Prevalence and current approaches to psychological treatment of Borderline Personality Disorder diagnosis in private sector children’s homes.
Background: Personality Disorders (PD) are serious mental health problems that impact on the lives and wellbeing of sufferers, those around them, and society in general, and yet little is known about the general distribution and prevalence of these disorders. The essential feature of borderline personality disorder (BPD) is “a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts”. Adolescents overwhelmingly find the diagnosis to be validating of their experience; and early diagnosis can mean an earlier targeted intervention that will help avoid multiple and unnecessary medication trials and adverse effects.
Unstable emotions, impulsivity, interpersonal difficulties and distorted thinking are all symptomatic of BPD. Whilst they may not all be present, they combine to produce difficulties with identity, another feature of this condition.
There is longstanding concern about the mental health of Looked After Children, but little research into personality disorders in this group, in part at least, due to historical concern about making a diagnosis of BPD for adolescents, despite the evidence that young people show symptoms at diagnosable levels. Most epidemiological studies of psychiatric disorders in adolescents do not look for the presence of adolescent BPD.
Diagnosis of BPD in adolescents is controversial as there is widespread agreement that personality continues to develop into early adulthood, but DSM-IV supports diagnosis if symptoms persist for at least one year, and adolescents with BPD symptoms often present to services seeking help. This has led to adolescent BPD being almost invisible, and the diagnosis and treatment of other disorders (such as depression and anxiety).
The aetiology of BPD is uncertain, but there is a growing consensus for a combination of genetic risk factors and environmental factors. There is some parallel between environmental risk factors and the home environments that trigger state intervention through the care system.
Childhood abuse or neglect increases the likelihood of PD in adult life by a factor of four. Low parental nurturing and aversive parental behaviour are associated with an elevated risk for later personality disorder. BPD
now appears to be a neurodevelopmental disorder, influenced by genetic factors
and brain development, and shaped by early environment, including experiences
of attachment and early trauma.
Adolescents with BPD symptoms are at risk of life-time personality disorder and their care and treatment as adolescents deserves consideration. The National Institute for Clinical Excellence acknowledges that some adolescents with BPD symptoms reside in private sector children’s homes. Adolescents with BPD may be known to social services departments because they are designated as a “child in need” and they may be living in foster homes or residential settings. Clinical experience suggests that the home environments of some hospitalised BPD adolescents are difficult enough that they cannot safely return home after treatment, and that they are typically accommodated in private sector children’s homes. Method: The study employs mixed methods. A questionnaire to determine prevalence and treatment approaches is being followed-up with some respondents through a semi-structured interview to explore experiences in organisations that care for this population of adolescents
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