Targeted Early Intervention
Two novel early intervention programs have been developed in Australia and the Netherlands.4-6 The Australian Helping Young People Early (HYPE) and Dutch Emotional Regulation Training (ERT) programs. 4,5 Their inclusion criteria are broad, encompassing not only adolescents with BPD but also with BPD and co-occurring conditions (such as substance abuse). Both programs approach BPD dimensionally, combining subsyndromal (“indicated prevention”) and syndromal (“early intervention”) presentations of the disorder. Both programs are time-limited, lasting between 16 and 24 sessions, and both adapt adult-oriented interventions (eg, cognitive-analytic therapy and Systems Training for Emotional Predictability and Problem Solving [STEPPS] respectively) to make them developmentally suitable for adolescents.
Results from two trials found that ERT plus treatment as usual did not yield substantially superior outcomes to self-standing treatment as usual,5 while HYPE—which employs a comprehensive, team-based intervention—achieved faster rates of improvement in internalizing and externalizing psychopathology, and lower levels of psychopathology at two-year follow-up.7 The authors outline the effective elements in the HYPE intervention:
- Assertive, psychologically informed case management integrated with individual psychotherapy
- Active integration of family and caregivers, with psychoeducation and family intervention
- General psychiatric care by the same team, including assessment and treatment of psychiatric comorbidities and pharmacotherapy when indicated
- Outreach care in the community, with flexible timing and location of intervention
- Crisis team and inpatient care, using brief, goal-directed approaches
- Access to psychosocial recovery program
- Individual and group supervision of staff
- Quality assurance program
Barriers to Treatment of Adolescents with BPD
BPD is frequently regarded negatively by health care professionals as well as patients. The authors point out that the “well-intentioned” reluctance on the part of clinicians to diagnose BPD in adolescents so as to “protect” them from stigma is actually counterproductive because it perpetuates negative stereotypes, reduces the chance that the patient will receive beneficial interventions, and increases the likelihood of inappropriate and potentially harmful interventions (such as polypharmacy). They note that the National Institute for Health and Clinical Excellence (NICE) Guideline supports the diagnosis of BPD in adolescents.8
The authors conclude that BPD should be regarded as a “lifespan developmental disorder” and suggest that future research should be undertaken to focus on the development of “clinical staging for BPD,” analogous to disease staging in general medicine. This might offer a “potential integrating framework for selecting appropriate interventions and predicting outcome,” with treatments tailored to different phases, ages, and stages of the disorder.