Evaluating Clinical Guidelines for Adolescent Self-Harm and BPD
School
St. John's University**We aren't endorsed by this school
Course
PSY 726
Subject
Psychology
Date
Dec 10, 2024
Pages
11
Uploaded by SargentElementMosquito33
An Evaluation of Clinical Practice Guidelines for Self-Harm inAdolescents: The Role of Borderline Personality PathologyKhrista BoylanMcMaster Children’s Hospital, Hamilton, Canada, andMcMaster UniversityJasmine ChahalUniversity of TorontoDarren B. CourtneyCentre for Addiction and Mental Health, Toronto, Canada, andUniversity of TorontoCarla SharpUniversity of HoustonKathryn BennettMcMaster UniversityBorderline personality disorder (BPD) is associated with high rates of self-harm, suicide attempts, anddeath by suicide in adults and adolescents. Screening and assessment of BPD in self-harming adolescentscould be an important clinical intervention. The aim of this article was to identify whether existingclinical practice guidelines (CPGs) for the care of self-harm in adolescents considered the screening,diagnosis, and/or treatment of BPD. Previous work byCourtney, Duda, Szatmari, Henderson, andBennett (2018)used Preferred Reporting Items for Systematic Reviews and Meta-Analyses methods toidentify 10 CPGs relevant to self-harm in children and adolescents. In this study, the 10 CPGs werereviewed for content about screening, assessment, and/or treatment recommendations for adolescentswith BPD. Out of the 10 CPGs, 4 acknowledged the association between BPD and self-harm inadolescents. There was minimal to no guidance provided in the CPGs regarding specific screening,assessment, or treatment strategies for BPD. This may be due to the lack of evidence for efficacy andeffectiveness of screening for BPD, thereby limiting the development of guideline recommendations.Studies that examine the impact of screening for BPD in clinical settings are needed. In the interim, CPGsshould cite the prevalence of BPD in adolescents who self-harm and reference research showing thebenefit of treatment with dialectical behavioral therapy for self-harm and suicide attempts in youth withBPD.Keywords:borderline personality disorder, self-harm, major depressive disorder, adolescents, clinicalpractice guidelinesSelf-harm is an important indicator of mental health disturbancein adolescents and one of the major reasons for admission to aninpatient adolescent unit in different parts of the world (Cohen,Spirito, Apter, & Saini, 1997). It is a major risk factor for suicidalideation (SI), suicide attempts, and death by suicide (Ribeiro et al.,2016). Self-harm may or may not involve suicidal intent (Hawton,Saunders, & O’Connor, 2012).In community samples, the prevalence of self-harm in adoles-cents is estimated to be between 5% and 10% over a 12-monthperiod (Madge et al., 2008;Patton et al., 2007) and 17% during theadolescent’s lifetime at the time of reporting (Gillies et al., 2018).Clinical prevalence of self-harm is higher; up to 85% of young peopleexperiencing depressive symptoms also report engaging in self-harm(Kovacs, Goldston, & Gatsonis, 1993). Repetition of self-harm iscommon in adolescents, with 40% of adolescents reporting continuedself-harm at 1 year (Heerde et al., 2015) and 15% to 20% of individ-uals returning to hospital within a year of their previous visit forself-harm (Hawton & Harriss, 2008).This article was published Online First September 2, 2019.XKhrista Boylan, McMaster Children’s Hospital, Hamilton, Canada,and Department of Psychiatry and Behavioural Neurosciences, McMasterUniversity; Jasmine Chahal, School of Medicine, University of Toronto;Darren B. Courtney, Centre for Addiction and Mental Health, Toronto,Canada, and Department of Psychiatry, University of Toronto; Carla Sharp,Department of Psychology, University of Houston; Kathryn Bennett, De-partment of Health Research Methods, Evidence and Impact, McMasterUniversity.This guideline search step of the research was funded by the CundillCentre for Youth Depression and the Margaret and Wallace McCainCentre for Child, Youth and Family Mental Health. The authors ac-knowledge and thank Joanna Henderson and Peter Szatmari for theirleadership in the guideline search. The authors declare that they have nocompeting interests.Correspondence concerning this article should be addressed to KhristaBoylan, McMaster Children’s Hospital, 1200 Main Street West, Hamilton,ON L8N 3Z5, Canada. E-mail:boylank@mcmaster.caThis document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.Personality Disorders: Theory, Research, and Treatment© 2019 American Psychological Association2019, Vol. 10, No. 6, 500–510ISSN: 1949-2715http://dx.doi.org/10.1037/per0000349500
Self-harm occurs in the context of many psychiatric disorders.In adolescents, the most common comorbid disorders are majordepressive disorder (MDD) and borderline personality disorder(BPD;Haw, Hawton, Houston, & Townsend, 2001). In clinicalsamples, 40% to 50% of adolescents who self-harm have a diag-nosis of MDD (Jacobson, Muehlenkamp, Miller, & Turner, 2008;Nock, Joiner Jr., Gordon, Lloyd-Richardson, & Prinstein, 2006),and 11% to 50% of these adolescents have a diagnosis of BPD(Chanen et al., 2004,2008;Grilo et al., 1996). Both MDD andBPD have been shown to be among the strongest predictors ofself-harm in adolescents, as well as predicting continued risk forsuicide attempts in adulthood (Sharp et al., 2012;Weissman et al.,1999;Yen et al., 2003). Given that approximately 50% to 70% ofadolescents with BPD have comorbid MDD (Andrewes, Hulbert,Cotton, Betts, & Chanen, 2017;Horesh, Orbach, Gothelf, Efrati, &Apter, 2003), it can be argued that BPD, MDD, or both conditionsare highly associated with self-harm in clinical settings.Despite evidence supporting the reliability and validity of BPDduring adolescence (Chanen, 2015;Kaess, Brunner, & Chanen,2014;Sharp, 2016;Sharp & Fonagy, 2015;Sharp, Tackett, &Oldham, 2014), the diagnosis is stigmatized among clinicians.Many clinicians deliberately avoid diagnosing BPD in adolescentswith the aim of “protecting” these adolescents from discriminationby other health professionals (Chanen, Sharp, & Hoffman, 2017).However, this practice may propagate negative stereotypes, in-crease the likelihood of inaccurate diagnosis, and reduce the op-portunity for adolescents to be exposed to interventions that havebeen shown to reduce BPD symptoms and prevent suicide attempts(Andrewes et al., 2017). For instance, up to 76% of adolescentswith first-presentation BPD seeking help from adolescents’ mentalhealth services reported engaging in current self-harm, with 66%reporting at least one suicide attempt over the previous year(Andrewes et al., 2017). Because data suggests considerable mal-leability and