early  adult  borderline  PD  (165). With regard to internalizing disorders, major depression  and  anxiety  disorder  in  childhood  has been prospectively linked with a heightened risk of developing  PD  during  young  adulthood  (155,156). Symptoms of social anxiety have also been directly linked with avoidant PD (53,155), and some investigators  argue  that  generalized  social  phobia and  avoidant  PD  are  not  separate  disorders  but rather part of a single spectrum (53).

Few  studies  have  investigated  PD  in  childhood and  adolescence  as  a  predictor  of  adult  PD  using prospective longitudinal designs. However, the available  studies  indicate  that  PD  symptoms  in childhood  and  adolescence  are  the  strongest  longterm predictors of PD diagnoses in adulthood, over and above other predictors such as disruptive behavior disorders and depression (23,25,53,55, 74,78,155).

Few  studies  have  examined  the  perinatal  factors associated  with  PD.  However,  for  schizotypal  PD, and  to  some  extend  also  schizoid  PD,  studies suggest links with prenatal malnutrition, exposure to prenatal stress, and influenza (166).

There is little empirical knowledge about resilience  and  protective  factors  for  PD  (167,168). One study has investigated the association between retrospective accounts of positive childhood experiences related to resiliency among adult patients  with  PD  and  prospective  remission  from avoidant, schizotypal, borderline, and  obsessivecompulsive  PD  over  the  course  of  4  years  (167). This study found that positive achievement experiences were significantly associated with remission  from  avoidant  and  schizotypal  PD.  In addition, various  types of positive interpersonal relationships  were  associated  with  remission  from avoidant, borderline, and schizotypal PD. For obsessive-compulsive PD, they found no significant predictors of remission, which the authors speculate could be due to the generally higher functioning of this group. Although competent parenting is considered important for the fostering of resiliency, perceived  caretaker  competence  variables  in  this study were not found to be broadly associated with remission. The more general finding from the study was that the greater the number of positive experiences  and  the  broader  the  developmental periods  they  spanned,  the  better  the  prognosis  of the individuals with PDs (167).

## Treatment: Prevention and early intervention

Whilst diagnosing PD during adolescence is evidence  based  and  feasible,  there  would  be  little point  in  doing  so  unless  corresponding  treatments were available. The empirical evaluation of treatments has been slow to develop, but this is now changing.

Prevention and early intervention :  The available data on PD in adolescence makes a compelling case for the development  and  implementation  of empirically based  prevention  and  early  intervention  programs (161,169,170). Like other forms of psychopathology, PD interferes with normative development  and  adaptation.  PD  can  have  severe repercussions,  and  its  developmental  disruptions have  cascading  effects  (171-173)  that  potentially alter  or  divert  the  entire  course  of  development (174).  Prevention  and  early  intervention  programs hold  the  promise  of  not  only  alleviating  present difficulties but also potentially averting future negative outcomes through targeting PD pathology before it become more ingrained and chronic (175).

Chanen and colleagues (161,169,176) have argued for applying preventive and early intervention strategies to PD during childhood and adolescence following the general framework for prevention of mental disorders outlined by the Institute of Medicine (177). An advantage of this framework is that  it  is  not  specifically  concerned  with  aetiology, onset,  and  incidence-matters  of  which  we  only have limited knowledge-but rather focuses on risk factors associated with the persistence and maintenance of these disorders. Such a framework suits  our  current  knowledge  and  understanding  of PD. Chanen and colleagues argue that the available data do not yet support universal population based or  selective  risk-factor  based  prevention  programs. Instead,  they  argue  that  indicated  prevention  and early  intervention  are  currently  the  most  feasible strategies (161,170,176). In contrast with conventional treatment programs that target individuals  with  established  PD  (i.e.,  those  who meet the full criteria), indicated prevention programs target children and adolescents who display  precursor  signs  and  symptoms  associated with  PD  (i.e.,  those  who  display  some  but  not necessarily  all  of  the  required  PD  criteria).  Early intervention  programs  aim  for  the  early  detection and treatment of the full-syndrome disorder. Consistent with knowledge  on the course and development of PD, indicated prevention and early intervention  programs  should  not  just  target  the diagnostic  features  of  PDs,  which  might  naturally attenuate  over  time;  rather,  they  should  aim  to improve adaptive functioning and alter the developmental  trajectory  of  PD.  Furthermore,  it should be noted, that not all treatment that occurs for  individuals  who  are  less  than  18  years  old  by definition is prevention or early intervention (161,169,178).  For  example,  it  is  possible  to  see  a 15-year-old child with many  years of enduring personality  pathology  who  is  in  need  of  standard treatment,  and  it  is  also  possible  to  see  a  nevertreated 24-year-old adult with subsyndromal personality  pathology  who  is  in  need  of  indicated prevention.

