4a
Eric M. Vernberg and Madelaine Abel
Sharp and De Clercq (this volume) summarize several major issues in applying concepts and knowledge derived from the study of personality disorders (and personality pathology) in adults to children and adolescents. The most compelling arguments in favor of incorporating these concepts and knowledge include (1) recognition that some clinical features and diagnostic symptoms of personality disorders and pathology in adults begin to emerge during adolescence, and (2) that the extensive body of research on the identification and treatment of personality disorders in adults may inform efforts focused on the early identification and treatment of nascent personality pathology in adolescence before a more severe and intransigent personality disorder emerges. A number of challenges to synthesizing and integrating knowledge from a personality pathology perspective to adolescents are also noted and discussed.
The authors focus on efforts to measure and treat borderline personality pathology (BPP) among children and adolescents to illustrate potential benefits and challenges of applying a personality pathology framework in research and intervention. They note difficulties that arise when using interview-based tools validated with adults (such as the SCID modules for assessing personality disorders in DSM-IV) with adolescents, and describe efforts to validate and refine more developmentally-sensitive interviews for assessing BPP. Important points from their summary include that BPP as measured in these alternative interviews tends to have a unidimensional factor structure and may be an indicator of the presence and severity of a more general personality pathology, rather than borderline personality disorder (BPD) per se. This point of view fits well with other lines of research suggesting that the self-system generally becomes more differentiated, domain-specific, and stable over the course of adolescence and emerging adulthood (e.g., Rosen, 2016). Similarly, research on the MMPI-A often suggests that this downward extension of the MMPI for adults tends to provide an index of an adolescent’s current distress and impairment, rather than a measure of the more discrete dimensions of personality that are typically found among adults (Baer, Wetter, & Berry, 1992). In other words, the underlying dimensions of personality (and personality pathology) found in adults may not yet have emerged in children and adolescents, although difficulties indicative of more general personality pathology may be discernible.
In their discussion of dimensional versus categorical approaches for measuring BPP and BPD among youth, Sharp and De Clerq argue that there is stronger empirical support for taking a dimensional approach to assessing BPP. Whether or not current measures of BPP for youth indicate BPD specifically or severity of overall personality pathology, symptoms of personality pathology in adolescents may be present without reaching full diagnostic criteria for a personality disorder and still cause functional impairment and indicate increased risk for developing a personality disorder in adulthood. At a practical level, if researchers and clinicians are able to accurately identify and address severe behavioral symptoms related to personality pathology without these youth receiving a diagnosis, there may be no additional benefit to the personality disorder diagnosis for children or adolescents. Symptoms may still be treated even without the diagnosis. In fact, many of the commonly used treatment manuals for youth are symptom specific, rather than focused on diagnoses directly (e.g., Chorpita & Weisz, 2009). Conversely, the authors suggest that a categorical approach to BPD may be more realistic in clinical practice settings in which assessment and treatment planning are often constrained by the categorical presence or absence of a diagnosis.
Regardless, accurate diagnosis of a personality disorder among youth may be difficult due to the overlap between many BPP symptoms and traits common to other youth mental health problems. The strong covariance of symptoms across disorders may increase the likelihood of false positives. Moreover, it is often hard to tease apart the underlying causes of symptoms of various youth mental health disorders. For example, distinguishing between oppositional or disruptive behaviors that may be due to anxiety, neurodevelopmental disorders that interfere with social understanding (such as autism spectrum disorder), or antisocial traits can be challenging, and comorbidity rates are often high among children. Thus, we must consider if there is an actual benefit to the BPD diagnosis, particularly when there are other means through which children can receive appropriate accommodations and services without the BPD label. The overall trend in clinical child and adolescent psychology toward developing transdiagnostic interventions that address specific problem behaviors and distress may make questions related to categorical diagnoses (including personality disorders) less relevant over time (McHugh, Murrary, & Barlow, 2009). At the same time, it is worth noting that the effort to identify and validate transdiagnostic intervention strategies and techniques is sometimes misunderstood to imply that a specific problem behavior (such as oppositional or disruptive behavior) would be addressed in the same manner regardless of diagnosis. Instead, an idiographic clinical case formulation of the underlying processes (both internal and environmental) that contribute to the emergence and maintenance of a specific problem behavior for a specific child or adolescent guides the selection of intervention approaches (e.g., Chu, 2012). In this context, more valid and reliable measures of personality pathology in children and adolescents could be extremely helpful in guiding clinical case formulation and decision-making.