flexibility of BPD traits in adolescence (Lenzenweger& Castro, 2005), this is a key developmental period for earlyintervention(Gundersonetal.,2011;Zanarini,Frankenburg,Reich, & Fitzmaurice, 2010).Over the past few years, there has been a growing movementadvocating for increased screening and early identification ofadolescents with features of BPD (Chanen & McCutcheon, 2013;Chanen et al., 2017). Current early intervention programs, such asHelping Young People Early (Chanen, McCutcheon, et al., 2009)and emotion regulation training (Schuppert et al., 2009), have beendesigned to specifically target adolescents with BPD. These pro-grams are based on randomized controlled trials of psychothera-pies, such as cognitive analytic therapy (CAT), which have shownsignificant, clinically substantial improvement in BPD adoles-cents, demonstrating “proof of concept” for early intervention inBPD (Chanen, Jackson, et al., 2009;Schuppert et al., 2012). Suchinitiatives are promising and may help to decrease fears of iatro-genic harm arising from early diagnosis and treatment specificallyfor BPD (Chanen & McCutcheon, 2008;Chanen et al., 2017).However, it is important to note that no studies have yet tested theefficacy and effectiveness of screening for BPD adolescents.Given the importance of early diagnosis of BPD and its highprevalence in adolescents with suicidal behaviors, it is reasonableto expect that practice guidelines for the treatment of self-harm inadolescents may address (a) screening for BPD in adolescents whoharm themselves and/or (b) referral for diagnostic clarification andtreatment of BPD. Whether or not this evidence has been translatedinto clinical practice guidelines (CPG) recommendations is un-known. The aim of this article is to review existing CPGs thataddress the assessment, prevention or treatment of self-harm inchildren and adolescents for recommendations, or commentary,relevant to the screening, diagnosis, and treatment of BPD or BPDsymptoms.MethodSearch Strategy and Selection CriteriaPrevious work by Courtney and colleagues (Courtney et al.,2018) used Preferred Reporting Items for Systematic Reviews andMeta-Analyses methods to identify CPGs, practice parameters orcommittee recommendations relevant to the assessment, preven-tion or treatment of suicide-related behavior or self-harm in ado-lescents, defined as persons less than 19 years of age. Eligibledocuments were appraised by two independent trained reviewersusing the Appraisal of Guidelines for Research and Evaluation(AGREE II;Brouwers et al., 2010) tool and designated as beingeither of minimum (50%) or high (70%) quality using threeAGREE II domain scores [stakeholder involvement, rigor of de-velopment (clinical validity/trustworthiness), editorial indepen-dence]. This effort identified 10 documents (Table 1) eligible forconsideration in this study (Carter et al., 2016;Cincinnati Chil-dren’s Hospital Medical Centre, 2011;Doan, LeBlanc, Roggen-baum, & Lazear, 2012;National Collaborating Centre for MentalHealth (U.K.), 2004;Penn & Thomas, 2005;Plener et al., 2016;White, 2014;Working Group of the Clinical Practice Guideline forPrevention & Treatment of Suicidal Behavior, 2012;NationalInstitute for Health and Care Excellence, 2012).Data AnalysisEach of the 10 documents was read in detail by two independentraters (KB and JC) to identify each specific mention of BPD or theterms borderline personality “symptoms” or “traits.” Raters cate-gorized each identified instance as being relevant to one or more ofthe content areas of any of screening, assessment, or treatment ofBPD, BPD symptoms, or traits. Raters also noted whether theinstance was an evidence-based recommendation or simply a men-tion in the text without a specific recommendation. Disagreementswere resolved through consensus with coauthors.ResultsFour of the 10 eligible CPGs made mention of BPD in adoles-cents at any point in the document (Carter et al., 2016;NationalCollaborating Centre for Mental Health (U.K.), 2004;WorkingGroup of the Clinical Practice Guideline for Prevention & Treat-ment of Suicidal Behavior, 2012;National Institute for Health andCare Excellence, 2012). Two of the four CPGs (National Collab-orating Centre for Mental Health (U. K.), 2004;Working Group ofthe Clinical Practice Guideline for Prevention & Treatment ofSuicidal Behavior, 2012) were rated as minimum quality in theprevious work byCourtney and colleagues (2018), one met highquality criteria (National Institute for Health and Care Excellence,2012) and one was rated below minimum quality (Carter et al.,This document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.501ROLE OF BPD IN SELF-HARM CPGS
Table 1Borderline Personality Disorder Information Within Clinical Practice Guidelines for Self-Harm in AdolescentsGuidelineOrganizationIs screening for borderlinepersonality disorder (BPD)recommended/mentionedin the guideline?Are screening proceduresfor BPD described?Are evidence-basedrecommendations on BPD management/treatment provided?Other commentary related to BPD?Self-harm in childrenover the age of 8 years:long-term management(National Institute forHealth and CareExcellence, 2012)National Institute forHealth and CareExcellence(United Kingdom)NoNo• Yes; in a separate referenceddocument for BPD (NICE, 2009).Recommendations includeassessment, care planning,management, psychologicaltreatment (DBT); drug treatment isdiscouraged.• A wide range of psychiatric problems,such as BPD, depression, bipolardisorder, schizophrenia, and drug andalcohol-use disorders, are associatedwith self-harm (p. 4).• During risk assessment, in general, theguideline encourages identification ofany psychiatric illness and itsrelationship to self-harm (p. 8).Self-harm: The short-termphysical andpsychologicalmanagement andsecondary preventionof self-harm in primaryand secondary care(National CollaboratingCentre for MentalHealth (U.K.), 2004)National Institute forHealth and CareExcellence (NICE;United Kingdom)NoNo• Yes; for people who self-harm andhave a diagnosis of BPD,consideration may be given to theuse of DBT (p. 69). This shouldnot preclude other psychologicaltreatments with evidence ofeffectiveness for people with thisdiagnosis, but not reviewed for thisguideline.• People diagnosed as having certaintypes of mental disorder are muchmore likely to self-harm. For thisgroup, the recognition and treatmentof these disorders can be an importantcomponent of care (p. 22).• Self-harm is considered to be one ofthe defining features of both BPD andhistrionic personality disorder (p. 22).Royal Australian andNew Zealand Collegeof Psychiatrists clinicalpractice guideline forthe management ofdeliberate self-harm(Carter et al., 2016)The RoyalAustralian andNew ZealandCollege ofPsychiatrists (NewZealand,Australia)NoNo• Yes; people with BPD who self-harmshould be offered psychologicaltherapies that have been shown toreduce the number of repetitions ofDSH, such as DBT, CBT, or MBT(p. 970).