Treatment programs: In adult populations, psychotherapy remains the treatment of choice for PDs  (179,180),  although  most  of  the  evidence  is limited to borderline PD and antisocial PD. Similarly, treatment research on PD in adolescence primarily  focuses  on  borderline  PD,  with  most  of the studies combining indicated prevention (subsyndromal  cases)  and  early  intervention  (fullsyndrome  disorder). Of  note, only two  studies (181,182)  explicitly  included  participants  who  had never before been treated for borderline PD (early intervention).

Three  randomized  controlled  trials  (RCTs)  have been conducted to assess the effectiveness of cognitive  analytic  therapy  (CAT)  for  adolescents with borderline PD. CAT is an integrative and timelimited form of psychotherapy that combines object relations  theory  with  cognitive  psychology.  The initial  study  (181)  compared  the  effectiveness  of adding  up  to  24  sessions  of  CAT  to  the  Helping Young People Early (HYPE) program (183) versus manualized good clinical care (GCC). Seventy-eight participants  between  the  ages  of  15  and  18  years who  fulfilled  two  to  nine  DSM-IV  borderline  PD criteria completed the trial. No significant differences between the two treatment groups with regard to predetermined outcomes were found at 24 months.  However,  participants  in  the  CAT  group improved  more  rapidly.  No  adverse  effects  were observed for either treatment. Using a quasiexperimental design, this research group later compared  the effectiveness  of  CAT  and  good clinical  care  (GCC)  as  determined  by  their  RCT with historical data on treatment-as-usual (TAU) in their  clinic  (182).  Results  from  this  study  revealed that  both HYPE with CAT and HYPE with GCC were more effective than TAU and that HYPE with CAT was the most effective. Recently, a pilot RCT (184)  have  also  been  conducted  to  investigate  the feasibility of treating co-occurring first-episode psychosis and borderline PD in adolescents with a hybrid  treatment  model  that  mixed  elements  from the  HYPE  with  CAT  program  with  a  specialized first episode psychosis  treatment  program.  The preliminary  results  were  promising,  suggesting  that the brief hybrid intervention program was safe and acceptable to this complex subgroup of adolescent patients.

Mentalization-based  treatment  (MBT)  has  also been  adapted  for  adolescents  (MBT-A)  (185-187). An  RCT  (188)  included  80  adolescents  (73%  of whom  met  full  diagnostic  criteria  for  borderline PD) who consecutively presented to mental health services with self-harm and co-occurring depression. Participants were randomly assigned to MBT-A  or  TAU  (not  manualized).  MBT-A  is  an attachment and psychodynamically oriented treatment  program  comprised  of  weekly  individual therapy  sessions  and  monthly  MBT family groups. Results  indicated  that  MBT-A  was  more  effective than  TAU  for  reducing  self-harm  and  depression and that the superior effectiveness  of MBT-A was explained by improvements  in mentalizing and borderline PD features as well as reduced attachment  avoidance.  Further  studies  of  MBT-A are underway to investigate the efficacy and effectiveness of this treatment for adolescents with borderline PD (187,189,190).

Dialectical  behavior  therapy  (DBT)  is  another treatment that has been implemented for the treatment  of  suicidal  and  self-harming  adolescents (DBT-A) displaying features of borderline  PD (191,192).  DBT  is  a  modified  form  of  cognitivebehavioral therapy that combines cognitivebehavioral therapy techniques for emotion regulation and reality testing with Zen Buddhist and mindfulness  concepts  and  techniques  (193).  The only RCT of DBT-A for adolescents with borderline PD compared the effectiveness of DBT with  non-manualized  enhanced  usual  care  (EUC) for  the  reduction  of  self-harm  (194).  The  study included 77 self-harming adolescents (of which 21% met full  criteria  for  borderline  PD)  recruited  from psychiatric  outpatient  clinics.  The  results  revealed that  DBT-A  was  superior  to  enhanced  EUC  for reducing self-harm, depressive symptoms, and suicidal ideation.

