Borderline Kişilik Envanteri’nin Psikometrik Özelliklerinin Ergen Örnekleminde Sınanması

Borderline kişilik bozukluğu (BKB) kişilerarası ilişkileri oldukça olumsuz etkileyen; hastane yatış olasılığının, kendine zarar verme davranışının ve ölüm oranının diğer psikolojik bozukluklara göre daha yüksek olduğu bir psikolojik bozukluktur. Borderline kişilik özelliklerinin ergenlik döneminde tespit edilmesinin ve bu özelliklere yönelik uygun müdahale yönteminin belirlenmesinin önemli olduğu düşünülmektedir. Bu araştırmanın amacı Leichsenring (1999) tarafından geliştirilen Borderline Kişilik Envanteri’nin (BKE) psikometrik özelliklerini ergen örnekleminde inceleyerek ulusal alanyazına kazandırmaktır. Bu amaç doğrultusunda 14-18 yaş aralığında toplam 476 ergen katılımcıya ulaşılmış ve Sosyo-Demografik Bilgi Formu, BKE, Yeme Tutumu Testi-26 (YTT-26) ve Güçler ve Güçlükler Anketi (GGA) uygulanmıştır. Yürütülen yapı geçerliği analizleri ışığında BKE’nin Kimlik ve Gerçeklikte Dağılma, Duygulanım ve İlişkilerde Dengesizlik ve Dürtüsellik olmak üzere üç faktörden oluştuğu görülmüştür. Güvenirlik analizleri kapsamında, BKE’nin Cronbach alfa iç-tutarlık katsayısının tüm envanter için .86 olduğu ve faktörler için .74 ile .85 arasında değiştiği görülmüştür. Ölçeğin yapı geçerliğini destekleyen korelasyon bulguları, BKE’den alınan toplam ve faktör puanları ile YYT-26 ve GGA toplam ölçek puanları arasında anlamlı düzeyde pozitif yönde ilişkiler bulunduğunu ortaya koymuştur. Sonuç olarak, BKE’nin ergenlik döneminde borderline kişilik özelliklerini değerlendirmek için geçerli ve güvenilir bir ölçüm aracı olduğuna dair kanıtlar elde edilmiştir. Ayrıca, ergenlerde BKE ile değerlendirilen klinik görünümün psikopatolojik belirtilere işaret eden diğer yapılar ile ilişkisi, ergenlerde görülen borderline kişilik özelliklerinin geçici bir gelişimsel olgu olmadığını ve duygusal/davranışsal sorunlarla ilişkili olduğunu desteklemektedir. Mevcut çalışma, borderline kişilik özellikleri yükselen ergen bireyler için klinik görünüm yetişkinlik döneminde kişilik bozukluğuna dönüşmeden belirtilere yönelik gerekli müdahalelerin öneminin altını çizmektedir. Ergen örneklemlerinde yürütülecek gelecek araştırma ve klinik uygulamalarda, BKE’nin borderline kişilik özellikleri yüksek olan bireyleri belirlemek üzere kullanılabileceği önerilmektedir.

Examination of the Psychometric Properties of the Borderline Personality Inventory in an Adolescent Sample

Borderline personality disorder (BPD) is a psychopathology that negatively impacts one’s interpersonal relationships. The risk of hospitalization, self-harm, and suicidality are much higher in BPD compared to other psychopathologies. Detecting BPD symptoms during adolescence and determining the necessary treatment modalities are important. The aim of the present study is to contribute to the national literature by examining the psychometric properties of the Borderline Personality Inventory (BPI) developed by Leichsenring (1999). Adolescents between the ages of 14-18 (N = 476) were reached and administered a socio-demographic form, the BPI, the Eating Attitudes Test-26 (EAT-26), and the Strengths and Difficulties Questionnaire (SDQ). The construct validity analyses indicated that the BPI was composed of the subfactors of identity and reality diffusion, volatile affect and interpersonal relationships, and impulsivity. According to the reliability analysis, Cronbach’s alpha values of internal consistency for the BPI were found to be .86 for the whole inventory and to range between .74 and .85 for each of the three subfactors. Further evidence from the construct validity analyses indicate a significant positive correlation to be present for the overall score and subfactor scores of BPI with the EAT-26 and SDQ. Thus, evidence has shown the BPI to be a reliable and valid measure for evaluating BPD symptoms in adolescents. Additionally, the relationship between the borderline symptoms evaluated using BPI and the other psychopathology symptoms supports that borderline personality features in adolescents are not a passing developmental phenomenon and are related to emotional and behavioral problems. The present study underlines the importance of interventions for symptoms before a clinical presentation turns into a personality disorder in adulthood in adolescents possessing increased borderline personality traits. The study recommends the applicability of BPI for identifying individuals with high borderline personality traits in future research and clinical practices to be conducted over adolescent samples.