• BPD is associated with high risksof repeated DSH and suicide (p. 971).• The majority of adults (83.9%) andadolescents who present for hospital-treated DSH have an underlyingpsychiatric disorder (p. 956).• Psychosocial assessment by a trainedmental health professional may havean effect on DSH repetition rates.Further evaluation is warranted (p.956).• For children and adolescents whoself- harm, consider offering CBT,MBT, or DBT, where suitable (p.970).• Do not rely on group therapy alone toreduce the risk of repetition ofDSH in people with BPD whoself-harm (p. 970).• Do not use pharmacotherapyspecifically for the purpose ofreducing the risk of repetition ofDSH in people with BPD whoself-harm (p. 970).This document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.502BOYLAN, CHAHAL, COURTNEY, SHARP, AND BENNETT
Table 1 (continued)GuidelineOrganizationIs screening for borderlinepersonality disorder (BPD)recommended/mentionedin the guideline?Are screening proceduresfor BPD described?Are evidence-basedrecommendations on BPD management/treatment provided?Other commentary related to BPD?Clinical practice guidelinefor the prevention andtreatment of suicidalbehavior (WorkingGroup of the ClinicalPractice Guideline forPrevention andTreatment of SuicidalBehaviour, 2012)Ministry of Healthand Social Policy,Galician HealthTechnologyAssessmentAgency (Spain)NoNoScreening/assessment recommendations:1. Children and adolescents withpresence of risk factors for suicidalbehavior are recommended toundergo a comprehensivepsychopathological and socialassessment, paying particularattention to the presence ofcomorbidity (p. 35).2. In primary care, it is suggested toimplement suicide risk screeningprograms in adolescents with thepresence of suicide risk factorswho may need to be referred to aspecialist service (p. 34).Treatment recommendations:1. Specific psychotherapeutictreatment is recommended inadolescents: DBT in BPD andCBT in major depression. Foranticonvulsant treatment of BPD,carbamazepine is recommended asthe first-choice drug to control therisk of suicidal behavior (p. 30).Screening for SuicideRisk in Adolescents,Adults, and OlderAdults in Primary Care(LeFevre, 2014)United StatesPreventiveServices TaskForce (UnitedStates)NoNoPractice Guidelines forWorking With ChildrenAnd Youth At-Risk forSuicide in CommunityMental Health Settings(White, 2014)Ministry of Childrenand FamilyDevelopment,British Columbia(Canada)NoNo(table continues)This document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.503ROLE OF BPD IN SELF-HARM CPGS
Table 1 (continued)GuidelineOrganizationIs screening for borderlinepersonality disorder (BPD)recommended/mentionedin the guideline?Are screening proceduresfor BPD described?Are evidence-basedrecommendations on BPD management/treatment provided?Other commentary related to BPD?Youth suicide preventionschool-based guide–Issue Brief 5: Suicideprevention guidelines(Doan, LeBlanc,Roggenbaum, &Lazear, 2012)Department of Child& Family Studies,Louis de la ParteFlorida MentalHealth Institute,USF College ofBehavioral &CommunityScience (UnitedStates)NoNoBest Evidence Statement:Preventing patient self-harm (CincinnatiChildren’s HospitalMedical Centre, 2011)CincinnatiChildren’sHospital MedicalCentre (UnitedStates)NoNoPractice parameter for theassessment andtreatment of youth injuvenile detention andcorrectional facilities(Penn and Thomas,2005)American Academyof Child &AdolescentPsychiatry (UnitedStates)NoNoTreating nonsuicidal self-injury in adolescents:consensus-basedGerman guidelines(Plener et al., 2016)Department of Childand AdolescentPsychiatry andPsychotherapy,Central Instituteof Mental Health(Germany)NoNoNote.DSHdeliberate self-harm; CBTcognitive behavioral therapy; DBTdialectical behavioral therapy; MBTmentalization-based therapy.This document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.504BOYLAN, CHAHAL, COURTNEY, SHARP, AND BENNETT
2016).Table 1displays the content of each of these four CPGsrelevant to BPD, BPD symptoms, or traits, while further descrip-tion is as follows.The most detailed mention of BPD was included in the RoyalAustralian and New Zealand College of Psychiatrists’ ClinicalPractice Guideline for the Management of Deliberate Self-Harm(DSH;Carter et al., 2016). This CPG aimed to provide guidanceand advice regarding the management of DSH in patients within anevidence-based framework, supplemented by expert clinical con-sensus. This guideline includes commentary on adolescents as aspecial population. The guideline acknowledges, “the majority ofadults (83.9%) and adolescents who present for hospital-treatedDSH have an underlying psychiatric disorder” (p. 956). In terms ofassessment, the guideline notes that “psychosocial assessment by atrained mental health professional may have an effect on DSHrepetition rates.” They note that “further evaluation of BPD iswarranted” (p. 956) but do not mention how to screen or diagnoseBPD. For treatment, the guideline recommends that in general,people with BPD who self-harm “should be offered effectivepsychological therapies that have been shown to reduce the risk ofrepetition of DSH, such as dialectical behavior therapy (DBT),cognitive behavioral therapy (CBT) or mentalization-based ther-apy (MBT)” (p. 941). In addition, the guideline suggests thatpharmacotherapy is not effective for reducing repetition of DSHamong people with BPD and should not be initiated unless other-wise indicated for comorbid disorders. Specific commentary re-garding treatment for adolescents versus adults is not differenti-ated. Although many comments regarding BPD were made in thisguideline, it did not achieve an AGREE II quality rating (Courtneyet al., 2018).The CPG with the next most detailed mention of BPD was the“Clinical Practice Guideline for the Prevention and Treatment ofSuicidal Behavior” by Spain’sWorking Group of the ClinicalPractice Guideline for Prevention & Treatment of Suicidal Behav-ior (2012). This guideline contains recommendations regardingassessment, prevention, and treatment of suicidal behavior in pri-mary and secondary health-care settings and received a minimumquality rating (Courtney et al., 2018). The guideline recommends“paying particular attention to the presence of comorbidity” (p. 8)and conducting a “comprehensive psychopathological and socialassessment” (p. 7) when assessing adolescents who self-harm,similar to the process for adults. It mentions that BPD and anti-social personality disorder are the most common comorbid per-sonality