Prospective study of family adversity and maladaptive parenting in childhood and borderline personality disorder symptoms in a non-clinical population at 11 years

Background Retrospective studies have consistently indicated an association between maladaptive parenting and borderline personality disorder (BPD). This requires corroboration with prospective, longitudinal designs. We investigated the association between suboptimal parenting and parent conflict in childhood and BPD symptoms in late childhood using a prospective sample. Method A community sample of 6050 mothers and their children (born between April 1991 and December 1992) were assessed. Mothers' family adversity was assessed during pregnancy and parenting behaviours such as hitting, shouting, hostility and parent conflict across childhood. Intelligence quotient (IQ) and DSM-IV Axis I diagnoses were assessed at 7–8 years. Trained psychologists interviewed children at 11 years (mean age 11.74 years) to ascertain BPD symptoms. Results After adjustment for confounders, family adversity in pregnancy predicted BPD probable 1 to 2 adversities: odds ratio (OR)=1.34 [95% confidence interval (CI) 1.01–1.77]; >2 adversities: OR 1.99 (95% CI 1.34–2.94) and definite 1 to 2 adversities: OR 2.48 (95% CI 1.01–6.08) symptoms. Each point increase in the suboptimal parenting index predicted BPD probable: OR 1.13 (95% CI 1.05–1.23) and definite: OR 1.28 (95% CI 1.03–1.60) symptoms. Parent conflict predicted BPD probable: OR 1.19 (95% CI 1.06–1.34) and definite: OR 1.42 (95% CI 1.06–1.91) symptoms. Within the path analysis, the association between suboptimal parenting and BPD outcome was partially mediated by DSM-IV diagnoses and IQ at 7–8 years. Conclusions Children from adverse family backgrounds, who experience suboptimal parenting and more conflict between parents, have poor cognitive abilities and a DSM-IV diagnosis, are at increased risk of BPD symptoms at 11 years

The developmental precursors of borderline personality disorder symptoms at 11 years in a British cohort

Borderline Personality Disorder (BPD) is a severe and chronic mental health disorder, affecting many areas of functioning including: affect regulation, impulse control, interpersonal relationships and self-image. Causal factors are only partly known due to a scarcity of prospective, longitudinal studies which enable one to delineate the time ordering of antecedents, and allow for tentative causal inferences. This thesis explored the developmental precursors of BPD symptoms at 11 years, using a British cohort sample, with assessments pertaining to the study child from pregnancy to 11 years of age. Three studies were conducted. Firstly, the predictive relationship between exposure to maladaptive parenting and subsequent BPD symptoms was explored within a child population, using a clinically relevant assessment of BPD symptoms. This association has been previously shown in a range of retrospective studies. Secondly, the role of peer victimisation in the development of BPD was considered. This study was designed to extend current aetiological models, which focus on parental rather than peer relationships. It was based on the recognition of a strong interpersonal core in the BPD symptom constellation, and the role of trauma experiences in the development of BPD. Finally, the third study was designed to consider how these two experiential factors (maladaptive parenting and peer victimisation) might magnify a predisposition towards dysregulation, eventually culminating in BPD symptoms. Data was obtained from the Avon Longitudinal Study of Parents and Children (ALSPAC), which studied 6,050 children (43.1% of the total sample population), using questionnaire and interview assessments. Results revealed that, firstly, family adversity during pregnancy and suboptimal parenting, during early to middle childhood was predictive of BPD symptoms at 11 years. Secondly, peer victimisation during early to late childhood was predictive of BPD symptoms at 11 years. There was an especially strong dose response effect for severe, combined or chronic victimisation. Finally, those evincing stable dysregulated trait behaviour from 4 to 8 years were more likely to develop BPD symptoms, and this effect was especially strong for high levels of dysregulation. Consistent with the biosocial developmental model of BPD, the association was fully mediated by psychosocial risk factors (peer victimisation). Those with high levels of dysregulation were more likely to be victimised and, in turn, develop BPD symptoms. Further, the indirect associations were significantly stronger for BPD, compared to psychotic or depression outcomes. The strengths and weaknesses, along with practical and theoretical implications, and future directions are discussed in the final chapter