It is also important to comment on the need for greater understanding of developmental pathways and processes that distinguish between maturation-related rises and declines in patterns of thoughts, emotions, and behaviors that appear similar to personality pathology versus symptom trajectories that presage the emergence of a personality disorder in adulthood. As the authors highlight, BPP symptom trajectories are likely influenced by the interplay of personal characteristics (including neurobiological vulnerabilities) and environmental factors. Longitudinal research using a combination of person-centered and variable-centered analytic strategies, such as latent growth mixture modeling (Muthén & Muthén, 2000), to identify common trajectories of BPP symptoms from childhood through adolescence may help elucidate why some youth with elevated BPP develop BPD later in life whereas others do not. For example, the severity of early symptoms and the presence of certain symptom patterns over time (e.g., high, stable levels versus normative decline), either alone or in combination with key environmental factors (e.g., prolonged exposure to invalidating environments or otherwise disrupted attachment relationships), may predict eventual diagnosis of BPD. As suggested by the authors and others (e.g., Crowell, Kaufman, & Lenzenweger, 2013), there may be multiple developmental pathways that lead to BPD.
In many ways, concepts emerging from a developmental psychopathology perspective fit well with both categorical and dimensional approaches to understanding personality pathology. For example, Sharp and De Clercq note the utility of the concepts of homotypic and heterotypic continuity for understanding how an underlying core form of psychopathology may result in different clusters and types of symptoms at different points in development during childhood and adolescence. The extensive body of research on the emergence and persistence of disruptive and antisocial behavior from early childhood through adolescence (and into adulthood) shows that manifestations of an underlying conduct disorder emerge early in life and continue into adulthood for a subset of children. The neurobiological vulnerabilities and environmental risk factors that contribute to this early-onset and persistent pattern of antisocial and disruptive behavior are increasingly well-documented. The diagnostic criteria for conduct disorder in DSM-5 (American Psychiatric Association, 2013) include a specifier to indicate if the individual shows a persistent pattern of limited prosocial emotions such as lack of remorse or guilt, shallow or deficient affect, or a callous lack of empathy for or concern about the feelings of others. These persistent, trait-like characteristics of conduct disorder in children and adolescents overlap considerably with diagnostic criteria for antisocial personality disorder (ASPD) and the presence of conduct disorder with onset before the age of 15 years old is one of the diagnostic criteria for ASPD. Although Sharp and De Clerq use BPP/BPD to illustrate their perspective on personality pathology in youth, many of their points are relevant to attempts to synthesize the substantial bodies of research on the emergence of conduct disorder among children and ASPD among adults. Indeed, in the case of childhood-onset conduct disorder, manifestations of a persistent underlying personality pathology seem to be present at an even younger age than described by Sharp and De Clerq in their discussion of BPP (e.g., White, Moffitt, Earls, Robins, & Silva, 1990).
It is not difficult to accept the notion that some children and adolescents may have early manifestations of persistent patterns of thoughts, emotions, and behavior characteristic of (or similar to) personality pathology. The bigger challenge is to integrate and synthesize research conducted predominantly with adults from a personality pathology perspective with the increasingly robust research conducted with children and adolescents from a developmental psychopathology perspective. There is clearly an ongoing debate about how to reconcile the categorical diagnostic system represented by DSM with the more dimensional approaches used in much of the research on developmental psychopathology. Would it be useful to allow adolescents (or children) to receive a personality disorder diagnosis? In a diagnostic system already fraught with overlapping diagnostic criteria and the frequent diagnosis of multiple co-occurring conditions among children and adolescents, it is difficult to imagine how this would be helpful. However, there seems to be potential value to applying concepts and knowledge derived from the study of personality pathology to clinical case formulation and treatment planning for children and adolescents. In our opinion, a number of concepts from a personality pathology perspective have already been incorporated into research with children and adolescents from a developmental psychopathology perspective (e.g., Crowell et al., 2013). Additional translation and synthesis of concepts and knowledge derived from personality pathology and developmental psychopathology perspectives could be very helpful. Sharp and De Clercq’s work represents a good model for this effort.
References
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