The Mediating Role of Parenting Dimensions and Mentalisation between ADHD and BPD in Adolescents: A Cross-Sectional Study

The Mediating Role of Parenting Dimensions and Mentalisation between ADHD and BPD in Adolescents: A Cross-Sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Mediating Role of Parenting Dimensions and Mentalisation between ADHD and BPD in Adolescents: A Cross-Sectional Study Yee Xin Tan, Soon Ken Chow, Manveen Kaur, Fatin Liyana Azhar, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7484039/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background: Attention-deficit/hyperactivity disorder (ADHD) and borderline personality disorder (BPD) share overlapping features such as impulsivity and emotional dysregulation, yet their co-occurrence in adolescents is rarely examined outside Western settings. In Southeast Asia, where parenting practices and cultural norms may shape developmental pathways differently, this relationship remains underexplored. Evidence is also limited on how parenting dimensions and mentalisation contribute to the ADHD–BPD link. This study addresses these gaps by examining Malaysian adolescents, providing cross-cultural insights into early psychosocial risk factors that may inform targeted interventions. Methods: A cross-sectional study was conducted from March to July 2025 in three government secondary schools in urban Selangor, Malaysia, involving 126 adolescents aged 14 to 16 years. ADHD symptoms were assessed using the parent-rated Swanson, Nolan, and Pelham Rating Scale–Fourth Edition (SNAP-IV), while adolescents completed a sociodemographic questionnaire, the Borderline Symptom List–23 (BSL-23), the Parental Bonding Instrument (PBI), and the Mentalisation Scale–12 (MentS–12). Descriptive statistics and bivariate correlations were conducted using SPSS version 30, and mediation analyses were performed using Jamovi version 2.6.26. Results: Clinically significant ADHD and BPD symptoms were present in 10.3% and 15.9% of adolescents, respectively. ADHD and BPD symptoms were moderately correlated ( r = 0.33, p < .001). Mediation analyses revealed that paternal parenting dimensions and lower adolescent mentalisation capacity significantly mediated the association between ADHD and BPD symptoms. Conclusions: These findings suggest that paternal parenting and mentalisation capacity may play important roles in the co-occurrence of ADHD and BPD symptoms among adolescents. Longitudinal research is warranted to clarify the causal pathways involved. Trial registration: Not applicable. Attention-deficit/hyperactivity disorder (ADHD) borderline personality disorder (BPD) adolescents parenting dimensions mentalisation mediation analysis cross-sectional study Malaysia Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Adolescence is a key transitional stage marked by rapid physical, emotional, and cognitive changes ( 1 ) and often occurs when many mental health conditions become more pronounced or are first recognized. Attention deficit hyperactivity disorder (ADHD) and borderline personality disorder (BPD) are two such conditions. ADHD is characterized by inattention, hyperactivity, and impulsivity ( 2 , 3 ), with a global prevalence estimated between 5.8% and 8.0% ( 2 , 4 ), whereas Malaysian rates are lower at 1.6–4.6% ( 5 ). BPD involves emotional dysregulation, impulsivity, unstable relationships, and identity disturbance, affecting 3.0–5.4% of adolescents ( 6 , 7 ). It is now recognized in this age group, with early detection considered crucial for timely intervention ( 8 – 10 ). Local data on ADHD and BPD are scarce, and stigma along with diagnostic challenges hinders recognition, particularly within school settings ( 11 ). These conditions often cooccur, partly because of shared features such as impulsivity and emotional dysregulation ( 12 , 13 ). However, the psychosocial mechanisms underlying this association remain underexplored in non-Western populations. Parenting dimensions of care and overprotection ( 14 ) have been linked to difficulties observed in both disorders ( 15 , 16 ). Mentalisation is the capacity to understand and reflect on one’s own and others’ mental states; it is reduced in ADHD (hypo-mentalisation) and heightened in BPD (hyper-mentalisation) ( 17 , 18 ), yet empirical research in Malaysian adolescents is lacking. This study aimed to examine the association between ADHD and BPD symptoms among Malaysian adolescents and to investigate whether parenting dimensions and mentalisation mediate this relationship. Understanding these mechanisms may inform culturally sensitive interventions to support adolescents at risk of ADHD and BPD. Methods Study Design and Setting This cross-sectional study was conducted from March to July 2025 in three government secondary schools located in urban Selangor, a state bordering the capital, Kuala