disorders in people who self-harm (p.56). There was noguidance regarding screening or diagnostic tools specifically forBPD. However, treatments are discussed for patients with BPDwho engage in self-harm, specifically DBT for both adolescent andadult patients. It is also stated that “[f]or anticonvulsant treatmentof BPD, carbamazepine is recommended as the first choice drug tocontrol risk of suicidal behaviors” (p. 5). It should be noted thatthis specific recommendation was given a grade of C by theguideline authors, as it was based off of one systematic review(Ernst & Goldberg, 2004).The guideline by NICE and National Collaborating Centre forMental Health focuses on the short-term management and second-ary prevention of self-harm in primary and secondary care (Na-tional Collaborating Centre for Mental Health (U.K.), 2004). Ac-knowledgingtheassociationbetweenself-harmandmentaldisorders, the guideline specifically mentions “self-harm is con-sidered to be one of the defining features of both BPD andhistrionic personality disorder” (p. 22). Beyond this, no mention ismade of specific screening or assessment of BPD in persons whoengage in self-harm. In terms of assessment, the guideline recog-nizes personality disorders as a predictor of high risk of fatal ornonfatal repetition of self-harm and mentions that people withpersonality disorders might “need a long-term strategy for treat-ment and help in specialist services” (p. 159). The guidelinerecommends treatment of BPD using DBT for individuals aged 8years and over (p. 69) based on evidence from one randomizedcontrolled trial (Linehan et al., 1991).NICE also published a CPG for the long-term management ofself-harm in children over the age of 8 years (National Institute forHealth and Care Excellence, 2012) as a follow-up to the previouslymentioned document. This CPG, NICE Clinical Guideline 16(National Institute for Health and Care Excellence, 2012), focusedon the treatment of self-harm within the first 48 hr of a self-harmincident. These were the only guidelines that received a highquality AGREE II rating (Courtney et al., 2018). Acknowledgingthat BPD is associated with self-harm, the guidelines direct thereader to a separate document for its management and treatment(National Institute for Health and Care Excellence, 2009). There isno other mention of screening or assessment procedures for BPDadolescents within this guideline.DiscussionBPD is known to be an important comorbidity—or primarydisorder—which influences both the severity and treatment respon-siveness of self-harm in adolescents (Andrewes et al., 2017;Sharpet al., 2012;Yen et al., 2003). Our aim in this report was to identifywhether CPGs relevant to self-harm contain recommendations—orcommentary—relevant to the screening, assessment or treatment ofadolescents with BPD.Among the 10 self-harm CPGs identified in previous work(Courtney et al., 2018), we found that only four made any mentionof BPD (Table 1). Within these four guidelines, there is no guid-ance regarding specific screening or assessment recommendationsfor BPD in adolescents. However, there is commentary that rec-ognized that “self-harm is considered to be one of the definingfeatures of both BPD and histrionic personality disorder” (NationalCollaborating Centre for Mental Health (U.K.), 2004, p. 22). Moregenerally, the guidelines acknowledge that “people diagnosed ashaving certain types of mental disorder are much more likely toself-harm. For this group, the recognition and treatment of thesedisorders can be an important component of care” (National Col-laborating Centre for Mental Health (U.K.), 2004, p. 22).Each CPG referenced the use of psychotherapy, specificallyDBT to treat self-harm in adolescents with BPD. DBT is one ofthree evidence-based treatments for BPD symptoms in adolescents(Panos, Jackson, Hasan, & Panos 2014;Linehan, 1993), with theother two being CAT and MBT (Bateman & Fonagy, 2008,2009,2010;Clarkin et al., 2001;Ryle & Kerr, 2002). These latter twotherapies were mentioned in two of these four CPGs (Table 1).One CPG (National Institute for Health and Care Excellence,2012) specifically referenced readers to the NICE Clinical Guide-line 78, a detailed guideline for treatment of BPD (National Insti-tute for Health and Care Excellence, 2009). Referring to anotherThis document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.505ROLE OF BPD IN SELF-HARM CPGS
guideline is appropriate considering that the management of BPDis multifaceted and complex.Each of the four CPGs notes that pharmacotherapy is currentlythought to be ineffective in relieving core symptoms of BPD andis not recommended as a treatment. One CPG (Working Group ofthe Clinical Practice Guideline for the Prevention & Treatment ofSuicidal Behavior, 2012) recommended the use of carbamazepinefor prevention of suicidal behaviors (p. 5) based on evidence ratedas Grade C according to the Scottish Intercollegiate GuidelinesNetwork (SIGN) Grades of Recommendation (Harbour & Miller,2001). This grade is given to a body of evidence consisting of“well-conducted case control or cohort studies with a low risk ofconfounding or bias and a moderate probability that the relation-ship is causal” (Harbour & Miller, 2001).We recommend that developers of CPGs for adolescent self-harm consider the following suggestions in future guideline iter-ations:1.Given the prevalence and predictive role of BPD inself-harm severity in adolescents (Andrewes et al., 2017;Chanen & McCutcheon, 2013;Sharp et al., 2012), allguidelines regarding the care of self-harm in adolescentsshould make mention of BPD as a common comorbidity,citing comorbidity rates.2.Given reported positive outcomes in studies on DBT,CAT, and MBT, guideline developers should review andappraise the controlled clinical trials assessing treatmentTable 2Selected Validated Screening and Assessment Measures for Adolescent Borderline Personality DisorderMeasuresNumber of items; response formatAdministration andscoring timePsychometric propertiesScreening toolsMSI-BPD (Chanen et al., 2008;Gardner &Qualter, 2009;Noblin, Venta, & Sharp,2014;Zanarini et al., 2003)10 items; yes/no clinician-reported scaleNAInternal consistency: .73–.78Sensitivity: .71–.90Specificity: .75–.93Diagnostic accuracy: .73–.83NPV: .89BPFS-C (Chang, Sharp, & Ha, 2011;Crick,Murray–Close, & Woods, 2005)24-items; self-reported scaleNAInternal consistency: .76–.88Sensitivity: .85Specificity: .84Diagnostic accuracy: NABPFSC-11 (Sharp, Mosko, Chang, & Ha, 2011;Sharp, Steinberg, et al., 2014)11-items; self-reported scaleNAInternal consistency: .85Sensitivity: .740Specificity: .714Diagnostic accuracy: .80BPQ (Chanen et al., 2008;Poreh et al., 2006)80 items; true/false self-reported