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  • Akın, E. (2017). Borderline Şiddet Değerlendirme Ölçeği Türkçe versiyonunun (Türkçe Best) geçerlik, güvenirliği ve faktör yapısı [Yayımlanmamış Yüksek Lisans Tezi]. Hasan Kalyoncu Üniversitesi. google scholar
  • Al-Salom, P. ve Boylan, K. (2019). Borderline personality disorder and disordered eating behaviour: The mediating role of rejection sensitivity. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 28(2), 72-81. google scholar
  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5. baskı). American Psychiatric Publishing. google scholar
  • Aydemir, Ö., Demet, M. M., Danacı, A. E., Deveci, A., Taşkın, E. O., Mızrak, S., Şimsek, E. ve İçelli, İ. (2006). Borderline Kişilik Envanterinin Türkçe’ye uyarlanması, güvenilirlik ve geçerliliği. Türkiye’de Psikiyatri, 8(1), 6-10. google scholar
  • Babinski, D. E. ve McQuade, J. D. (2019). Borderline personality features mediate the association between ADHD, ODD, and relational and physical aggression in girls. Journal of Attention Disorders, 23(8), 838-848. https://doi.org/10.1177/1087054718797445 google scholar
  • Badoud, D., Luyten, P., Fonseca-Pedrero, E., Eliez, S., Fonagy, P ve Debbane, M. (2015). The French version of the Reflective Functioning Questionnaire: Validity data for adolescents and adults and its association with non-suicidal self-injury. PLoS One, 10(12), e0145892. https://doi.org/10.1371/ journal.pone.0145892 google scholar
  • Batum, P. (2008). Kişilik bozuklukları ve yeme bozuklukları: Etiolojik ilişkiler ve cevaplanmamış sorular. Türk Psikoloji Yazıları, 11(21), 65-76. google scholar
  • Batur, S. (2004). Yeme tutum bozukluğu gösterenlerde ve göstermeyenlerde temel bilişsel şemalar [Yayımlanmamış Doktora Tezi]. Ankara Üniversitesi. google scholar
  • Black, D. W., Blum, N., Pfohl, B. ve Hale, N. (2004). Suicidal behavior in borderline personality disorder: Prevalence, risk factors, prediction, and prevention. Journal of Personality Disorders, 18(3), 226-239. https://doi.Org/10.1521/pedi.18.3.226.35445 google scholar
  • Bo, S. ve Kongerslev, M. (2017). Self-reported patterns of impairments in mentalization, attachment, and psychopathology among clinically referred adolescents with and without borderline personality pathology. Borderline Personality Disorder and Emotion Dysregulation, 4(1), 4. https://doi. org/10.1186/s40479-017-0055-7 google scholar
  • Bond, M. (1990). Are “borderline defenses” specific for borderline personality disorders? Journal of Personality Disorders, 4(3), 251-256. https://doi.Org/10.1521/pedi.1990.4.3.251 google scholar
  • Bozzatello, P., Bellino, S., Bosia, M. ve Rocca, P. (2019). Early detection and outcome in borderline personality disorder. Frontiers in Psychiatry, 10, 710. https://doi.org/10.3389/fpsyt.2019.00710 google scholar
  • Bradley, R., Zittel Conklin, C. ve Westen, D. (2005). The borderline personality diagnosis in adolescents: Gender differences and subtypes. Journal of Child Psychology and Psychiatry, 46(9), 1006-1019. https://doi.org/10.1111/j.1469-7610.2004.00401.x google scholar
  • Butler, A. C., Brown, G. K., Beck, A. T. ve Grisham, J. R. (2002). Assessment of dysfunctional beliefs in borderline personality disorder. Behaviour Research and Therapy, 40(10), 1231-1240. https:// doi.org/10.1016/S0005-7967(02)00031-1 google scholar
  • Ceylan, V., Kose, S., Akin, E. ve Turkcapar, M. H. (2017). Normative data and factorial structure of the Turkish version of the Borderline Personality Questionnaire (Turkish BPQ). Psychiatry and Clinical Psychopharmacology, 27(2), 143-151. https://doi.org/10.1080/24750573.2017.1298422 google scholar
