Borderline Symptoms at Age 12 Signal Risk for Poor Outcomes During the Transition to Adulthood: Findings From a Genetically Sensitive Longitudinal Cohort Study


Our follow-up of 12-year-olds with borderline symptoms to age 18 revealed three main findings. First, at a time in life when young people take a leap toward greater social, economic, and personal maturity, study members with a history of borderline symptoms were held back by psychosocial difficulties. Difficulties were evident in numerous areas (personality; psychopathology; vocational, health, and social functioning; and experiences of victimization); observed by multiple informants; and assessed through multiple methods, including official records. Differences in outcomes were striking: young people with the highest borderline symptom scores at age 12 were nearly three times more likely to engage in suicidal and self-harming behavior, to find themselves without training or job opportunities, to have a criminal record, and to have experienced victimization compared with their cohort peers with lower symptom scores. These findings show that adolescent borderline symptoms observed as early as at age 12 forecast meaningful individual differences in young people’s lives.

Second, although many 12-year-olds experienced behavioral and emotional problems alongside their borderline symptoms, borderline symptoms added incremental value to predicting most poor outcomes over and above these other problems, indicating that the later-life impairments associated with adolescent borderline pathology are insufficiently described by these problems. Notably, behavioral and emotional problems of 12-year-olds accounted for associations with nearly all of their psychiatric diagnoses at age 18, but did not account for associations with many other adverse outcomes. This finding illustrates that psychiatric diagnoses do not capture the full scope of life challenges associated with adolescent borderline symptoms and shows that it is important to look beyond psychiatric status when testing the predictive validity of adolescent borderline symptoms.

Third, borderline symptoms of 12-year-olds were under considerable genetic influence, and genetically identical twins of children with elevated borderline symptoms were at increased risk for poor outcomes even if they did not have equally elevated borderline symptoms themselves. This finding raises three issues. First, it raises the question of why twins with the same genetic susceptibility do not share similar borderline symptoms. Our previous study pointed to twins’ unique environmental experiences as a possible explanation: we reported that twins in the same families experienced different levels of harsh parental treatment and that adolescents’ genetic vulnerability interacted with harsh parental treatment in the etiology of borderline symptoms.12x12Belsky, D.W., Caspi, A., Arseneault, L. et al. Etiological features of borderline personality related characteristics in a birth cohort of 12-year-old children. Dev Psychopathol. 2012;
24: 251–265
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Our work expands on previous literature in three ways. First, although several studies have investigated the clinical and psychosocial outcomes of borderline personality disorder, a recent systematic review concluded that many of these studies have limitations, such as sampling bias, high rates of attrition, and a narrow range of psychosocial outcomes.11x11Winsper, C., Marwaha, S., Lereya, S.T., Thompson, A., Eyden, J., and Singh, S.P. Clinical and psychosocial outcomes of borderline personality disorder in childhood and adolescence: a systematic review. Psychol Med. 2015;
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Our findings should be interpreted in light of some limitations. First, we did not make a formal diagnosis of borderline personality disorder. Without a replication in adolescents with a diagnosis of borderline personality disorder, we cannot be sure that our findings generalize to this population. However, our measure captures core diagnostic features of borderline personality disorder (affective instability, cognitive disturbance, impulsivity, and interpersonal dysfunction), and our previous study showed that the etiological factors, comorbidity, sex differences, and heritability of our measure of borderline symptoms are comparable to results from studies of borderline personality disorder in community samples.10x10Winograd, G., Cohen, P., and Chen, H. Adolescent borderline symptoms in the community: prognosis for functioning over 20 years. J Child Psychol Psychiatry. 2008;
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Crossref | PubMed | Scopus (81)
| Google ScholarSee all References
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Second, a general weakness of discordant twin analyses is their higher likelihood of false-negative findings because the limited variation within twin pairs magnifies the impact of measurement error and reduces the precision of estimates.36x36Boardman, J.D. and Fletcher, J.M. To cause or not to cause? That is the question, but identical twins might not have all of the answers. Soc Sci Med. 2015;
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Our findings have implications for health professionals working with adolescents who display borderline symptoms. First, our findings support the assessment of adolescents’ borderline symptoms in addition to other emotional and behavioral disorders if borderline pathology is suspected. Some clinicians are thought to prefer assessing only emotional and behavioral disorders in adolescents presenting with borderline symptoms, perhaps to avoid a stigmatizing diagnosis of personality disorder.6x6Miller, A.L., Muehlenkamp, J.J., and Jacobson, C.M. Fact or fiction: diagnosing borderline personality disorder in adolescents. Clin Psychol Rev. 2008;
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However, our findings and findings of others show that adolescents’ borderline symptoms provide independent prognostic information. Second, our findings argue in favor of early access to treatment for adolescents with borderline symptoms and against a wait-and-see approach.39x39Chanen, A., Sharp, C., and Hoffman, P. Global Alliance for Prevention and Early Intervention for Borderline Personality Disorder. Prevention and early intervention for borderline personality disorder: a novel public health priority. World Psychiatry. 2017;
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