scaleNAInternal consistency: .92Sensitivity: .68Specificity: .90Diagnostic accuracy: .85NPV.91BSL-23 (Bohus et al., 2007)23 items; self-reported scaleNAInternal consistency: .935–.936Sensitivity: .90Specificity: .93Diagnostic accuracy: NAAssessment measuresCI-BPD (Zanarini, 2003)Nine items; clinician interview30–45 minsInternal consistency: .81External validity: associateswith PAI-BOR (r.66),BPFS-C, clinician diagnosis(.34), internalizing andexternalizing problemsPAI-BOR (Morey, 2007)20 items; self-report scale15 minsInternal consistency: .85–.87External validity: associatedwith range of other BPDrelevant pathology, CI-BPDSCID II (First, 1997;First, Williams, Benjamin,& Spitzer, 2016)Nine items for BPD; clinician interview30 minsInternal consistency: .71–.94External validity: associateswith the BPQ (.57)Diagnostic accuracy: .80NPV: .89DIB-C (Guzder, Paris, Zelkowitz, & Feldman,1999;Greenman, Gunderson, Cane, &Saltzman, 1986)24 items; clinician interview30 minsInterrater reliability, k.72Note.NAnot available; MSI-BPDMcLean Screening Instrument for BPD; BPFS-CBorderline Personality Disorder Features Scale for Children;BPQBorderline Personality Questionnaire; BSLBorderline Symptom List; CI-BPDChildhood Interview forDiagnostic and Statistical Manualof Mental Disorders, Fourth EditionBorderline Personality Disorder; PAI-BORPersonality Assessment Inventory–Borderline Features; SCID-IIStructured Clinical Interview forDiagnostic and Statistical Manual of Mental DisordersDisorders–Axis II Disorders; DIB-CDiagnostic Interview forBorderline Personality Disorder–Child Version; NPVNegative Predictive Value.This document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.506BOYLAN, CHAHAL, COURTNEY, SHARP, AND BENNETT
of adolescents with features of BPD and subsequentlymake corresponding clinical recommendations.Research Questions for Future CPGsAt present, there are no prospective trials evaluating the predic-tive validity, benefits, or harms of screening for BPD in adoles-cents who engage in self-harm. Future research is needed todetermine the impact of screening, diagnosis and treatment ofadolescent BPD in the context of primary outcomes such asclinical efficacy, as well as patient satisfaction and clinician ac-ceptability. A key research question for self-harm CPG developersto consider going forward is as follows: “For adolescents whopresent with a history of self-harm, does screening for borderlinepersonality disorder improve outcomes?”To conduct this research, it is important to recognize thatseveral screening measures have been validated for BPD inadolescents, and further research is needed to determine whichof these measures are most useful in which settings. For exam-ple, there are several self- and clinician-report scales advocatedfor screening of BPD in adolescents (Table 2). Two instrumentsthat do not require clinician training to administer include theMcLean Screening Instrument for BPD (Zanarini et al., 2003),the Borderline Personality Features Scale for Children (Chang,Sharp, & Ha, 2011;Crick, Murray–Close, & Woods, 2005), andits shorter 11-item version (BPFSC-11;Sharp, Mosko, Chang,& Ha, 2011;Sharp, Steinberg, Temple, & Newlin, 2014). TheBorderline Personality Questionnaire (Poreh et al., 2006) hasbeen shown to achieve the best balance of the desired propertiesin a screening instrument such as high sensitivity (the truepositive rate) and high negative predictive value (probabilitythat a negative test means the person does not have the condi-tion;Chanen et al., 2008), but its length (90 items) mightpreclude more widespread clinical application. Another re-search question is “Which measures have the most robustevidence for screening and diagnosing BPD in adolescents?”One post screening intervention for adolescents who screenpositive for BPD should include a diagnostic assessment, ideally,using a structured diagnostic instrument (seeTable 2for exam-ples). These tools require training or advanced clinical skill. Cli-nicians should consider psychiatric referral for adolescents withsuspected BPD, given their need for specialized services in mostcases.There are also several personality trait measures that will availthe assessment of BPD traits consistent with theDiagnostic andStatistical Manual of Mental Disorders, –Fifth Edition,AlternativeModel of Personality Disorders (American Psychiatric Associa-tion, 2013). These measures include the Personality Inventory forDiagnostic and Statistical Manual of Mental Disorders, FifthEdition,(De Clercq, Decuyper, & De Caluwé, 2014), the Dimen-sional Inventory of Personality Symptom Item Pool (De Clercq,De Fruyt, Van Leeuwen, & Mervielde, 2006), the Five FactorBorderline Inventory (Mullins-Sweatt et al., 2012), and the Per-sonality Diagnostic Questionnaire – 4 (Bagby & Farvolden, 2004).Other than the Personality Inventory forDiagnostic and StatisticalManual of Mental Disorders, –Fifth Editionand the DimensionalInventory of Personality Symptom Item Pool, these measures haveyet to be tested for use in adolescents. It is important to mentionthese measures for future study in adolescents, as the field will notmove forward if the clinical utility of these measures are not alsodemonstrated in young people.Until screening research has been conducted, there is sufficientevidence available about the prevalence and stability of adolescentBPD as well as the reliability of screening tools to justify conven-ing an expert group to generate consensus about specific recom-mendations about the assessment and treatment of adolescents whoself-harm who may also have BPD. The use of transparent meth-ods (e.g., A Delphi Process;Jorm, 2015) throughout this process isindicated.Limitations and Future ResearchBecause research about the validity of BPD in adolescenceand its treatment has burgeoned in recent years, this could be areason why some of the selected CPGs in our research did notaddress BPD in adolescents who self-harm in greater detail.Updating of CPGs is therefore needed. Given the high comor-bidity between BPD and other psychiatric disorders such asMDD and substance abuse disorders (Sharp & Fonagy, 2015), itis important to also explore the assessment, diagnosis, andtreatment of BPD in the context of CPGs for these conditions inadolescents.ReferencesAmerican Psychiatric Association. (2013).Diagnostic and statistical man-ual of mental disorders(5th ed.). Arlington, VA: American PsychiatricPublishing.Andrewes, H. E., Hulbert, C., Cotton, S. M., Betts, J., & Chanen, A. M.