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

Objective Borderline personality disorder in adolescence remains a controversial construct. We addressed concerns about the prognostic significance of adolescent borderline pathology by testing whether borderline symptoms at age 12 years predict functioning during the transition to adulthood, at age 18 years, in areas critical to life-course development. Method We studied members of the Environmental Risk (E-Risk) Longitudinal Twin Study, which tracks the development of a birth cohort of 2,232 British twin children. At age 12, study members' borderline symptoms were measured using mothers’ reports. At age 18, study members’ personality, psychopathology, functional outcomes, and experiences of victimization were measured using self-reports, coinformant reports, and official records. Results At age 18, study members who had more borderline symptoms at age 12 were more likely to have difficult personalities, to struggle with poor mental health, to experience poor functional outcomes, and to have become victims of violence. Reports of poor outcomes were corroborated by coinformants and official records. Borderline symptoms in study members at 12 years old predicted poor outcomes over and above other behavioral and emotional problems during adolescence. Twin analyses showed that borderline symptoms in 12-year-olds were influenced by familial risk, particularly genetic risk, which accounted for associations with most poor outcomes at age 18. Conclusion Borderline symptoms in 12-year-olds signal risk for pervasive poor functioning during the transition to adulthood. This association is driven by genetic influences, suggesting that borderline symptoms and poor outcomes are manifestations of shared genetic risk.

orderline personality disorder is characterized by pervasive instability in a person's mood, sense of self, impulse control, and interpersonal relationships. In adults, borderline personality disorder is considered a valid diagnosis by most clinicians. 1 In adolescents, the diagnosis is more controversial. 2,3 Although diagnostic classification systems allow for a diagnosis of borderline personality disorder in adolescence, clinicians are reluctant to assess and treat borderline symptoms before adulthood. 4,5 Among the reasons cited for this reluctance are concerns that adolescents' borderline symptoms may be transient; that a diagnosis could be stigmatizing; that personality development is still in flux; and that some borderline symptoms, such as impulsivity and difficulty in establishing a sense of identity, are inseparable from what is thought to be a normative degree of storm and stress during adolescence. 4 In this study, we addressed concerns about the validity of adolescent borderline pathology by testing in 12-year-old adolescents the prognostic significance of borderline symptoms for psychosocial adjustment during the transition to adulthood, at age 18 years.
In recent years, research has made great strides toward establishing the validity of the borderline personality disorder diagnosis in adolescents. This research shows that borderline symptoms can be observed and reliably measured in adolescents, that symptoms are as prevalent in adolescents as they are in adults, that symptoms are relatively stable across time, and that symptoms predict a diagnosis of borderline personality disorder in adulthood. 2,[6][7][8] Studies also report significant psychosocial impairment in adolescents who experience borderline symptoms. 9 Another approach to testing the validity of borderline personality 1 2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58 pathology is to examine the significance of adolescent borderline symptoms for adult adjustment. Previous findings suggest that adolescents who display borderline symptoms experience adjustment difficulties in adulthood. 10 However, studies investigating the clinical and psychosocial outcomes of adolescent borderline symptoms are sparse, and a recent review of the literature concluded that many of the studies are limited by problems such as sampling bias, high attrition, and a narrow range of psychosocial outcomes. 11 The aim of our study was to extend previous research by drawing a comprehensive picture of how adolescents with borderline symptoms fare during the transition to adulthood. Seven years ago, we described predictors and correlates of borderline symptoms measured in 12-year-old study members of the Environmental Risk (E-Risk) Longitudinal Twin Study, a population-representative birth cohort of twins born in the United Kingdom. 12 Study members have now been followed up to age 18, with high retention (93%). At age 18, we assessed study members' performance on a wide range of outcomes in areas critical to positive life-course development: personality functioning, mental health, functional outcomes, and experiences of victimization. Using these data, we tested the hypothesis that adolescent borderline symptoms predict poor outcomes during the transition to adulthood.
In addition to analyzing implications of borderline symptoms in 12-year-olds for outcomes at age 18, we tested whether symptoms contributed to poor outcomes independently of comorbid adolescent psychopathology and familial risk. We tested the role of comorbid psychopathology to investigate whether borderline symptoms demonstrate incremental validity beyond common disorders that clinicians assess in adolescents who present with emotional and behavioral dysregulation, such as conduct disorder, depression, and anxiety. Previous studies, including our own, show that many adolescents who display borderline symptoms also experience symptoms of these other disorders. 7,12 We tested the incremental validity of age 12 borderline symptoms by accounting for comorbid behavioral and emotional problems when evaluating effects of adolescent borderline symptoms on age 18 outcomes.
We tested the role of familial risk because adolescent borderline behaviors are strongly influenced by risk factors originating in families, both environmental and genetic. 12,13 Familial risk factors implicated in adolescent borderline symptoms, such as harsh parenting, maltreatment, and genetic susceptibility, also predict psychosocial adjustment in young adulthood. 13,14 These findings raise the possibility that poor outcomes are not due to adolescent borderline symptoms themselves, but that symptoms index familial risk for poor outcomes. We tested this hypothesis by comparing age 18 outcomes within genetically identical twin pairs growing up in the same family who differed in adolescent borderline symptoms when assessed at age 12. Because these twins share all of their family-wide environment and genes, these analyses effectively control for familial risk factors shared between members of a family.