Cannabis use and hypomania in young people: a prospective analysis

Background: Cannabis use in young people is common and associated with psychiatric disorders. However, the prospective link between cannabis use and bipolar disorder symptoms has rarely been investigated. The study hypothesis was that adolescent cannabis use is associated with hypomania in early adulthood via several potential etiological pathways. Methods: Data were used from the Avon Longitudinal Study of Parents and Children, a UK birth cohort study. The prospective link between cannabis use at age 17 and hypomania at age 22–23 years was tested using regression analysis, adjusted for gender, early environmental risk factors, alcohol and drug use, and depression and psychotic symptoms at age 18 years. Path analysis examined direct and indirect effects of the link and whether gender, childhood family adversity, or childhood abuse are associated with hypomania via an increased risk of cannabis use. Results: Data were available on 3370 participants. Cannabis use at least 2–3 times weekly was associated with later hypomania (OR = 2.21, 95% CI = 1.49–3.28) after adjustment. There was a dose–response relationship (any use vs weekly). Cannabis use mediated the association of both childhood sexual abuse and hypomania, and male gender and hypomania. The cannabis use-hypomania link was not mediated by depression or psychotic symptoms. Conclusions: Adolescent cannabis use may be an independent risk factor for future hypomania, and the nature of the association suggests a potential causal link. Cannabis use mediates the link between childhood abuse and future hypomania. As such it might be a useful target for indicated prevention of hypomania

Improving mental healthcare access and experience for people from minority ethnic groups: an England-wide multisite experience-based codesign (EBCD) study

Background Long-standing ethnic inequalities in access and mental healthcare were worsened by the COVID-19 pandemic. Objectives Stakeholders coproduced local and national implementation plans to improve mental healthcare for people from minority ethnic groups. Methods Experience-based codesign conducted in four areas covered by National Health Service (NHS) mental health trusts: Coventry and Warwickshire, Greater Manchester, East London and Sheffield. Data were analysed using an interpretivist–constructivist approach, seeking validation from participants on their priority actions and implementation plans. Service users (n=29), carers (n=9) and health professionals (n=33) took part in interviews; focus groups (service users, n=15; carers, n=8; health professionals, n=24); and codesign workshops (service users, n=15; carers, n=5; health professionals, n=21) from July 2021 to July 2022. Findings Each study site identified 2–3 local priority actions. Three were consistent across areas: (1) reaching out to communities and collaborating with third sector organisations; (2) diversifying the mental healthcare offer to provide culturally appropriate therapeutic approaches and (3) enabling open discussions about ethnicity, culture and racism. National priority actions included: (1) co-ordination of a national hub to bring about system level change and (2) recognition of the centrality of service users and communities in the design and provision of services. Conclusions Stakeholder-led implementation plans highlight that substantial change is needed to increase equity in mental healthcare in England. Clinical implications Working with people with lived experience in leadership roles, and collaborations between NHS and community organisations will be essential. Future research avenues include comparison of the benefits of culturally specific versus generic therapeutic interventions

Sleep problems in childhood and borderline personality disorder symptoms in early adolescence