(2017). Relationships between the frequency and severity of non-suicidal self-injury and suicide attempts in youth with borderline per-sonality disorder.Early Intervention in Psychiatry, 13,194–201.http://dx.doi.org/10.1111/eip.12461Bagby, R. M., & Farvolden, P. (2004). The Personality DiagnosticQuestionnaire-4 (PDQ-4). In M. J. Hilsenroth, D. L. Segal, & M. Hersen(Eds.),Comprehensive handbook of psychological assessment: Vol. 2.Personality assessment(pp. 122–133). New York, NY: John Wiley.Bateman, A., & Fonagy, P. (2008). 8-year follow-up of patients treated forborderline personality disorder: Mentalization-based treatment versustreatment as usual.American Journal of Psychiatry, 165,631–638.http://dx.doi.org/10.1176/appi.ajp.2007.07040636Bateman, A., & Fonagy, P. (2009). Randomized controlled trial of outpa-tient mentalization-based treatment versus structured clinical manage-ment for borderline personality disorder.The American Journal ofPsychiatry, 166,1355–1364.http://dx.doi.org/10.1176/appi.ajp.2009.09040539Bateman, A., & Fonagy, P. (2010). Mentalization based treatment forborderline personality disorder.World Psychiatry, 9,11–15.http://dx.doi.org/10.1002/j.2051-5545.2010.tb00255.xBohus, M., Limberger, M. F., Frank, U., Chapman, A. L., Kühler, T., &Stieglitz, R.-D. (2007). Psychometric properties of the borderline symp-tom list (BSL).Psychopathology, 40,126–132.http://dx.doi.org/10.1159/000098493Brouwers, M. C., Kho, M. E., Browman, G. P., Burgers, J. S., Cluzeau, F.,Feder, G., . . . Zitzelsberger, L. (2010). AGREE II: Advancing guidelinedevelopment, reporting and evaluation in health care.Canadian MedicalAssociation Journal, 182,E839–E842.http://dx.doi.org/10.1503/cmaj.090449Carter, G., Page, A., Large, M., Hetrick, S., Milner, A. J., Bendit, N., . . .Christensen, H. (2016). Royal Australian and New Zealand College ofPsychiatrists clinical practice guideline for the management of deliberateThis document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.507ROLE OF BPD IN SELF-HARM CPGS
self-harm.Australian and New Zealand Journal of Psychiatry, 50,939–1000.http://dx.doi.org/10.1177/0004867416661039Chanen, A. M. (2015). Borderline personality disorder in young people:Are we there yet?Journal of Clinical Psychology, 71,778–791.http://dx.doi.org/10.1002/jclp.22205Chanen, A. M., Jackson, H. J., McCutcheon, L. K., Jovev, M., Dudgeon,P., Yuen, H. P., . . . McGorry, P. D. (2009). Early intervention foradolescents with borderline personality disorder: Quasi-experimentalcomparison with treatment as usual.Australian and New Zealand Jour-nalofPsychiatry,43,397– 408.http://dx.doi.org/10.1080/00048670902817711Chanen, A. M., Jackson, H. J., McGorry, P. D., Allot, K. A., Clarkson, V.,& Yuen, H. P. (2004). Two-year stability of personality disorder in olderadolescent outpatients.Journal of Personality Disorders, 18,526–541.http://dx.doi.org/10.1521/pedi.18.6.526.54798Chanen, A. M., Jovev, M., Djaja, D., McDougall, E., Yuen, H. P., Rawl-ings, D., & Jackson, H. J. (2008). Screening for borderline personalitydisorder in outpatient youth.Journal of Personality Disorders, 22,353–364.http://dx.doi.org/10.1521/pedi.2008.22.4.353Chanen, A. M., & McCutcheon, L. K. (2008). Personality disorder inadolescence: The diagnosis that dare not speak its name.Personality andMental Health, 2,35–41.http://dx.doi.org/10.1002/pmh.28Chanen, A. M., & McCutcheon, L. (2013). Prevention and early interven-tion for borderline personality disorder: Current status and recent evi-dence.The British Journal of Psychiatry, 202,s24–s29.http://dx.doi.org/10.1192/bjp.bp.112.119180Chanen, A. M., McCutcheon, L. K., Germano, D., Nistico, H., Jackson,H. J., & McGorry, P. D. (2009). The HYPE Clinic: An early interventionservice for borderline personality disorder.Journal of Psychiatric Prac-tice, 15,163–172.http://dx.doi.org/10.1097/01.pra.0000351876.51098.f0Chanen, A., Sharp, C., & Hoffman, P. (2017). Prevention and earlyintervention for borderline personality disorder: A novel public healthpriority.World Psychiatry, 16,215–216.http://dx.doi.org/10.1002/wps.20429Chang, B., Sharp, C., & Ha, C. (2011). The criterion validity of theBorderline Personality Features Scale for Children in an adolescentinpatient setting.Journal of Personality Disorders, 25,492–503.http://dx.doi.org/10.1521/pedi.2011.25.4.492Cincinnati Children’s Hospital Medical Centre. (2011).Best EvidenceStatement (BESt): Preventing patient self-harm. Retrieved fromhttps://www.cincinnatichildrens.org/-/media/cincinnati%20childrens/home/service/j/anderson-center/evidence-based-care/recommendations/type/self-harm-checklist.pdf?laenClarkin, J. F., Foelsch, P. A., Levy, K. N., Hull, J. W., Delaney, J. C., &Kernberg, O. F. (2001). The development of a psychodynamic treatmentfor patients with borderline personality disorder: A preliminary study ofbehavioral change.Journal of Personality Disorders, 15,487–495.http://dx.doi.org/10.1521/pedi.15.6.487.19190Cohen, Y., Spirito, A., Apter, A., & Saini, S. (1997). A cross-culturalcomparison of behavior disturbance and suicidal behavior among psy-chiatrically hospitalized adolescents in Israel and the United States.Child Psychiatry and Human Development, 28,89–102.http://dx.doi.org/10.1023/A:1025141202404Courtney, D. B., Duda, S., Szatmari, P., Henderson, J., & Bennett, K.(2018). Systematic review and quality appraisal of practice guidelinesfor self-harm in children and adolescents.Suicide and Life-ThreateningBehavior, 49,707–723.Crick, N. R., Murray–Close, D., & Woods, K. (2005). Borderline person-ality features in childhood: A short-term longitudinal study.Develop-ment and Psychopathology, 17,1051–1070.http://dx.doi.org/10.1017/S0954579405050492De Clercq, B., Decuyper, M., & De Caluwé, E. (2014). Developmentalmanifestations of borderline personality pathology from an age-specificdimensional personality disorder trait framework. In C. Sharp & J. L.Tackett (Eds.),Handbook of borderline personality disorder in childrenand adolescents(pp. 81–94). New York, NY: Springer.http://dx.doi.org/10.1007/978-1-4939-0591-1_7De Clercq, B., De Fruyt, F., Van Leeuwen, K., & Mervielde, I. (2006). Thestructure of maladaptive personality traits in childhood: A step toward anintegrative developmental perspective for DSM-V.Journal of AbnormalPsychology, 115,639–657.http://dx.doi.org/10.1037/0021-843X.115.4.639Doan, J., LeBlanc, A., Roggenbaum, S., & Lazear, K. J. (2012).Youthsuicide prevention school-based guide-Issue brief 5: Suicide preventionguidelines. Retrieved fromhttp://theguide.fmhi.usf.edu/pdf/2012PDFs/2012GuideAll.pdfErnst, C. L., & Goldberg, J. F. (2004). Antisuicide properties ofpsychotropic drugs: A critical review.Harvard Review of Psychiatry,12,14–41.First, M. B. (Ed.), (1997).User’s guide for the structured clinical interviewfor DSM–IV axis II personality disorders: SCID-II. Washington, DC:American Psychiatric Press.First, M. B., Williams, J. B. W., Benjamin, L. S., & Spitzer, R. L. (Eds.).