Lumpur (Fig. 1): SMK Damansara Jaya, SMK Taman Sea, and SMK Kota Damansara 10. Data were collected via self-administered questionnaires with parents completing the Swanson, Nolan, and Pelham Rating Scale–Fourth Edition (SNAP-IV) and adolescents completing a sociodemographic questionnaire, Borderline Symptom List–23 (BSL-23), Parental Bonding Instrument (PBI), and Mentalisation Scale (MentS-12). The map shows the urban study area in Selangor, Malaysia. Kuala Lumpur is shown in orange, the rest of Selangor in blue, and other parts of Peninsular Malaysia in grey. Participants The participants were 14- and 16-year-old students from the three selected schools. A convenience sampling method was used, recruiting students based on their availability and willingness to participate from the selected schools. The inclusion criteria included sufficient English proficiency, written assent, and parental consent; those lacking consent or with cognitive/language limitations were excluded. The required sample size was estimated using the Raosoft calculator, with a 95% confidence level, 5% margin of error, and an estimated ADHD prevalence of 5.6% among adolescents ( 2 ). The calculation yielded a minimum of 82 participants: n = (1.96² × 0.056 × (1 − 0.056)) / 0.05² = 81.3 Based on the formula, the minimum required sample size was approximately 81 and was rounded up to 82 participants. Among the approximately 900 eligible students, 126 returned both complete consent and assent forms, yielding a response rate of approximately 14%. Procedure Ethical approval was obtained from the University of Malaya Medical Centre Medical Research Ethics Committee (Ref: 20241114-14401), the Malaysian Ministry of Education (KPM.600-3/2/3-eras (23061)), and the Selangor State Education (JPNS. SPD 600-1/1/2 JLD.52( 8 )). All procedures were conducted in accordance with the Declaration of Helsinki. The principal investigator liaised with schoolteachers to distribute study information sheets, consent forms, and the SNAP-IV to parents via students; completed forms were returned to schools. Only students who provided parental consent were invited to participate. After receiving explanations and providing assent, the students completed questionnaires during school hours under supervision. Participation was voluntary and anonymous, with no incentives. No adverse events were reported, but a. referral protocol to school counsellors was in place in case of distress. Measures Sociodemographic Questionnaire Developed by the research team, this questionnaire collected data on gender, age, ethnicity, religion, household composition, parental education and employment, income, and family history of physical or mental illness. SNAP-IV A parent-report scale assessing ADHD symptoms ( 19 ) across inattention (items 1–9), hyperactivity/impulsivity ( 10 – 18 ), and oppositional symptoms ( 19 – 26 ) was used, with a 4-point Likert scale (0–3). A score ≥ 13 on the inattention or hyperactivity subscale indicates mild ADHD symptoms ( 20 ). The scale has been validated for Malaysian use ( 21 ). BSL-23 Self-reports assess BPD symptoms across domains such as emotional instability and impulsivity ( 22 ). The items are rated on a 5-point scale (0–4), with a total score ranging from 0–92. A score ≥ 46 indicates clinically relevant BPD symptoms ( 23 ). Although not locally validated, it is widely used cross-culturally. PBI A self-report assessing perceived parenting during childhood across two dimensions: Care and Overprotection. Higher Care scores reflect warmth; higher Overprotection scores reflect control ( 14 ). The tool has been validated for Malaysian use ( 24 ). MentS-12 A self-report scale is used to assess the capacity to reflect on one’s own and others' mental states ( 25 ). The items are rated on a 5-point scale; total scores range from 12–60, with higher scores indicating stronger mentalisation. All instruments were reviewed by an expert panel for adolescent suitability. Statistical Analysis Descriptive statistics and bivariate correlations were conducted via SPSS version 30. The prevalence of ADHD and BPD symptoms was calculated. Pearson correlations assessed the relationships between ADHD symptoms and BPD symptoms. Data were complete for all measures except for paternal PBI, which was missing for three participants due to absence of a father. Analyses were conducted using available data for each measure. Mediation analyses were performed in Jamovi version 2.6.26. Maternal care and overprotection and paternal care and overprotection were tested as paired mediators in separate models. Mentalisation was tested as an independent mediator. The results are presented in tables and figures; figures were prepared via Microsoft PowerPoint. Statistical significance was set at p < .05. Results Sociodemographic Characteristics Most participants were