Sleep disorders, such as insomnia and nightmares, are commonly associated with Borderline Personality Disorder (BPD) in adulthood. Whether nightmares and sleep-onset and maintenance problems predate BPD symptoms earlier in development is unknown. We addressed this gap in the literature using data from the Avon Longitudinal Study of Parents and Children (ALSPAC). Participants included 6,050 adolescents (51.4% female) who completed the UK Childhood Interview for DSM-IV BPD at 11 to 12 years of age. Nightmares and sleep onset and maintenance problems were prospectively assessed via mother report when children were 2.5, 3.5, 4.8 and 6.8 years of age. Psychopathological (i.e., emotional temperament; psychiatric diagnoses; and emotional and behavioural problems) and psychosocial (i.e., abuse, maladaptive parenting, and family adversity) confounders were assessed via mother report. In logistic regressions, persistent nightmares (i.e., regular nightmares at three or more time-points) were significantly associated with BPD symptoms following adjustment for sleep onset and maintenance problems and all confounders (Adjusted Odds Ratio=1.67; 95% Confidence Interval=1.18, 2.38). Persistent sleep onset and maintenance problems were not significantly associated with BPD symptoms. In path analysis controlling for all associations between confounders, persistent nightmares independently predicted BPD symptoms (Probit co-efficient [β] = 0.08, p = 0.013). Emotional and behavioural problems significantly mediated the association between nightmares and BPD (β =0.016, p<0.001), while nightmares significantly mediated associations between emotional temperament (β=0.001, p=0.018), abuse (β=0.015, p=0.018), maladaptive parenting (β=0.002, p=0.021) and subsequent BPD. These findings tentatively support that childhood nightmares may potentially increase the risk of BPD symptoms in early adolescence via a number of aetiological pathways. If replicated, the current findings could have important implications for early intervention, and assist clinicians in the identification of children at risk of developing BPD

Prevalence of mental disorders and symptoms among incarcerated youth : a meta-analysis of 30 studies

Incarcerated youth have high levels of mental disorders. However, there are no up-to-date reviews examining the prevalence rates of a broad range of mental disorders and symptoms across youth justice populations. The current review aims to bridge this gap. We conducted a systematic search of the literature using PsycINFO, Medline, Embase, and Web of Science databases. We used meta-analyses to produce pooled prevalence figures for each mental health disorder and symptoms, and meta-regression to test for the moderating effects of covariates, such as gender. Thirty studies were included involving 8,153 participants. Meta- regression analysis showed that females had higher prevalence rates for depression, separ- ation anxiety disorder and suicide. Males had higher prevalence rates for conduct disorder and emerging antisocial personality disorder. Emerging personality disorders (borderline per- sonality disorder: 21%; 95% CI: 13–28%; antisocial personality disorder: 62%; 95% CI: 39–82%) were relatively common in both genders. The findings of this meta-analysis show the need for robust mental health services in custody settings. Adopting a developmentally focused approach would increase understanding of incarcerated youths’ needs and help to early detection of emerging personality symptoms. To improve young people’s mental health, we need to ensure that services do not misidentify young people’s needs due to diagnostic limitations

School mobility during childhood predicts psychotic symptoms in late adolescence

Background: Recently, school mobility was identified as a risk factor for psychotic symptoms in early adolescence. The extent to which this risk continues into late adolescence, and the trajectories via which this risk manifests, remain unexplored. Methods: Psychotic symptoms in 4, 720 adolescents aged 18 were ascertained by trained psychologists using the Psychosis-Like Symptoms Interview. Mothers reported on sociodemographic factors (i.e., family adversity, ethnicity, urbanicity) from pregnancy to 4 years; child’s involvement in bullying at age 6 to 7 years; residential mobility at 11 years and school mobility at 11 to 12 years. Young people reported on their friendships at 8 years, and antisocial behaviour and cannabis use at 15 years. Results: School mobility across childhood significantly predicted psychotic symptoms at 18 years (Adjusted Odds Ratio = 2.17; 95% Confidence Intervals = 1.06, 4.41). Within path analysis, school mobility (β=0.183, p=0.035); involvement in bullying (β=0.133, p=0.013); antisocial behaviour (β=0.052, p=0.004); cannabis use (β= 0.254, p=0.020); and female sex (β=0.420, p<.001) significantly predicted psychotic symptoms. Residential mobility (β=0.375, p<.001), involvement in bullying (β= 0.120, p= 0.022) and poor friendships (β= 0.038, p= 0.014) significantly predicted school mobility. Residential mobility indirectly increased risk of psychotic symptoms via school mobility (β= 0.069, p= 0.041). Conclusions: Children who move schools often are more likely to have experienced peer problems. School mobility, in turn, appears to be a robust marker for psychotic symptoms in late adolescence. Clinicians and teachers should consider school mobility as an important risk indicator for both peer problems and psychopathology

