September 2014
The Menninger Clinic Adolescent Treatment Program
Research
News
Handbook of BPD in Children,
Adolescents Informs Clinicians
By Carla Sharp, PhD
Director, Adolescent Treatment Program Research
W
hile Borderline
Personality Disorder (BPD) typically
emerges in adolescence, it was not until the fourth
edition of the Diagnostic and Statistical Manual of Mental Disorders
(1994) that the diagnosis of BPD in
youth was permitted. Despite this
allowance, diagnosing youth with
BPD has engendered a great deal of
reluctance for
several reasons:
The diagnosis
of personality disorders in
adolescents is
associated with
controversy due
to the erroneous
perception that
Carla Sharp, PhD
personality is
unstable in adolescence, the stigma
associated with a diagnosis of personality disorder and the suggestion
that symptoms of BPD are better
explained symptoms of other
disorders such as depression or
conduct problems.
During the past 15 years, there
has been explosion of research in
support of the diagnosis of juvenile BPD, including evidence of its
stability over time, a genetic basis,
reliable risk factors and marked
separation of course and outcome
from other disorders.
Therefore, the time was right for
an edited book to be compiled that
summarizes the literature base on
BPD in adolescents. Carla Sharp,
PhD, Director of Research for the
Menninger Adolescent Treatment
Program, took the lead in editing
the book that features international
and national experts on BPD in
adolescents.
The “Handbook of Borderline
Personality Disorder in Children
and Adolescents” was published in
May 2014 by Springer. It contains
discussion of the most recent studies in establishing adolescent BPD
as a valid and reliable disorder, its
social and biological correlations,
causes and consequences, and its
Find your survey online — https://outcomes.menninger.edu
treatment. Dr. Sharp’s own work
on BPD in adolescents is informed
and inspired by ATP patients and
relies on the outstanding work that
Elizabeth Newlin, MD, and her
teams have been doing with their
adolescents.
Newsletter Editors
Allison Kalpakci
Tessa Long
Adolescents’ Symptoms Decrease from Admission
to Post-discharge
By Salome Vanwoerden, BS
Former Research Coordinator II
Sample Characteristics at Time of Admission
Percentage of the Sample
By the Characteristics
time of discharge,
weofsaw
a
Sample
at Time
Admission
70%
60%
50%
40%
30%
20%
10%
0
decrease in symptoms64%
as measured with
61%
symptom checklists
completed by patients.
55%
49%
When looking at44%changes from admis37%
sion to discharge, we found statistically
significant reductions in depression, anxiety, emotion regulation and a significant
10%
increase in mentalizing.
clinical
eating extemalizing anxiety
lifetime
clinical
mood
After
leaving
patients
level of
disorderwent:
disorder
suicide
level of Menninger,
disorderourdisorder
attempt internalizing externalizing
• Home (53%)
problems
problems
• To residential treatment centers (29%)
• To therapeutic boarding schools (4%)
• To wilderness programs (13%)
When looking at changes from admission
to six months after discharge, we found
Depressive Symptoms
Admissionin
statistically
significantfrom
reductions
to Discharge
30 internalizing problems, externalizing
problems and total problems (an index
25 of psychiatric severity).
Moderate level
20 Internalizing problems
of Depressive
Symptoms
refer to
problems
like anxiety and depression. Externalizing
problems refer to problems like rule10 breaking and aggression toward others.
15
At Admission
Continued
on page 3 At Discharge
2
70%
70%
64%
61%
60%
49%
61%
60%
55%
50%
50%
44%
4
40%
37%
40%
30%
30%
20%
20%
10%
10%
0
lifetime
suicide
attempt
clinical
clinical
level of
level of
internalizing externalizing
problems
problems
mood
disorder
10%
eating
disorder
extemalizing
disorder
0
anxiety
disorder
Internali
Proble
Notes: All diagnostic criteria were measured by a computerized diagnostic interview with patients at the
time of admission. A mood disorder diagnosis included any of the following: major depressive disorder,
dysthymia, hypomania or mania. An eating disorder diagnosis included anorexia or bulimia. An externalizing disorder diagnosis included oppositional defiant disorder and conduct disorder. An anxiety disorder
included PTSD, generalized anxiety disorder, separation anxiety disorder, specific phobia, social phobia,
Percentage of Patie
OCD, panic disorder and agoraphobia.
Percentage of the Sample
At the time of admission to ATP, this
group was an average age of 15.18
(ranging from 12-17 years) with 62 girls
and 38 boys.
Percentage of the Sample
We are excited to share our first look at
post-discharge treatment outcomes among
ATP patients.
To study this, we chose a sub-sample
of 100 consecutive patients admitted to
ATP who consented to participate in our
outcomes study. This sample was chosen
because it was the first with a participation rate of at least 50 percent at six
months post-discharge. This number of
responses was statistically large enough to
investigate symptom change from admission to post-discharge.
