It is commonly believed that borderline personality disorder [BPD] cannot be diagnosed in adolescents. Symptomatic adolescents with potential BPD are typically diagnosed with Axis I conditions,1 leading to inappropriate treatments and exacerbating serious problems such as suicidality, delinquency, academic failure, social dysfunction, substance abuse,1 impaired self-care, and an increased risk of developing actual Axis I disorders in the future.2

Reluctance to diagnose BPD in adolescence is no longer justified, according to Chanen and McCutcheon, whose article “Prevention and Early Intervention for Borderline Personality Disorder” outlines methods of early diagnosis and intervention in adolescents with suspected BPD. In fact, current evidence suggests that there is considerable “flexibility and malleability” of BPD in youth, making adolescence a “key developmental period” for intervention.

Risk Factors and Precursor Signs and Symptoms of BPD in Youth

The authors list genetic, neurobiological, psychopathologic, and environmental risk factors for the development of BPD. Although no specific gene has been implicated in the development of BPD, evidence supports a gene-environment interaction—ie, increased risk when a “sensitive genotype” is coupled with a “predisposing environment.”1 Additional risk factors include adverse childhood experiences, early relationship difficulties, parental problems, maladaptive parenting or school experiences, childhood abuse or neglect, physical and sexual abuse, and low socioeconomic status.

Early precursors (but not necessary predictors) of the development of BPD include oppositional defiant disorder (ODD), conduct disorder, substance use, depression, self-harm, and disturbances in attention, emotional regulation, and behavior during childhood and adolescence. In particular, self-harm, a “core feature” of BPD, has childhood onset in more than 30% of those with BPD, and adolescent onset in another 30%.3

The authors note that “dimensional representations of BPD” (impulsivity, negative affectivity, and interpersonal aggression) have similar stability in childhood, adolescence, and adulthood, and can be measured and directly targeted for interventions. They advise that disruptive behavior and depressive disorders, self-harm, and substance use should be specifically regarded as targets for indicated prevention of BPD, rather than “separate domains of psychopathology” that might later be reframed as BPD in adulthood.