Participants
Participants were members of the E-Risk Longitudinal Twin Study, which tracks the development of a birth cohort of 2,232 British children. 15 Briefly, the E-Risk sample was constructed in 1999À2000, when 1,116 families (93% of those eligible) with same-sex 5-year-old twins participated in home-visit assessments. This sample comprised 56% monozygotic (MZ) and 44% dizygotic (DZ) twin pairs; sex was evenly distributed within zygosity (49% male sex). The study sample represents the full range of socioeconomic conditions in Great Britain, as reflected in the families' distribution on a neighborhood-level socioeconomic index (ACORN [A Classification of Residential Neighborhoods], developed by CACI, Inc., Arlington, Virginia, for commercial use): Q4 16,17 25.6% of E-Risk families live in "wealthy achiever" neighborhoods compared with 25.3% nationwide; 5.3% compared with 11.6%, in "urban prosperity" neighborhoods; 29.6% compared with 26.9%, in "comfortably off" neighborhoods; 13.4% compared with 13.9%, in "moderate means" neighborhoods; and 26.1% compared with 20.7%, in "hard-pressed" neighborhoods. "Urban prosperity" neighborhoods are underrepresented in E-Risk because such households are often childless.

Assessment of Borderline Symptoms
When study members were 12 years old, we collected information on their borderline symptoms during interviews with mothers, using items from the Shedler-Westen Assessment Procedure 200-item Q-Sort for Adolescents (SWAP-200-A) 5 supplemented with items from the Achenbach System of Empirically Based Assessment. 18 Items were selected from the set of SWAP-200-A items most commonly used by a sample of 294 doctoral-level clinicians to describe adolescent patients meeting DSM-IV diagnostic criteria for adult borderline personality disorder ( Table 1). 19 Of the 15 items selected from the SWAP, 5 items were very similar to items on the Achenbach scales used in E-Risk (eg, the SWAP item "Tends to be angry or hostile" was similar to the Achenbach scale item "Angry and hostile"). In these cases, we used the Achenbach scales item instead of the SWAP item to avoid asking mothers to rate the same item twice. All items and their descriptive statistics are reported in Table 1. Mothers were asked how well each item described their child (0, not true; 1, somewhat or sometimes true; 2, very true or often true). Data were available for 2,141 (99.8%) of participating members at age 12. Item responses were summarized into two measures that have been previously developed and described. 12 First, a dimensional borderline symptoms scale was computed by summing up across items, with an internal consistency reliability of a ¼ .86 (mean, 4.24; SD, 4.54; range, 0-26). We used this measure in our main analyses. Second, for illustrative purposes and to approximate clinically significant levels of borderline symptoms, we created a dichotomous measure identifying study members scoring at or above versus below the 95th percentile of the continuous borderline symptom scale at age 12 (n ¼ 122, 5.7% of the sample). The 5% (or 2 SD) cutoff was chosen a priori because it is consistent with previous approaches to identifying clinically significant borderline pathology using a dimensional measure, 10 falls within the range of prevalence estimates reported for clinically significant borderline pathology in adolescents, 20 and is consistent with estimates of the prevalence of borderline personality disorder in adults in the community. 21