  • Chabrol, H. ve Leichsenring, F. (2006). Borderline personality organization and psychopathic traits in nonclinical adolescents: Relationships of identity diffusion, primitive defense mechanisms and reality testing with callousness and impulsivity traits. Bulletin of the Menninger Clinic, 70(2), 160170. https://doi.org/10.1521/bumc.2006.70.2.160 google scholar
  • Chabrol, H., Montovany, A., Duconge, E., Kallmeyer, A., Mullet, E. ve Leichsenring, F. (2004). Factor structure of the borderline personality inventory in adolescents. European Journal of Psychological Assessment, 20(1), 59-65. https://doi.org/10.1027/1015-5759.20.1.59 google scholar
  • Chanen, A., Jovev, M., McCutcheon, L., Jackson, H. ve McGorry, P. (2008). Borderline personality disorder in young people and the prospects for prevention and early intervention. CurrentPsychiatry Reviews, 4(1), 48-57. https://doi.org/10.2174/157340008783743820 google scholar
  • Chanen, A. ve Kaess, M. (2012). Developmental pathways to borderline personality disorder. Current Psychiatry Reports, 14(1), 45-53. https://doi.org/10.1007/s11920-011-0242-y google scholar
  • Chanen, A. M. ve McCutcheon, L. (2013). Prevention and early intervention for borderline personality disorder: Current status and recent evidence. The British Journal of Psychiatry, 202(54), 24-29. https://doi.org/10.1192/bjp.bp.112.119180 google scholar
  • Coşkun, F., Akça, Ö. F., Bilgiç, A. ve Sharp, C. (2020). Borderline Kişilik Özellikleri Çocuk Ölçeği-Kısa Formunun Türk ergenlerinde geçerlik ve güvenirlik çalışması. Türk Psikiyatri Dergisi, 33(1), 44-52. https://doi.org/10.5080/u25637 google scholar
  • Crick, N. R., Murray-Close, D. ve Woods, K. (2005). Borderline personality features in childhood: A short-term longitudinal study. Development and Psychopathology, 17(4), 1051-1070. https://doi. org/10.1017/s0954579405050492 google scholar
  • Davids, E. ve Gastpar, M. (2005). Attention deficit hyperactivity disorder and borderline personality disorder. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 29(6), 865-877. https://doi.org/10.1016/j.pnpbp.2005.04.033 google scholar
  • Ellison, W. D., Rosenstein, L. K., Morgan, T. A. ve Zimmerman, M. (2018). Community and clinical epidemiology of borderline personality disorder. Psychiatric Clinics of North America, 41(4), 561573. https://doi.org/10.1016/j.psc.2018.07.008 google scholar
  • Erguney-Okumus, F. E. ve Sertel-Berk, H. O. (2020). Yeme Tutum Testi kısa formunun (YTT-26) üniversite örnekleminde Türkçeye uyarlanması ve psikometrik özelliklerinin değerlendirilmesi. Psikoloji Çalışmaları - Studies in Psychology. Advance online publication. https://doi.org/10.26650/ SP2019-0039 google scholar
  • Field, A. (2005). Discovering statistics using SPSS. Sage. google scholar
  • Garner, D. M. ve Garfinkel, P. E. (1979). The eating attitudes test: An index of the symptoms of anorexia nervosa. Psychological Medicine, 9, 273-279. https://doi.org/10.1017/s0033291700030762 google scholar
  • Garner, D. M., Olmsted, M. P., Bohr, Y. ve Garfinkel, P. E. (1982). The eating attitudes test: Psychometric features and clinical correlates. Psychological Medicine, 12(4), 871-878. https://doi.org/10.1017/ s0033291700049163 google scholar
  • Goodman, R. (1997). The Strengths and Difficulties Questionnaire: A research note. Journal of Child Psychology and Psychiatry, 38(5), 581-586. https://doi.org/10.1111/j.1469-7610.1997.tb01545.x google scholar