Two RCTs have investigated the effectiveness of emotion  regulation  training  (ERT).  ERT  is  a  17session  adjunctive  program,  based  on  the  Systems Training for  Emotional Predictability  and  Problem Solving (STEPPS) program for adults with borderline  PD  (195)  that  combines  group-based skills training with family psychoeducation. In both studies,  the  effectiveness  of  ERT  was  compared with  TAU. In the  first  study  (196),  43  adolescents were randomized to ERT plus TAU or TAU alone. The results revealed a significant decrease in borderline PD symptoms in both groups, and there was  no significant difference between  the  two groups  in  terms  of  improvements.  In  the  second study (197), 109 participants with features of borderline  PD  (73%  met  the  full  criteria  for  this condition)  were  randomized  to  ERT  plus  TAU  or TAU  alone.  This  study  also  found  no  significant differences between the two treatment groups. Both groups improved equally on measures of borderline PD  severity,  general  psychopathology,  and  quality of life.

Psychopharmacological treatment: To our knowledge, the only pharmacotherapeutic RCT for adolescents with borderline  PD  was  a  small  ( N =  15)  post  hoc subgroup analysis of a larger RCT that investigated the effects of long-chain omega-3 (n-3) polyunsaturated fatty acids (PUFAs) on functioning and  psychiatric  symptoms  among  young  people with  borderline  PD  who  also  met  ultra-high-risk criteria  for  psychosis  (198).  Results  indicated  that fatty  acid  (n-3  PUFA)  levels  at  baseline  correlated positively with psychosocial functioning and negatively with psychopathology. At the end of the intervention,  these  fatty  acids  were  associated  with improved functioning and reduced psychiatric symptoms as compared with placebo.

Taking  the  Dodo  Bird  serious:  effective  ingredients  and common factors: The RCTs just discussed suggest that indicated prevention, early intervention, and standard treatment  programs  for  borderline  PD  in adolescents are acceptable and effective. It is noteworthy that all interventions, including manualized  TAU  and  other  control  treatments, were  effective.  Hence  it  remains  unclear  to  what extent  the  reported  effects  can  be  attributed  to specific  psychotherapeutic  interventions  (161).  Of course,  control  treatments  such  as  TAU  or  GCC should not be equated across studies, and research suggests  that  the  choice  of  comparison  treatment can considerably influence effect sizes in psychotherapy  research  (199,200),  which  has  also been  demonstrated  in  recent  RCTs  for  treatments of borderline PD  in adult patients (201-205). However, a general finding from RCTs for treatment of borderline PD in both adolescent and adult samples  (206) and  in  reviews  and  metaanalyses of psychotherapy outcome research is that there  is  often  little  or  no  difference  in  efficacy among various bona fide psychotherapeutic treatments (207-210); a finding commonly referred to as the Dodo bird verdict (211). Taken together this points  toward  the  importance  of  common  factors, extra-therapeutic factors, and placebo effects (206,212-216).  It  may  thus  be  proposed  that  some of  the  most  important  factors  related  to  effecting change have less to do with the specific techniques promoted by the various schools of psychotherapy and more  to do with  the  core  and  common elements shared across these various therapies (113,161,170,206,217-219).

On  the  basis  of  studies  of  adults,  Fonagy  (218) and other investigators (179,206,217) have identified a number of common features of effective treatments for borderline PD in adults, such as: 1) considerable  efforts  to  enhance  treatment  compliance;  2)  consistent  focus  on  problem  behaviors (e.g.,  self  harm)  and  interpersonal  problems;  3)  a coherent conceptual theory, framework, and language  for  the  patient  and  the  therapist/staff  to share; 4) encouragement of a supportive attachment relationship  between  the  therapist  and  the  patient that  is  of  relatively  long  duration;  and  5)  that  the treatment  is  highly  structured  and  well  integrated with other services that the patient uses.