Assessment of Outcomes at Age 18 Years
When study members were 18 years old, we collected information on a variety of outcomes indicating psychosocial adjustment: personality functioning, mental health, functional outcomes, and experiences of victimization (Table 2). We assessed outcomes using study members' self-reports, reports by coinformants nominated by each twin (typically their cotwin and a parent), and official records. Outcomes and their assessment are described in Table 2.

Covariates: Adolescent Behavioral and Emotional Problems and Childhood Victimization
Symptoms of conduct disorder at age 12 were measured using mothers' and teachers' reports of children's behavioral problems, using the Achenbach family of instruments and DSM-IV items as previously described. [22][23][24] Consistent with DSM-IV criteria, children with five or more symptoms were assigned a diagnosis of conduct disorder (5.5% of cohort). Depression and anxiety at age 12 were assessed using children's self-reports on the Children's Depression Inventory 25 and the 10-item version of the Multidimensional Anxiety Scale for Children, 26 respectively. Scores of 20 or more on the Children's Depression Inventory were used to indicate clinically significant depressive symptoms 25,27 (3.5% of cohort), and scores of 13 or more (corresponding to the 95th percentile) on the Multidimensional Anxiety Scale for Children were used to indicate extreme anxiety 28 (6.1% of cohort).

Statistical Analyses
Our statistical analysis proceeded as follows. First, we tested associations between the continuous measure of age 12 borderline symptoms, standardized to mean (SD) 0 (1), and poor outcomes at age 18. We did this by predicting each poor outcome from age 12 borderline symptoms. All models included sex of study members. We illustrate the results of these analyses by comparing percentages and means of poor outcomes at age 18 years among study members with a high versus lower adolescent borderline symptom score, defined as being at or above versus below the 95th percentile for borderline symptoms at age 12. Second, we tested whether borderline symptoms added incremental value to other behavioral and emotional problems that study members experienced at age 12. We did this by adding symptoms of conduct disorder, depression, and anxiety at age 12 as additional covariates to test unique effects of adolescent borderline symptoms on poor outcomes. Third, we tested whether borderline symptoms were influenced by familial risk. We did this by comparing correlations in borderline symptoms among genetically identical (MZ; n ¼ 594) and nonidentical (DZ; n ¼ 476) twin pairs. We also formally analyzed genetic and environmental influences on adolescent borderline symptoms using a univariate twin model. 29 Twin models compare within-pair similarity for MZ twins, who are genetically identical, and DZ twins, who share on average half their segregating genes. This information can be used to estimate genetic (A), shared environmental (C), and nonshared environmental (E) influences on a phenotype. C represents environmental factors that make members of a family similar, whereas E represents factors that make members of a family different and also includes error of measurement. Fourth, we compared poor outcomes among genetically identical twins who differed in their borderline symptoms at age 12 to test whether adolescent borderline symptoms predict poor outcomes over and above familial influences-both genetic and environmental-shared between identical twins growing up in the same family. Differences in borderline symptoms were operationalized as any difference in the continuous symptoms score between identical (MZ) twins. There were 462 MZ pairs who differed in their age 12 borderline symptom score.
Poisson regression models were used for binary outcomes, and linear regression models were used for continuous outcomes. We chose Poisson over logistic regression models for the binary outcomes to obtain risk ratios, which are a more easily interpretable measure of risk, particularly when outcomes are common. Standard errors were adjusted for the clustering of twins within families. Fixed-effects Poisson and linear regression models with robust standard errors were used for the twin comparisons. Stata version 14.1 30 was used for these analyses. Twin models were fitted using the structural equation modeling program OpenMx. 31
14.3% 28,44 Service use for behavioral or emotional problems Participant At age 18, study members reported whether they had accessed support services (eg, mental health professionals, medical doctors, or social services), spent time in the hospital, or had taken medication for dealing with emotional or behavioral problems in the past year.