  • Goodman, R., Meltzer, H. ve Bailey, V. (1998) The Strengths and Difficulties Questionnaire: A pilot study on the validity of the self-report version. International Review of Psychiatry, 15, 173-177. https://doi.org/10.1007/s007870050057 google scholar
  • Guile, J. M. ve Greenfield, B. G. (2004). Introduction personality disorders in childhood and adolescence. Canadian Child Adolescent Psychiatry Review, 13(3), 51-2. google scholar
  • Güvenir, T., Özbek, A., Baykara, B., Arkar, H., Şentürk, B. ve İncekaş, S. (2008). Güçler ve Güçlükler Anketi’nin (GGA) Türkçe uyarlamasınınn psikometrik özellikleri. Çocuk ve Gençlik Ruh Sağliği Dergisi, 15, 65-74. google scholar
  • Ha, C., Balderas, J. C., Zanarini, M. C., Oldham, J. ve Sharp, C. (2014). Psychiatric comorbidity in hospitalized adolescents with borderline personality disorder. Journal of Clinical Psychiatry, 75(5), e457-64. https://doi.org/10.4088/JCP.13m08696 google scholar
  • Kaess, M., Brunner, R. ve Chanen, A. (2014). Borderline personality disorder in adolescence. Pediatrics, 134(4), 782-793. https://doi.org/10.1542/peds.2013-3677 google scholar
  • Kernberg, O. (1967). Borderline personality organization. Journal of the American Psychoanalytic Association, 15(3), 641-685. https://doi.org/10.1177/000306516701500309 google scholar
  • Kernberg, O. (1978). The diagnosis of borderline conditions in adolescence. Adolescent Psychiatry, 6, 298-319. google scholar
  • Kernberg, O. F., Goldstein, E. G., Carr, A. C., Hunt, H. F., Bauer, S. F. ve Blumenthal, R. (1981). Diagnosing borderline personality. A pilot study using multiple diagnostic methods. The Journal of Nervous and Mental Disease, 169(4), 225-231. google scholar
  • Korsgaard, H. O., Torgersen, S., Wentzel-Larsen, T. ve Ulberg, R. (2016). Personality disorders and Axis I comorbidity in adolescent outpatients with ADHD. BMC Psychiatry, 16, Article 175. https:// doi.org/10.1186/s12888-016-0871-0 google scholar
  • Laurenssen, E. M. P., Hutsebaut, J., Feenstra, D. J., Van Busschbach, J. J. ve Luyten, P. (2013). Diagnosis of personality disorders in adolescents: A study among psychologists. Child and Adolescent Psychiatry and Mental Health, 7(1), 3. https://doi.org/10.1186/1753-2000-7-3 google scholar
  • Lee, S., Kwok, K., Liau, C. ve Leung, T. (2002). Screening Chinese patients with eating disorders using the Eating Attitudes Test in Hong Kong. International Journal of Eating Disorders, 32(1), 91-97. https://doi.org/10.1002/eat.10064 google scholar
  • Lee, K. S. ve Vaillancourt, T. (2018). Longitudinal associations among bullying by peers, disordered eating behavior, and symptoms of depression during adolescence. JAMA Psychiatry, 75(6), 605612. https://doi.org/10.1001/jamapsychiatry.2018.0284 google scholar
  • Leichsenring, F. (1999). Development and first results of the Borderline Personality Inventory: A self-report instrument for assessing borderline personality organization. Journal of Personality Assessment, 73(1), 45-63. https://doi.org/10.1207/S15327752JPA730104 google scholar
  • Leichsenring, F., Leibing, E., Kruse, J., New, A. S. ve Leweke, F. (2013). Borderline personality disorder. FOCUS, 11 (2), 249-260. https://doi.Org/10.1176/appi.focus.11.2.249 google scholar
  • Lereya, S. T., Winsper, C., Tang, N. K. ve Wolke, D. (2017). Sleep problems in childhood and borderline personality disorder symptoms in early adolescence. Journal of Abnormal Child Psychology, 45(1), 193-206. https://doi.org/10.1007/s10802-016-0158-4 google scholar
  • Ludolph, P. S., Westen, D., Misle, B., Jackson, A., Wixom, J. ve Wiss, F. C. (1990). The borderline diagnosis in adolescents: Symptoms and developmental history. American Journal of Psychiatry, 147(4), 470-476. https://doi.org/10.1176/ajp.147.4.470 google scholar