(2016).Structured clinical interview for DSM–5 personality disorders:SCID-5-PD. Arlington, VA: American Psychiatric Association.Gardner, K., & Qualter, P. (2009). Reliability and validity of three screen-ing measures of borderline personality disorder in a nonclinical popu-lation.Personality and Individual Differences, 46,636–641.http://dx.doi.org/10.1016/j.paid.2009.01.005Gillies, D., Christou, M. A., Dixon, A. C., Featherston, O. J., Rapti, I.,Garcia-Anguita, A., . . . Christou, P. A. (2018, October). Prevalence andcharacteristicsofself-harminadolescents:Meta-analysesofcommunity-based studies 1990–2015.Journal of the American Acad-emy of Child and Adolescent Psychiatry, 57,733–741.http://dx.doi.org/10.1016/j.jaac.2018.06.018Greenman, D. A., Gunderson, J. G., Cane, M., & Saltzman, P. R. (1986).An examination of the borderline diagnosis in children.The AmericanJournal of Psychiatry, 143,998–1003.http://dx.doi.org/10.1176/ajp.143.8.998Grilo, C. M., Becker, D. F., Fehon, D. C., Walker, M. L., Edell, W. S., &McGlashan, T. H. (1996). Gender differences in personality disorders inpsychiatrically hospitalized adolescents.The American Journal of Psy-chiatry, 153,1089–1091.http://dx.doi.org/10.1176/ajp.153.8.1089Gunderson, J. G., Stout, R. L., McGlashan, T. H., Shea, M. T., Morey,L. C., Grilo, C. M., . . . Skodol, A. E. (2011). Ten-year course ofborderline personality disorder: Psychopathology and function from thecollaborative longitudinal personality disorders study.Archives of Gen-eral Psychiatry, 68,827– 837.http://dx.doi.org/10.1001/archgenpsychiatry.2011.37Guzder, J., Paris, J., Zelkowitz, P., & Feldman, R. (1999). Psychologicalrisk factors for borderline pathology in school-age children.Journal ofthe American Academy of Child and Adolescent Psychiatry, 38,206–212.http://dx.doi.org/10.1097/00004583-199902000-00021Harbour, R., & Miller, J. (2001). A new system for grading recommenda-tions in evidence based guidelines.British Medical Journal, 323,334–336.http://dx.doi.org/10.1136/bmj.323.7308.334Haw, C., Hawton, K., Houston, K., & Townsend, E. (2001). Psychiatricand personality disorders in deliberate self-harm patients.The BritishJournal of Psychiatry, 178,48–54.http://dx.doi.org/10.1192/bjp.178.1.48Hawton, K., & Harriss, L. (2008). Deliberate self-harm by under-15-year-olds: Characteristics, trends and outcome.Journal of Child Psychologyand Psychiatry, 49,441–448.http://dx.doi.org/10.1111/j.1469-7610.2007.01852.xHawton, K., Saunders, K. E., & O’Connor, R. C. (2012). Self-harm andsuicide in adolescents.The Lancet, 379,2373–2382.http://dx.doi.org/10.1016/S0140-6736(12)60322-5This document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.508BOYLAN, CHAHAL, COURTNEY, SHARP, AND BENNETT
Heerde, J. A., Toumbourou, J. W., Hemphill, S. A., Herrenkohl, T. I.,Patton, G. C., & Catalano, R. F. (2015). Incidence and course ofadolescent deliberate self-harm in Victoria, Australia and WashingtonState.Journal of Adolescent Health, 57,537–544.http://dx.doi.org/10.1016/j.jadohealth.2015.07.017Horesh, N., Orbach, I., Gothelf, D., Efrati, M., & Apter, A. (2003).Comparison of the suicidal behavior of adolescent inpatients with bor-derline personality disorder and major depression.Journal of Nervousand Mental Disease, 191,582–588.http://dx.doi.org/10.1097/01.nmd.0000087184.56009.61Jacobson, C. M., Muehlenkamp, J. J., Miller, A. L., & Turner, J. B. (2008).Psychiatric impairment among adolescents engaging in different types ofdeliberate self-harm.Journal of Clinical Child and Adolescent Psychol-ogy, 37,363–375.http://dx.doi.org/10.1080/15374410801955771Jorm, A. F. (2015). Using the Delphi expert consensus method in mentalhealth research.Australian and New Zealand Journal of Psychiatry, 49,887–897.http://dx.doi.org/10.1177/0004867415600891Kaess, M., Brunner, R., & Chanen, A. (2014). Borderline personalitydisorder in adolescence.Pediatrics, 134,782–793.Kovacs, M., Goldston, D., & Gatsonis, C. (1993). Suicidal behaviors andchildhood-onset depressive disorders: A longitudinal investigation.Journal of the American Academy of Child and Adolescent Psychiatry,32,8–20.http://dx.doi.org/10.1097/00004583-199301000-00003LeFevre, M. L. (2014, May). Screening for suicide risk in adolescents,adults, and older adults in primary care: U.S. Preventive Services TaskForce recommendation statement.Annals of Internal Medicine, 160,719–726.http://dx.doi.org/10.7326/M14-0589Lenzenweger, M. F., & Castro, D. D. (2005). Predicting change in bor-derline personality: Using neurobehavioral systems indicators within anindividual growth curve framework.Development and Psychopathology,17,1207–1237.http://dx.doi.org/10.1017/S0954579405050571Linehan, M. (1993).Cognitive-behavioral treatment of borderline person-ality disorder. New York, NY: Guilford Press.Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., & Heard, H. L.(1991). Cognitive-behavioral treatment of chronically parasuicidal bor-derline patients.Archives of General Psychiatry, 48,1060–1064.http://dx.doi.org/10.1001/archpsyc.1991.01810360024003Madge, N., Hewitt, A., Hawton, K., de Wilde, E. J., Corcoran, P., Fekete,S., . . . Ystgaard, M. (2008). Deliberate self-harm within an internationalcommunity sample of young people: Comparative findings from theChild & Adolescent Self-harm in Europe (CASE) Study.Journal ofChild Psychology and Psychiatry, 49,667–677.http://dx.doi.org/10.1111/j.1469-7610.2008.01879.xMorey, L. C. (2007).Personality Assessment Inventory (PAI): professionalmanual. Odessa, FL: Psychological Assessment Resources.Mullins-Sweatt, S. N., Edmundson, M., Sauer-Zavala, S., Lynam, D. R.,Miller, J. D., & Widiger, T. A. (2012). Five-factor measure of borderlinepersonality traits.Journal of Personality Assessment, 94,475–487.http://dx.doi.org/10.1080/00223891.2012.672504National Collaborating Centre for Mental Health (U.K.). (2004).Self-Harm: The short-term physical and psychological management andsecondary prevention of self-harm in primary and secondary care.Leicester, United Kingdom: British Psychological Society. Retrievedfromhttp://www.ncbi.nlm.nih.gov/books/NBK56385/National Institute for Health and Care Excellence. (2009).Borderlinepersonality disorder: Recognition and management. Retrieved fromhttps://www.nice.org.uk/guidance/cg78/chapter/About-this-guidelineNational Institute for Health and Care Excellence. (2012).Self-harm inover 8s: Long-term management. Retrieved fromhttps://www.nice.org.uk/guidance/cg133Noblin, J. L., Venta, A., & Sharp, C. (2014). The validity of the MSI-BPDamong inpatient adolescents.Assessment, 21,210–217.http://dx.doi.org/10.1177/1073191112473177Nock, M. K., Joiner, T. E., Jr., Gordon, K. H., Lloyd-Richardson, E., &Prinstein, M. J. (2006). Non-suicidal self-injury among