Recently, Chanen and colleagues (161,170) extended  this  line  of  reasoning  to  adolescents  by identifying  potential  (common)  key  ingredients  in effective prevention and early intervention programs  for  borderline  PD  -  including  factors beyond individual psychotherapy related to models of service delivery. Among  other things, they highlighted the importance of the following features:  1)  assertive  and  psychologically  informed case  management  integrated  with  the  delivery  of psychotherapy;  2)  the  capacity  for  outreach  care into  the  community;  3) the  active  engagement  and inclusion  of  family  members  and  carers  in  the treatment  process,  including  psychoeducation  and brief  family  interventions  delivered  in  accordance with the overall treatment model; 4) the consistent use  of  a  plain  and  common  language  based  on  a shared  model  of  the  self  and  the  psychopathology across  all  aspects  of  care;  5)  the  integration  of general psychiatric care within the specialist treatment team, including assessment and treatment of co-occurring disorders; 6) the presence of a crisis team and availability of inpatient care programs with clear and time-limited goals; 7) access to a psychosocial recovery program; and 8) regular supervision of staff and quality assurance. Elements such as those highlighted by Chanen and colleagues must be implicated in our future understanding of why  structured  treatments,  including  those  in  the control  conditions  of  the  RCTs,  for  adolescents with  borderline  PD  appear  to  be  equally  effective.

In passing it should be noted, that many of the key elements  highlighted by  Chanen  and  colleagues (161) are also identified and used in the adolescent mentalization-based  integrative  therapy  (AMBIT) approach to hard-to-reach adolescents with multiple mental health problems and vulnerabilities (220,221). This could indicate that they have wider applicability  beyond  borderline  PD,  for  management and treatment of youth with complex psychopathology.

First,  do  no  harm:  dropout  and  iatrogenic  harm: A  more disheartening finding from the previously described RCTs for borderline PD in adolescence is that the dropout rates appear to be relatively high across the studies  and  in  both  the  treatment  and  control groups (181,188,194,196,197). As a result of differences in defining and reporting dropout in the trials,  it  is  not  possible  to  compute  and  compare exact estimates of dropout rates across the trials and treatment  conditions.  But  based  on  the  published data  from  these  RCTs,  there  are  indications  that approximately  20%  to  54%  of  the  participants appear  to  dropout  of  treatment  prematurely. More generally, it is  estimated  that  20%  to  70%  of persons,  across  all  age  groups  and  diagnoses,  who begin psychosocial mental health treatment discontinue  such  treatment  against  their  clinicians' recommendations  (222).  For  adolescents  specifically, a study suggests that about a third of patients in mental health psychosocial treatments dropout prematurely (223). A systematic review that included 25 studies of non-completion among PD treatments found a median non-completion rate of 37% (224). Taken together,  such  data  suggest  that  dropout  or premature  termination  from  psychotherapy  is  a major challenge that should be addressed explicitly in future treatment research.

Another important issue to consider is the iatrogenic  or  harmful  effects  of  therapies.  Both quantitative and qualitative reviews find that around 75%  to  80%  of  those  individuals  treated  with psychotherapy benefit from it (225,226). However, a  somewhat  neglected  but  crucial  finding  of  such reviews is that 5% to 10% of those who participate in  treatment  trials  get  worse.  For  child  psychotherapy, these numbers may be even higher, with up to  24%  of  children  between  the  ages  of  4  and  17 years  who  are  treated  in  community  mental  health settings  deteriorating  (227).  A  recent  uncontrolled treatment  study  of  adolescent  inpatients  with  PD found that 26% of the participants showed reliable change  and  moved  into  a  normative  range  of symptom  severity;  the  rest  of  the  participants  did not  change  or  only  displayed  modest  symptom reduction, and 9% deteriorated (228). Data from an RCT  study  of  CAT  for  PD  in  adults  have  also demonstrated  that  TAU  can  act  as  a  'nocebo' condition  in  which  harmful  effects  arise  from  a placebo treatment (161,229,230). Furthermore, studies  have  demonstrated  that  therapists  are  not good at predicting patients' outcomes or at determining  patients'  perceptions  of  the  quality  of the  therapeutic  relationship  or  of  group  relationships; the therapists tend to underestimate  the number  of  patients  who  are  deteriorating  during therapy  (231-233).  Research  has  also  consistently demonstrated that the therapeutic alliance is one of the most consistent and robust predictors of therapeutic outcome (234,235) and that it is therapist variability-rather than patient variability-that brings about most of this allianceoutcome association (234,236). Moreover, intervention research suggests that focusing on the therapeutic  relationship  or  transference  seems  to have the strongest effect for patients with personality  problems  within  the  context  of  a  weak alliance  (237-239),  whereas  it  can  have  negative effects  for  patients  without  personality  problems and in the context of a strong alliance (240). Taken together,  these  data  make  a  compelling  case  for implementing routine outcome monitoring systems in the  treatment of PD  so  that  clinicians can respond adequately and flexible if progress is lacking  or  when  signs  of  deterioration  become apparent (113,233,241,242).