17.2% 45
Coinformant reports of poor mental health

Coinformants
Coinformants completed a questionnaire that included 10 items querying about study members' mental health within the previous 12 months (example items: "Feels depressed, miserable, sad, or unhappy"; "Has alcohol problems"). We created a binary measure indicating whether both coinformants had endorsed one or more symptoms of poor mental health.

11.6% 46
Cigarette smoking Participant Indicates whether study members reported that they were currently smoking daily.

22.3%
Risky sexual behavior Participant Indicates whether study members reported that they had engaged in two or more of the following risky sexual behaviors: having had sex before age 16; having had three or more sexual partners; practicing safe sex only sometimes or never; usually or always having sexual intercourse after a night out involving a lot of alcohol and/or drug use; having been told by a doctor that they had a sexually transmitted disease; and having had sexual relations resulting in pregnancy. Participants were interviewed about exposure to a range of adverse experiences between 12 and 18 years using the JVQ-R2, adapted as a clinical interview. Exposure to victimization was coded on a 3-point scale (0, no exposure; 1, probable or less severe exposure; 2, definite or severe exposure). Individuals who reported a definite or severe level of exposure were coded as positive. Our adapted JVQ comprised 45 questions covering 7 different forms of victimization: maltreatment (3.3%), neglect (2.2%), sexual victimization (2.6%), family violence (12.1%), peer/sibling victimization (15.6%), cyber-victimization (6.5%), and crime victimization (19.3%).

Borderline Symptoms in 12-Year-Olds Predicted Poor Functioning at Age 18
Study members with more borderline symptoms at age 12 experienced worse functioning at age 18 compared with their peers with fewer symptoms (Table 3). They had poorer educational and economic outcomes, as indicated by educational failure and unemployment; engaged in more unhealthy behaviors, as indicated by cigarette smoking and risky sexual activity; experienced lower well-being, as indicated by social isolation and dissatisfaction with life; and were more likely to have broken the law, as indicated by having an official crime record (Table 3). These findings are illustrated in Figure 2, which shows the prevalence of poor functional outcomes among study members with high versus lower borderline symptom scores at age 12.

Borderline Symptoms in 12-Year-Olds Predicted Becoming a Victim of Violence
Study members with more borderline symptoms at age 12 were more likely to become victims of violence during adolescence (age 12-18 years) compared to their peers with fewer symptoms (Table 3). Adolescents with borderline symptoms experienced victimization both within and outside of their families through maltreatment, neglect, family violence, bullying by peers, and as victims of crime (Table 3). These findings are illustrated in Figure 2, which shows the prevalence of victimization exposures among study members with high versus lower borderline symptom scores at age 12. Previous studies, including our own, have shown that adolescent borderline symptoms are often preceded by victimization during childhood. 12 Victimization during adolescence may therefore reflect continuing exposure to victimization rather than effects of borderline symptoms. However, even after statistically controlling for childhood victimization, borderline symptoms predicted adolescents' risk of becoming victimized in adolescence (