adolescents:Diagnostic correlates and relation to suicide attempts.Psychiatry Re-search, 144,65–72.http://dx.doi.org/10.1016/j.psychres.2006.05.010Panos, P. T., Jackson, J. W., Hasan, O., & Panos, A. (2014). Meta-analysisand systematic review assessing the efficacy of dialectical behaviortherapy (DBT).Research on Social Work Practice, 24,213–223.http://dx.doi.org/10.1177/1049731513503047Patton, G. C., Hemphill, S. A., Beyers, J. M., Bond, L., Toumbourou, J. W.,McMorris, B. J., & Catalano, R. F. (2007). Pubertal stage and deliberateself-harm in adolescents.Journal of the American Academy of Child andAdolescent Psychiatry, 46,508–514.http://dx.doi.org/10.1097/chi.0b013e31803065c7Penn, J. V., & Thomas, C. (2005). Practice parameter for the assessmentand treatment of youth in juvenile detention and correctional facilities.Journal of the American Academy of Child and Adolescent Psychiatry,44,1085–1098.http://dx.doi.org/10.1097/01.chi.0000175325.14481.21Plener, P. L., Brunner, R., Fegert, J. M., Groschwitz, R. C., In-Albon, T.,Kaess, M., . . . Becker, K. (2016). Treating nonsuicidal self-injury(NSSI) in adolescents: Consensus based German guidelines.Child andAdolescent Psychiatry and Mental Health, 10,46.http://dx.doi.org/10.1186/s13034-016-0134-3Poreh, A. M., Rawlings, D., Claridge, G., Freeman, J. L., Faulkner, C., &Shelton, C. (2006). The BPQ: A scale for the assessment of borderlinepersonality based onDSM–IVcriteria.Journal of Personality Disorders,20,247–260.http://dx.doi.org/10.1521/pedi.2006.20.3.247Ribeiro, J. D., Franklin, J. C., Fox, K. R., Bentley, K. H., Kleiman, E. M.,Chang, B. P., & Nock, M. K. (2016). Self-injurious thoughts andbehaviors as risk factors for future suicide ideation, attempts, and death:A meta-analysis of longitudinal studies.Psychological Medicine, 46,225–236.http://dx.doi.org/10.1017/S0033291715001804Ryle, A., & Kerr, I. B. (2002).Introducing cognitive analytic therapy:Principles and practice. Chichester, United Kingdom: Wiley.http://dx.doi.org/10.1002/9780470713587Schuppert, H. M., Giesen-Bloo, J., van Gemert, T. G., Wiersema, H. M.,Minderaa, R. B., Emmelkamp, P. M. G., & Nauta, M. H. (2009).Effectiveness of an emotion regulation group training for adolescents-arandomized controlled pilot study: Effectiveness of an emotion regula-tion group training for adolescents.Clinical Psychology and Psycho-therapy, 16,467–478.http://dx.doi.org/10.1002/cpp.637Schuppert, H. M., Timmerman, M. E., Bloo, J., van Gemert, T. G.,Wiersema, H. M., Minderaa, R. B., . . . Nauta, M. H. (2012). Emotionregulation training for adolescents with borderline personality disordertraits: A randomized controlled trial.Journal of the American Academyof Child and Adolescent Psychiatry, 51,1314–1323.e2.http://dx.doi.org/10.1016/j.jaac.2012.09.002Sharp, C. (2016). Bridging the gap: The assessment and treatment ofadolescent personality disorder in routine clinical care.Archives ofDisease in Childhood, 102,103–108.Sharp, C., & Fonagy, P. (2015). Practitioner review: Borderline personalitydisorder in adolescence—Recent conceptualization, intervention, andimplications for clinical practice.Journal of Child Psychology andPsychiatry, 56,1266–1288.http://dx.doi.org/10.1111/jcpp.12449Sharp, C., Green, K. L., Yaroslavsky, I., Venta, A., Zanarini, M. C., &Pettit, J. (2012). The incremental validity of borderline personalitydisorder relative to major depressive disorder for suicidal ideation anddeliberate self-harm in adolescents.Journal of Personality Disorders,26,927–938.http://dx.doi.org/10.1521/pedi.2012.26.6.927Sharp, C., Mosko, O., Chang, B., & Ha, C. (2011). The cross-informantconcordance and concurrent validity of the Borderline Personality Fea-tures Scale for Children in a community sample of boys.Clinical ChildPsychology and Psychiatry, 16,335–349.http://dx.doi.org/10.1177/1359104510366279This document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.509ROLE OF BPD IN SELF-HARM CPGS
Sharp, C., Steinberg, L., Temple, J., & Newlin, E. (2014). An 11-itemmeasure to assess borderline traits in adolescents: Refinement of theBPFSC using IRT.Personality Disorders: Theory, Research, and Treat-ment, 5,70–78.http://dx.doi.org/10.1037/per0000057Sharp, C., Tackett, J. L., & Oldham, J. M. (Eds.). (2014).Handbook ofborderline personality disorder in children and adolescents. New York,NY: Springer-Verlag.http://dx.doi.org/10.1007/978-1-4939-0591-1Weissman, M. M., Wolk, S., Wickramaratne, P., Goldstein, R. B., Adams,P., Greenwald, S., . . . Steinberg, D. (1999). Children with prepubertal-onset major depressive disorder and anxiety grown up.Archives ofGeneral Psychiatry, 56,794–801.http://dx.doi.org/10.1001/archpsyc.56.9.794White, J. (2014).Practice guidelines for working with children and youthat-risk for suicide in community mental health settings. Retrieved fromhttps://www2.gov.bc.ca/assets/gov/health/managing-your-health/mental-health-substance-use/child-teen-mental-health/practice_guidelines_children_youth_at_risk_suicide.pdfWorking Group of the Clinical Practice Guideline for Prevention & Treat-ment of Suicidal Behaviour. (2012).Clinical practice guideline for thepre-vention and treatment of suicidal behaviour. Ministry of Health,Social Policy and Equality National Health System Quality Plan. Gali-cian Agency for Health Technology Assessment (avalia-t), SNS ClinicalPractice Guidelines: Avalia-t 2010/0 2. Retrieved fromhttp://content.guidelinecentral.com/guideline/get/pdf/2934Yen, S., Shea, M. T., Pagano, M., Sanislow, C. A., Grilo, C. M.,McGlashan, T. H., . . . Morey, L. C. (2003). Axis I and axis II disordersas predictors of prospective suicide attempts: Findings from the collab-orative longitudinal personality disorders study.Journal of AbnormalPsychology, 112,375–381.http://dx.doi.org/10.1037/0021-843X.112.3.375Zanarini, M. C. (2003).Childhood Interview for DSM–IV borderlinepersonality disorder (CI-BPD). Belmont, MA: McLean Hospital.Zanarini, M. C., Frankenburg, F. R., Reich, D. B., & Fitzmaurice, G.(2010). The 10-year course of psychosocial functioning among patientswith borderline personality disorder and axis II comparison subjects.Acta Psychiatrica Scandinavica, 122,103–109.http://dx.doi.org/10.1111/j.1600-0447.2010.01543.xZanarini, M. C., Vujanovic, A. A., Parachini, E. A., Boulanger, J. L.,Frankenburg, F. R., & Hennen, J. (2003). A screening measure for BPD:The McLean screening instrument for borderline personality disorder(MSI-BPD).Journal of Personality Disorders, 17,568–573.http://dx.doi.org/10.1521/pedi.17.6.568.25355This document is copyrighted by the American Psychological Association or one of its allied publishers.This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.510BOYLAN, CHAHAL, COURTNEY, SHARP, AND BENNETT