## Conclusions and clinical implications

On the basis of the preceding selected review of the available research evidence, the following conclusions and clinical  implications  can  be  drawn with regard to PD in adolescence:

-  PD can be diagnosed as reliable and valid in adolescents as in adults.
-  The  point prevalence of  PD  diagnoses peaks in early adolescence and then declines  reaching  estimates  comparable  to those for adults by late adolescence.
-  Studies suggest that 41% to 64% of adolescents in clinical settings meets diagnostic  criteria  for  PDs,  indicating  they are highly prevalent
-  Co-occurrence between PDs is frequent.
-  PD changes from childhood through adulthood in similar ways to normal-range personality. In adolescence,  as  in adulthood,  the  rank  order  stability  of  PD  is moderate to high, whereas diagnostic stability is low.
-  The functional impairments associated with PD are stable across the lifespan.
-  PD  co-occurring  with  other  mental  disorders  is  frequent,  and  associated  with  a poorer prognosis.
-  PD  is  associated  with  considerable  treatment needs and mental health service use.
-  RCTs  show  that  indicated  prevention  and early  intervention  programs  are  promising and  effective  for  adolescents  with  borderline PD.
-  There  is  currently  no  evidence  to  support the  superiority  of  one  treatment  over  another for adolescents with borderline PD.
-  Considering  the  very  limited  evidence  for the psychopharmacological treatment of PD in adolescence (and even during adulthood), this type of treatment cannot be recommended at present.

Hume's Guillotine: Barriers and Potential Risks Although  diagnosing PD  during  adolescence is feasible,  this  does  not  necessarily  imply  that  one ought  to  diagnose  it  during  this  period.  As  the moral  philosopher  David Hume  (243) pointed out long ago, one cannot automatically make a normative  claim  solely  based  on  facts:  in  moral matters,  claims  of what  is must  be  severed  from claims about what ought to be .  Indeed, mental health professionals who work with children and adolescents often report concerns about stigma as a reason for not using PD diagnoses (20). Researchers and clinicians should always be wary of the potential harmful effects of diagnostic labeling. PD generally-and  borderline  and  antisocial  (including psychopathy) PD more specifically-are stigmatized among  some  mental  health  professionals,  patients, the  judicial  system,  and  society  at  large  (244-247). However, well-intentioned clinicians  who  purposefully refrain from using PD diagnoses with adolescent  patients  in  order  to  avoid  stigma  or discrimination may thereby unwittingly be reinforcing  and  perpetuating  the  very  stigma  that they wish to avoid (170). This in turn may increase the  risk  of  inappropriate  diagnosis  and  iatrogenic harm (e.g., from polypharmacy), which may hinder young  people  from  receiving  targeted  evidencebased treatment (170). We propose that, on balance, the potential harmful  effects of labeling  young people via the diagnosis of PD are outweighed by the risk of them not receiving appropriate treatment. In our clinical experience, most patients and families welcome the diagnosis and the implicit acknowledgement  of  their  difficulties  and  needs. Arguably, evidence-based prevention and early intervention programs for these conditions may also prove to be cost-effective for society at large (124). This  favorable  disposition  toward  early  detection and intervention through a diagnosis of PD during adolescence  is  also  reflected  in  national  guidelines (6,7),  alternative  classification  models  (60,98,248), and is likely to be included in the forthcoming ICD-

11 (249).

Although we are enthusiastic about these developments  within  the  field,  it  should  also  be recognized  that  the  removal  of  age-related  caveats from  the  diagnostic criteria for  PD  will  in all likelihood lead to more young people being diagnosed and treated, and some of these individuals  may  not  meet  the  full  criteria  for  PD (i.e., they may exhibit subthreshold PD) (22). In this context,  we  need  to  recognize  that  the  potential benefits arising from such changes will need to be weighed  against  the  potential  risks,  such  as  the 'medicalizing' of common or normative problems, as well as the problems  associated with overtreatment, side effects, stigma, and iatrogenic harm (169,250).