web 3C=FPO
Note: A high borderline symptom score at age 12 (operationalized as being at or above the 95th percentile for borderline symptoms at age 12) predicts a distinct personality profile at age 18, characterized by narrow-mindedness (low openness to experience), antagonism (low agreeableness), distress (high neuroticism), and poor impulse control (low conscientiousness). All analyses are adjusted for study members' sex .  884  885  886  887  888  889  890  891  892  893  894  895  896  897  898  899  900  901  902  903  904  905  906  907  908  909  910  911  912  913  914  915  916  917  918  919  920  921  922  923  924  925  926  927  928  929  930  931  932  933  934  935  936  937  938  939  940  941  942 high (ie, at or above the 95th percentile) borderline symptom score at age 12 met clinical criteria for at least one of these problems compared with 10% of study members with a lower symptom score (ie, below the 95th percentile). We tested whether borderline symptoms added incremental value to behavioral and emotional problems when predicting poor outcomes by statistically controlling for continuous symptom scores of conduct disorder, depression, and anxiety at age 12 when predicting poor outcomes (Table 3). Borderline symptoms continued to predict most outcomes independently of correlated problems, particularly a difficult personality at age 18, and most of the poor functional outcomes and experiences of victimization. Some associations between age 12 borderline symptoms and age 18 poor outcomes were explained away by co-occurring behavioral and emotional problems at age 12, most notably

Adolescent victimization
High age-12 borderline symptom score Lower age-12 borderline symptom score Prevalence of outcome web 3C=FPO Note: 12-year-olds with a high borderline symptom score (operationalized as being at or above the 95th percentile for borderline symptoms at age 12) experience worse outcomes at age 18 compared with their cohort peers with a lower borderline symptom score. Error bars indicate 95% confidence intervals. All analyses adjust for study members' sex. All outcome measures are described in Table 2 943  944  945  946  947  948  949  950  951  952  953  954  955  956  957  958  959  960  961  962  963  964  965  966  967  968  969  970  971  972  973  974  975  976  977  978  979  980  981  982  983  984  985  986  987  988  989  990  991  992  993  994  995  996  997  998  999  1000  1001 associations with nearly all diagnoses of mental disorders at age 18. However, even within the psychiatric outcomes domain, borderline symptoms in 12-year-olds continued to predict adverse outcomes, including conduct disorder, suicide attempts and self-harm, service use, and coinformant reports of poor mental health (Table 3).  (Table S2, available online). The remainder was accounted for by environmental influences not shared between family members (E) (estimate: E ¼ 0.34; 95% CI [0. 30, 0.38]). There were no shared environmental influences (C) (estimate: C ¼ 0.00; 95% CI [0.00, 0.07]). If genetic influences affect both borderline symptoms at age 12 and poor outcomes at age 18, adolescent borderline symptoms may be an expression of shared genetic risk for poor outcomes, rather than an influential factor in itself. Our findings supported this hypothesis: genetically identical twins who differed in borderline symptoms experienced similar levels of poor outcomes at age 18 (Table 3). This finding suggests that borderline symptoms in 12-year-olds predict poor outcomes at age 18 because borderline symptoms and poor outcomes are manifestations of shared genetic risk.