New models of care in general practice for the youth mental health transition boundary

Mental illness represents the highest proportion of disease burden for children and young people in the UK.1 However, despite this, young people can struggle to access timely and appropriate mental health care. One particular barrier to continuity of care occurs when young people reach the upper age limit (usually 18 years) of child and adolescent mental health services (CAMHS). If they require ongoing specialist support, their care should be transferred to an adult mental health service (AMHS), through a purposeful and planned transfer of care known as ‘transition’. However, only around a quarter of young people transition to AMHS,2 and in the absence of specialist adult mental health care, GPs often become involved in the young person’s care ‘by default’.3 Although GPs become responsible for the young person’s care after they leave CAMHS, they may not have the necessary skills and resources to manage complex mental health difficulties in young peopl

Psychopathological outcomes of adolescent borderline personality disorder symptoms

Objective: Despite considerable morbidity and functional losses associated with adolescent Borderline Personality Disorder (BPD), little is known about psychopathological outcomes. This study examined associations between adolescent BPD symptoms and subsequent depressive, psychotic, and hypomanic symptoms. Methods: We used data from the Avon Longitudinal Study of Parents and Children. Participants were adolescents living in the community who had data for all longitudinal outcomes (N=1758). We used logistic regression and path analysis to investigate associations between BPD (5 or more probable/definite symptoms) reported at age 11-12 years and depressive and psychotic symptoms reported at age 12 and 18, and lifetime hypomanic symptoms reported at age 22-23 years. Results: Adolescent BPD symptoms were associated with psychotic symptoms (OR: 2.36, CI: 1.82-3.06) and diagnosis of depression at age 18 years (OR: 1.30, CI: 1.03-1.64), and hypomanic symptoms (OR: 2.89, CI: 2.40-3.48) at 22-23 years. Path analysis controlling for associations between all outcomes, indicated that BPD symptoms were independently associated with depressive symptoms (β=0.97, p<.001) at 12 years and hypomanic (β=0.58, p<.01) symptoms at 22-23 years. BPD symptoms were also associated with psychotic symptoms at age 12 years (β=0.58, p<.01), which were linked (β =0.34, p<0.01) to psychotic symptoms at age 18 years. Conclusion: Adolescents with BPD symptoms are at future risk of psychotic and hypomanic symptoms, and a diagnosis of depression. Future risk is independent of associations between psychopathological outcomes, indicating that adolescent BPD symptoms have multifinal outcomes. Increasing awareness of BPD in early adolescence could facilitate timely secondary prevention of these symptoms subsequently helping to prevent future psychopathology

The sleep phenotype of Borderline Personality Disorder : a systematic review and meta-analysis

Aim: To delineate the sleep profile of Borderline Personality Disorder (BPD). Method: A meta-analysis to synthesise findings on the objective and subjective sleep characteristics of BPD. Results: We identified 32 studies published between 1980 and December 2015. Meta-analysis indicated significant differences between BPD and healthy control groups across objective sleep continuity (sleep onset latency, total sleep time, sleep efficiency) and architecture (rapid eye movement latency/density, slow wave sleep) measures, and self-reported sleep problems (nightmares, sleep quality). Findings were independent of depression (in clinical and community populations), and concomitant psychotropic medication use. There were few significant differences between BPD and clinical (majority depressed) control groups. Conclusion: BPD is associated with comparable sleep disturbances to those observed in depression. These disturbances are not solely attributable to comorbid depression. Given growing evidence that sleep disturbance may exacerbate emotional dysregulation and suicide risk, treatments for BPD should explicitly address sleep problems. Future studies should utilise prospective designs to ascertain whether (and in which circumstances) sleep problems predate or follow the onset of the disorder