## Future Research

Although the current evidence converges to support the clinical utility and feasibility of diagnosing PD in adolescence, it  also  reveals  the  limitations  inherent to our current diagnostic systems. Despite the similarities  between  the  adolescent  and  adult  PD phenotypes, it is important to note that these diagnostic  categories  were  originally  derived  from descriptions of adult patients. Hence, the downward extension of these diagnoses runs the risk of 'adultomorphizing' (251) PD during childhood and adolescence, potentially not encompassing the whole  domain  of  preadult  personality  pathology during  childhood  and  adolescence  (60,98,252,253). Both the DSM-5  (Section III, alternative  PD classification  system)  and  the  ICD-11  proposal  for PD classification are promising because they incorporate  developmental  evidence  regarding  PD in  adolescence,  remove  age  criteria,  and  take  a dimensional approach to classification (10,249,254). These  alternative  classification  schemes  combine  a dimensional approach with ratings of impairment in personality  functioning  and/or  severity.  Improvement in the classification of PD is likely to lead to improvements in the design and delivery of effective prevention and early intervention programs (4,22).

In  an  effort  to  extend  contemporary  approaches to the classification of PD, we propose a transdiagnostic clinical staging approach (255), eschewing diagnostic syndrome categories and arbitrary age criteria in favor of focusing on defining the stage of progression of PD at a particular point in time, and assessing symptom severity and persistence,  need  for  care,  and  the  proportionality of treatment interventions (256). The clinical staging approach  to  PD  (257,258)  attends  to  where  an individual  is  currently  placed  on  the  continuum  of the course of PD. The individual's treatment needs and the severity  of  PD  will  differ  as  a  function  of the stage or progression of the disorder, with treatment  in  theory  being  more  benign  (i.e.,  less intensive and invasive) and effective during the early stages (170). In accordance with this approach and its  inherently  transdiagnostic  nature,  the  task  for future research is to identify and describe a range of risk syndromes for the later development of psychopathology.  Such  risk  syndromes  can  act  as indicators for preventive and  early intervention programs (259).

Prospective  studies  are  required  to  advance  our understanding  of  the  course  of  the  full  range  of personality pathology throughout the life span and to  counter  our  current  overreliance  on  data  from the CIC Study. The meta-theoretical framework of developmental  psychopathology  could  be  used  in the  design  of  such  studies  (80,81).  Moreover,  we need  greater  knowledge  on  continuity  and  change dynamics,  different  developmental  trajectories,  and risk  and  protective  factors  associated  with  both adaptive  and  maladaptive  development,  including pathogenesis and salutogenesis. Future studies must include infants or children, and should ideally incorporate genetic/biological, individual, and environmental/societal  factors  into  their  designs. This would further our understanding of the factors, dynamics,  and  risk syndromes  that  are prospectively  associated  with  onset,  development, and  maintenance  of  PD,  as  well  as  of  the  factors and processes associated with resilience and remission.

Although  results  from  the  available  RCTs  are promising, we still need follow-up data from these to  evaluate  whether  they  effectively  alter  the  life course trajectory of PD and lead to stable improvements in functioning over time. Prospectively  improving  quality  of  life  and  adaptive functioning  should  indeed  be  the  main  aims  of future  prevention  and  early  intervention  programs targeting  PD  in  adolescence.  Improving  patient retention  in  the  treatment  programs  and  reducing iatrogenic  harm  are  also  high  priorities  for  future research to address. The use of client feedback and outcome  tracking  systems  has  been  shown  to  be effective  in  psychotherapy  research  (260)  for  the reduction of the harmful effects of treatments. We therefore  hypothesize  that  this  could  also  be  the case  for  the  treatment  of  PD  in  childhood  and adolescence.  Moreover,  the  future  development  of novel  prevention  and  early  interventions  programs targeting PD in adolescence should focus more on common  factors  and  effective  ingredients  rather than specific 'brand name' psychotherapies (161,179,261). This would include targeting both the young person as well as that person's environment, including  his  or  her  family  members  and  other relevant systems. Research is also needed to identify those subgroups that do not benefit from treatment or  deteriorates,  so  that  we  can  prevent  adverse effects and develop new interventions for the nonresponders. Finally, we  recommend  that  future research focus on relatively simple treatment programs to enhance the external validity of those programs, thereby enabling their implementation in routine clinical practice so that they might ultimately lessen  the  burden  of  PDs  on  individuals,  families, and society.

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