DISCUSSION
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. 12 This finding is consistent with diathesis-stress models of borderline personality, which propose that it is the interaction between children's genetically influenced, early emerging temperamental difficulties and an invalidating, abusive, and ineffective caregiving environment that increases risk for borderline problems (and other poor outcomes) in a transactional process across development. 12,32 Second, our findings indicate that adolescent borderline symptoms reflect broader genetic risk for poor outcomes, rather than being the cause of these outcomes. This finding does not undermine the prognostic significance of adolescent borderline symptoms. However, it suggests that adolescents remain at risk for adverse psychosocial outcomes even after symptom reduction. 10 Third, if borderline symptoms are not the cause of poor outcomes but are on the pathway from genetic risk to poor outcomes, more work is needed to understand how genetic risk influences both borderline symptoms and poor outcomes. A hypothesis consistent with diathesis-stress models of borderline personality is that genetic risk begins to manifest early in life, as a difficult temperamental profile characterized by high negative affect, poor impulse control, and high emotional sensitivity. A child's difficult temperament subsequently increases risk for borderline pathology as well as for other poor outcomes, particularly when it is met by an invalidating caregiving environment. 32 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. 11 Our study overcomes some of these limitations because our cohort is nationally representative, follow-up of participants has occurred with extremely low attrition, and we report associations with a wide range of clinical and psychosocial outcomes. Second, there are very few studies testing associations between borderline pathology and exposure to victimization, particularly in adolescence. Our study extends the literature by showing that borderline symptoms in 12-year-olds predict exposure to different types of victimization, both inside and outside the home, during adolescence. Third, in addition to reporting that adolescents' borderline pathology predicts poor outcomes, we find that these associations do not persist after accounting for familial influences shared between identical twins growing up in the same family. Although several studies have tested outcomes of adolescent borderline symptoms using a twin design, 33 to our knowledge our study is the first to apply this approach to a wide range of clinical and psychosocial outcomes.
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. 10,12,34,35 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. 36 Third, our study does not contain a measure of borderline symptoms at age 18, so we were unable to test the continuity of borderline symptoms. However, our findings show that 18year-olds with a history of borderline symptoms show a personality profile characterized by emotional and interpersonal lability that is typical of adults with borderline personality disorder. 37 Fourth, although a considerable portion of 12-year-olds with borderline symptoms went on to experience poor outcomes, there were also adolescents who bucked this trend and fared well despite their symptom history. Follow-on work is needed to investigate factors that predict variability in poor outcomes associated with borderline symptoms. Fifth, our study members are still young, so it is unclear how persistent their psychosocial difficulties will be. However, many of the outcomes we measured-low educational qualifications, cigarette smoking, personality dysfunction, having a criminal record, risky sexual behavior-are still meaningful because they represent barriers to leading a prosperous and healthy adult life. Moreover, previous work testing associations with some of the same outcomes we report, such as attainment and social support, has shown that adolescent borderline symptoms predict these outcomes up to age 33 years. 10 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. 6,38 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. 39 Psychological treatments for adult patients with borderline personality disorder have been adapted for use with adolescents and show promise for improving symptoms. 7 In addition to treatment for personality pathology, adolescents with borderline symptoms need access to support services that help reduce the risk for future poor functioning, such as educational support services. Third, our findings show that adolescents' borderline symptoms signal a longer-term need for care. Even if symptoms decrease after treatment, adolescents remain at risk for adverse outcomes because symptoms partly reflect genetic risk for future difficulties. Adolescents should be monitored and supported accordingly, particularly during the transition to adulthood when they face discharge from child and adolescent mental health services. Fourth, our findings imply that young people with a history of borderline symptoms may turn up on the doorsteps of many services, including mental health care services, unemployment offices, sexual health centers, courts, emergency departments, and social services. The breadth of poor outcomes among these young people requires an integrated treatment approach that involves coordination across multiple social and support services.  1297  1298  1299  1300  1301  1302  1303  1304  1305  1306  1307  1308  1309  1310  1311  1312  1313  1314  1315  1316  1317  1318  1319  1320  1321  1322  1323  1324  1325  1326  1327  1328  1329  1330  1331  1332  1333  1334  1335  1336  1337  1338  1339  1340  1341  1342  1343  1344  1345  1346  1347  1348  1349  1350  1351  1352  1353  1354 1355    1533  1534  1535  1536  1537  1538  1539  1540  1541  1542  1543  1544  1545  1546  1547  1548  1549  1550  1551  1552  1553  1554  1555  1556  1557  1558  1559  1560  1561  1562  1563  1564  1565  1566  1567  1568  1569  1570  1571  1572  1573  1574  1575  1576  1577  1578  1579  1580  1581  1582  1583  1584  1585  1586  1587  1588  1589  1590  1591