  • Mahler, M. S., Pine, F. ve Bergman, A. (1975). The Psychological birth of the human infant: Symbiosis and individuation. Basic Books. google scholar
  • Mann, L. S., Wise, T. N., Segall, E. A., Goldberg, R. L. ve Goldstein, D. M. (1988). Borderline Symptom Inventory: Assessing inpatient and outpatient borderline personality disorders. Psychopathology, 21(1), 44-50. https://doi.org/10.1159/000284540 google scholar
  • Martinussen, M., Friborg, O., Schmierer, P., Kaiser, S., 0vergârd, K. T., Neunhoeffer, A. L., Martinsen, E. W. ve Rosenvinge, J. H. (2016). The comorbidity of personality disorders in eating disorders: A meta-analysis. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity, 22(2), 201209. https://doi.org/10.1007/s40519-016-0345-x google scholar
  • Muthen, L. K. ve Muthen, B. O. (1998-2019). Mplus User’s Guide. (Eight Edition). Muthen & Muthen. google scholar
  • Oldham, J. M. (2013). Borderline personality disorder and suicidality. FOCUS, 11(2), 277-283. https:// doi.org/10.1176/appi.focus.11.2.277 google scholar
  • Pfohl, B., Blum, N., St. John, D., McCormick, B., Allen, J. ve Black, D. W. (2009). Reliability and validity of the Borderline Evaluation of Severity Over Time (BEST): A self-rated scale to measure severity and change in persons with borderline personality disorder. Journal of Personality Disorders, 23(3), 281-293. https://doi.org/10.1521/pedi.2009.23.3.281 google scholar
  • Philipsen, A., Limberger, M. F., Lieb, K., Feige, B., Kleindienst, N., Ebner-Priemer, U., Barth, J., Schmahl, C. ve Bohus, M. (2008). Attention-deficit hyperactivity disorder as a potentially aggravating factor in borderline personality disorder. The British Journal of Psychiatry, 192(2), 118-123. https://doi.org/10.1192/bjp.bp.107.035782 google scholar
  • Poreh, A. M., Rawlings, D., Claridge, G., Freeman, J. L., Faulkner, C. ve Shelton, C. (2006). The BPQ: A scale for the assessment of borderline personality based on DSM-IV criteria. Journal of Personality Disorders, 20(3), 247-260. https://doi.org/10.1521/pedi.2006.20.3.247 google scholar
  • Rathus, J. H. ve Miller, A. L. (2002). Dialectical behavior therapy adapted for suicidal adolescents. Suicide Life-Threatening Behavior, 32, 146-157. https://doi.org/10.1521/suli.32.2.146.24399 google scholar
  • Remington, G. J., ve Book, H. (1993). Discriminative validity of the borderline syndrome index. Journal of Personality Disorders, 7(4), 312-319. https://doi.org/10.1521/pedi.1993.7.4.312 google scholar
  • Sansone, R. A. ve Sansone, L. A. (2011). Personality pathology and its influence on eating disorders. Innovations in Clinical Neuroscience, 8(3), 14-18. google scholar
  • Savaşır, I. ve Erol, N. (1989). Yeme Tutum Testi: Anoreksiye nervoza belirtiler endeksi. Türk Psikoloji Dergisi, 7(23), 19-25. google scholar
  • Selby, E. A., Ward, A. C. ve Joiner Jr, T. E. (2010). Dysregulated eating behaviors in borderline personality disorder: Are rejection sensitivity and emotion dysregulation linking mechanisms? International Journal of Eating Disorders, 43(7), 667-670. https://doi.org/10.1002/eat.20761 google scholar
  • Sevinç, E., Şengül, C., Çakaloz, B. ve Herken, H. (2010). Psikiyatri polikliniğinde erişkin dikkat eksikliği hiperaktivite bozukluğu tanısı konan hastalarda eştanı. Archives of Neuropsychiatry/Noropsikiatri Arsivi, 47(2), 139-143. google scholar
  • Sharp, C. ve Romero, C. (2007). Borderline personality disorder: A comparison between children and adults. Bulletin of theMenninger Clinic, 71 (2), 85-114. https://doi.Org/10.1521/bumc.2007.71.2.85 google scholar