Percentag
Level of S
Sample Characteristics at Time of Admission
Depressive
from
Admission
Percentage
of Symptoms
Patients64%
at or
Above
Clinical
70%
to
Discharge
61%
30Level of Severity of Symptoms
60%
70%
50%
25
60%
55%
49%
Moderate
level
37%
of Depressive
Symptoms
40%
40%
50%
30%
20
47%
44%
40%
20%
0
60%
61%
10%
24%
lifetime
suicide
attempt
clinical
clinical
level of
level of
internalizing externalizing
problems
problems
At Admission
Internalizing
Problems
mood
disorder
eating
disorder
extemalizing
disorder
anxiety
disorder
Sym
6-m
75
47%
70
40%
65
30%
Admission
20%
60
10%
55
Discharge
15
10%
30%
0
20%
10
10%
70%
50%
64%
44%
61%
Level of Severity of
0
Internalizing
50
Problems
At Discharge
Externalizing
Problems
Total Problems
Note: These levels were measured by the Youth Self-report questionnaire completed by patients at
the time of admission and discharge.
Overall Symptoms
Satisfaction
Care
Depressive
from with
Admission
to Discharge
30100
Symptom Levels from Admission to
90
6-months Post-discharge
25
Moderate level
80 75
20 70
70
Me
Symptom Lev
Ca
6-months Pos
75
70
of Depressive
%Unfavorable65
Symptoms
Cutoff for clinical level of severity
60
60
%Favorable
Internalizing
Problems
50 65
55
Externalizing
Problems
10 40 60
50
Total
30 55
Problems
At Discharge
20 At Admission
50
10 symptomsAdmission
Note: Depressive
were measured by the
Beck Depression Inventory
completed by
Discharge
6-months
patients at the
Post-discharge
0 time of admission and discharge.
Adolescents
Parents
15
120
100
80
60
40
Admission
20
0
Mean Ratin
The Menninger Clinic Adolescent Treatment Program September 2014
Overall Satisfaction with Care
100
120
Care Domai
Percen
20%
20%
10%
10%
0
lifetime
suicide
attempt
clinical
clinical
level of
level of
internalizing externalizing
problems
problems
mood
disorder
eating
disorder
10%
extemalizing
disorder
anxiety
disorder
When interpreting these longer-term treatment
outcomes, it is important to note that we did not
have all of our patients participate six months
after discharge; therefore we cannot say these
changes were applicable to all patients. Additionally, when patient responses were unavailable we
used parental responses when they were available.
30
25
20
15
10
Depressive Symptoms from Admission
to Discharge
However, we still only had 50 percent completion, which begs the question whether the families
who did not respond hadModerate
a more
difficult time
level
of Depressive
after discharge and did not
benefit as much from
treatment at Menninger orSymptoms
whether follow-up
treatment programs made it difficult to complete
the outcomes questionnaire. To try to account for
this, we compared those who responded versus
those who did not respond on their symptom
levels
at admissionAtand
discharge. These groups
At Admission
Discharge
did not differ statistically from each other.
Further research should investigate the differences
between these groups in order to better target our
efforts to contact families to participate after dis-
Overall Satisfaction with Care
0
Internalizing
Problems
Externalizing
Problems
Total Problems
charge. We appreciate all of our families’ effort in
completing research questionnaires as it provides
valuable information of the long-term effects of
treatment at Menninger.
Symptom Levels from Admission to
6-months Post-discharge
75
70
Cutoff for clinical level of severity
65
Internalizing
Problems
60
Externalizing
Problems
55
Total
Problems
50
Admission
Discharge
6-months
Post-discharge
Note: These levels were measured by the Youth Self-report questionnaire completed
by patients at all time points. If information was missing from patients, we used the
parental reports.
Mean Rating across Perception of
Care Domains
120
100
90
100
80
80
%Unfavorable
70
Adolescent
By Elizabeth Newlin, MD
60
Program & Medical Director, Adolescent
Treatment60Program
%Favorable
Parent
50
40
40
cidality, non-suicidal self-injury and the
I run a group on ATP about relation30
development of a negative self-concept.
ships. I asked the dozen
20or so teens
20
present who among them had experi0 raised their
Children and adolescents
who are bulenced bullying. All but one
10
Interpersonal Continuity & Communication/
Global
lied are Info
at from
greaterEvaluation
risk of school avoidhand. Their stories about persistent,
Aspects
Coordination
0
of Care
of Care
Care The impact
Adolescents
Parents
ance andProvider
substanceof use.
emotionally abusive “frenemies,”
New Measure to Assess Bullying Experiences
abusive romantic relationships, as well
as relational bullying by cliques or a
particular bully could have filled weeks’
worth of group therapy.
“I couldn’t take it anymore.
I tried to convince my parents
to let me do home schooling
but I never told them all that
was going on. I started to
agree with what the kids
at school would say to me.”
This account of bullying is one of many
such stories told by teens on ATP.
The magnitude of the problems related
to bullying among our patients was
even greater than we imagined. As a result, additional effort was dedicated to
this issue in our clinical programming
and our research efforts.
Bullying has garnished additional attention and new resources from national
organizations, schools and governmental agencies following publication of
new research documenting the related
dangers over the past decade. We now
know bullying has a clear and significant association with adolescent sui-
The Menninger Clinic Adolescent Treatment Program September 2014
of bullying is far-reaching with demonstrated negative mental and physical health consequences in follow-up
studies up to 40 years later. Not only
are young people who are bullied more
likely to develop mental health problems, they are more likely to experience
treatment-resistant depression.
With the addition of a new measure,
the Bullying Victim Bystander Inventory (BVBI), we are now quantifying the number of teens admitted to
ATP who have experiences as a bully,
bystander or victim. We will have the
data available to examine the relationship between experiences with bullying
and their current diagnoses, response
to treatment and existence of possible
protective factors.
3
50%
44%
44%
37%
40%
30%
25
30%
20
20%
20%
lifetime
suicide
attempt
70
40%
24%
Moderate level
of Depressive
Symptoms
Discharge
65
60
Adolescents & Parents View Treatment
Differently: Does It Matter?
10%
10%
0
40%
clinical
clinical
level of
level of
internalizing externalizing
problems
problems
mood
disorder
eating
disorder
10%
extemalizing
disorder
0
anxiety
disorder
15
10
Internalizing
Problems
Externalizing
Problems
At Admission
55
50
Total Problems
Admissio
At Discharge
By Alok Madan, PhD, MPH
McNair Scholar & Senior Psychologist
Overall Satisfaction with Care
30
25
20
15
10
Depressive
Symptoms
from Admission
Patient
satisfaction
has long been used as
to Discharge
a measure of healthcare quality. Unfor-
tunately, psychiatric patients are rarely
asked for their opinion about the care
Moderate level
they receive (Hermann
et al., 2000), and
of Depressive
most efforts focus exclusively
Symptoms on adults’
perception of care. If asked at all, adolescent satisfaction with care might be based
on the patient’s or parent’s report but is
rarely specified.
At Admission
At Discharge
Distinguishing adolescents’ and parents’
perception of care is important because
we know that kids and their parents
don’t always agree (Verhulst & van der
Ende, 1992). Therefore, a better underOverall Satisfaction
with Care satisfaction with
standing of adolescents’
their care is important and should be
100
investigated further.
90
80
70
60
50
40
30
20
10
0
Our study had two aims: 1. We asked
%Unfavorable
adolescents and their parents to rate their
%Favorable
satisfaction with inpatient psychiatric
care, and 2. We compared how adolescent and parent satisfaction ratings
related to patients’ actual treatment
responses.
Symptom Levels from Admission to
100
6-months Post-discharge
75 90
80
70
Cutoff for clinical level of%Unfavorable
severity
70
Internalizing
65 60
Problems
%Favorable
Externalizing
50
60
Problems
40
Total
Problems
55 30
50 20
Discharge
6-months
10 Admission
Post-discharge
0
Adolescents
Parents
120
4
100
80
60
40
20
0
Mean Rating across Perception of
Care Domains
100
80
Adolescent
60
Parent
40
20
0
Between January 1, 2012, and September
30, 2013, adolescents
Adolescents
Parents and parents completed patient satisfaction surveys following adolescents’ stay at The Menninger
Clinic. Both adolescents and their parents
also completed treatment outcome measures. The vast majority of adolescents
and parents gave favorable overall ratings
of the care. Interestingly, adolescents
consistently rated their satisfaction lower
than their parents, and there was little
agreement between them across the survey’s four domains: interpersonal aspects
of care, continuity/coordination of care,
communication/information received
from treatment providers and global
evaluation of care. Further, adolescents’
ratings related to treatment outcomes,
whereas parents’ ratings rarely did.
120
Mean Rati
Care Doma
Interpersonal Continuity & Communication/
Global
Aspects
Coordination
Info from
Evaluation
of Care
of Care
Provider
of Care
In the end, our study found adolescents and parents are satisfied with care
at Menninger. Adolescents tended to be a bit more critical of services than
their parents and did not always agree with them. We argue that these
discrepancies contain value. Adolescents may be reporting a more accurate picture of the treatment program’s strengths and areas of opportunity
for growth. They experienced the treatment firsthand, whereas parents
had some but less contact with treatment team providers. Additionally,
adolescents’ perception of care was associated with their own and their
parents’ perspective of how much they benefitted from treatment; parents’
ratings were not associated with treatment outcomes.
This study suggests that adolescents’ satisfaction of care maybe a better
gauge of potential benefit from treatment compared to their parents.
A manuscript of this study is currently in press in the “Journal for
Healthy Quality”.
The Menninger Clinic Adolescent Treatment Program September 2014
Interpers
Aspec
of Car