  • Sharp, C., Steinberg, L., Temple, J. ve Newlin, E. (2014). An 11-item measure to assess borderline traits in adolescents: Refinement of the BPFSC using IRT. Personality Disorders: Theory, Research, and Treatment, 5(1), 70-78. https://doi.org/10.1037/per0000057 google scholar
  • Sharp, C. ve Wall, K. (2018). Personality pathology grows up: Adolescence as a sensitive period. Current Opinion in Psychology, 21, 111-116. https://doi.org/10.1016/j.copsyc.2017.11.010 google scholar
  • Somma, A., Sharp, C., Borroni, S. ve Fossati, A. (2016). Borderline personality disorder features, emotion dysregulation and non-suicidal self-injury: Preliminary findings in a sample of community-dwelling Italian adolescents. Personality and Mental Health, 11(1), 23-32. https://doi.org/10.1002/pmh.1353 google scholar
  • Speranza, M., Revah-Levy, A., Cortese, S., Falissard, B., Pham-Scottez, A. ve Corcos, M. (2011). ADHD in adolescents with borderline personality disorder. BMC Psychiatry, 11(1). https://doi. org/10.1186/1471-244x-11-158 google scholar
  • Stepp, S. D., Lazarus, S. A. ve Byrd, A. L. (2016). A systematic review of risk factors prospectively associated with borderline personality disorder: Taking stock and moving forward. Personality Disorders: Theory, Research, and Treatment, 7(4), 316-323. https://doi.org/10.1037/per0000186 google scholar
  • Storeb0, O. J. ve Simonsen, E. (2013). Is ADHD an early stage in the development of borderline personality disorder? Nordic Journal of Psychiatry, 68(5), 289-295. https://doi.org/10.3109/0803 9488.2013.841992 google scholar
  • Streeck-Fischer, A. (2013). Adolescence and borderline behavior-between personality development and personality disorder. Adolescent Psychiatry, 3(3), 220-232. https://doi. org/10.2174/2210676611303030003 google scholar
  • Van der Kolk, B. A. (2005). Developmental trauma disorder: Toward a rational diagnosis for children with complex trauma histories. Psychiatric Annals, 35(5), 401-408. google scholar
  • Viinamaki, A., Marttunen, M., Fröjd, S., Ruuska, J. ve Kaltiala-Heino, R. (2012). Subclinical bulimia predicts conduct disorder in middle adolescent girls. European Eating Disorders Review, 21(1), 38-44. https://doi.org/10.1002/erv.2168 google scholar
  • Winsper, C., Lereya, S. T., Marwaha, S., Thompson, A., Eyden, J. ve Singh, S. P. (2016). The aetiological and psychopathological validity of borderline personality disorder in youth: A systematic review and meta-analysis. Clinical Psychology Review, 44, 13-24. https://doi.org/10.1016/j.cpr.2015.12.001 google scholar
  • Yucel, B., Polat, A., Ikiz, T., Dusgor, B. P., Elif Yavuz, A. ve Sertel Berk, O. (2011). The Turkish version of the eating disorder examination questionnaire: Reliability and validity in adolescents. European Eating Disorders Review, 19(6), 509-511. https://doi.org/10.1002/erv.1104 google scholar
  • Zanarini, M. C. (2003a). Childhood Interview for DSM-IV borderline personality disorder (CI-BPD). Belmont, MA: McLean Hospital. google scholar
  • Zanarini, M. C. (2003b). Zanarini Rating Scale for borderline personality disorder (ZAN-BPD): A continuous measure of DSM-IV borderline psychopathology. Journal of Personality Disorders, 17(3), 233-242. https://doi.org/10.1521/pedi.17.3.233.22147 google scholar
  • Zanarini, M. C., Horwood, J., Wolke, D., Waylen, A., Fitzmaurice, G., ve Grant, B. F. (2011). Prevalence of DSM-IV borderline personality disorder in two community samples: 6,330 English 11-year-olds and 34,653 American adults. Journal of Personality Disorders, 25(5), 607-619. https://doi. org/10.1521/pedi.2011.25.5.607 google scholar