female (54%), in Form 4 (81%), Malay (58%), or Muslim (60%). Nearly all (93%) had no personal history of mental illness. The majority (86%) were either unaware of or unsure about access to mental health services. Most parents were married (91%), and both were employed (60%). Most mothers (70%) and fathers (67%) had a college or university education. Few reported a history of family mental illness (7%). (Table 1 ) Table 1 Sociodemographic Characteristics of the Participants (N = 126) Variable Category Frequency (n) Percentage (%) Gender Male 58 46.0 Female 68 54.0 Year in School Form 2 24 19.0 Form 4 102 81.0 Ethnic Background Malay 73 57.9 Chinese 40 31.7 Indian 7 5.6 Other 6 4.8 Religion Islam 76 60.3 Buddhist 26 20.6 Christian 16 12.7 Hinduism 5 4.0 Other 3 2.4 Participant’s Mental Illness History None 117 92.9 ADHD 1 0.8 Borderline PD 1 0.8 Anxiety 4 3.2 Depression 1 0.8 Other 2 1.6 Aware of Mental Health access Yes 18 14.3 No 36 28.6 Not sure 72 57.1 Parent's Marital Status Married 114 90.5 Divorced 10 7.9 Widowed 2 1.6 Parental Employment Status Father only 14 11.1 Mother only 22 17.5 Both working 75 59.5 Both not working 4 3.2 Not sure 10 7.9 Mother's Education No formal education 1 0.8 Primary School 1 0.8 Secondary School 26 20.6 College/University Level 88 69.8 Not sure 10 7.9 Father's Education No formal education 1 0.8 Primary School 4 3.2 Secondary School 22 17.5 College/University Level 84 66.7 Not sure 15 11.9 Family Mental Illness History Yes 9 7.1 No 112 88.9 Not sure 5 4.0 This table summarizes the sociodemographic characteristics of the 126 adolescent participants and their parents. Percentages may not total 100% due to rounding or missing responses. Descriptive Statistics Prevalence of ADHD and BPD Symptoms Clinically significant ADHD symptoms were identified in 13 participants (10.3%) based on a SNAP-IV subscale score ≥ 13 for Inattention or Hyperactivity/Impulsivity. For BPD, 20 participants (15.9%) scored ≥ 46 on the BSL-23, indicating clinically significant symptoms ( 20 , 23 ). Parenting Dimensions The mean scores were 10.44 (SD = 6.49) for maternal care and 25.49 (SD = 5.57) for maternal overprotection. For the paternal dimensions, the mean level of care was 14.57 (SD = 7.13), and that of overprotection was 26.56 (SD = 6.49). Mentalisation Capacity The total mentalisation score was calculated by summing all 12 items of the MentS-12. The scores ranged from 12.00 to 57.00, with a mean of 40.21 (SD = 7.65). Correlation between ADHD and BPD Symptoms Pearson correlation analysis indicated a significant moderate positive association between ADHD and BPD symptoms. ( r = 0.33, p < .001). Mediation Analysis Mediation analyses examined maternal and paternal care and overprotection (each pair in separate models) and mentalisation as independent mediators of the ADHD–BPD association. Maternal Parenting Dimension as a Mediator ADHD symptoms had a significant total effect on BPD symptoms (estimate = 0.6095, p < .001). Maternal care and maternal overprotection each significantly predicted BPD symptoms when controlling for ADHD (estimate = 0.7598, p = .007; estimate = − 0.7799, p = .017), although their indirect effects were not significant. The direct effect of ADHD on BPD remained significant (estimate = 0.4888, p < .001) (Table 2 and Fig. 2). Table 2 Path Estimates for the Maternal Parenting Mediation Model This table presents the path estimates for the mediation model examining maternal care (Mc) and maternal overprotection (Mo) as mediators of the relationship between ADHD symptoms and BPD symptoms. Type Effect Estimate SE 95% CI β z p Lower Upper Indirect ADHD ⇒ Mc ⇒ BPD 0.0700 0.0464 -0.02093 0.1609 0.0379 1.51 .131 ADHD ⇒ Mo ⇒ BPD 0.0507 0.0401 -0.02793 0.1294 0.0275 1.26 .206 Component ADHD ⇒ Mc 0.0921 0.0507 -0.00726 0.1914 0.1598 1.82 .069 Mc ⇒ BPD 0.7598 0.2806 0.20984 1.3097 0.2373 2.71 .007* ADHD ⇒ Mo -0.0650 0.0437 -0.15073 0.0207 -0.1314 -1.49 .137 Mo ⇒ BPD -0.7799 0.3253 -1.41751 -0.1423 -0.2092 -2.40 .017* Direct ADHD ⇒ BPD 0.4888 0.1445 0.20572 0.7720 0.2649 3.38 < .001** Total ADHD ⇒ BPD 0.6095 0.1558 0.30414 0.9149 0.3303 3.91 < .001** Note. CI = confidence interval; β = standardized coefficient. Mc = maternal care; Mo = maternal overprotection. * p < 0.05; ** p < 0.001 Structural model illustrating the associations between ADHD symptoms and BPD symptoms through maternal care and maternal overprotection. Solid arrows indicate significant paths (p < .05), dashed arrows indicate non-significant paths. Values represent unstandardized estimates with corresponding p-values. Paternal Parenting Dimensions as Mediators This model revealed significant indirect effects of ADHD symptoms on BPD symptoms through paternal care (estimate = 0.166, p = .017) and paternal overprotection (estimate = 0.113, p = .039). Both paternal care and overprotection were significantly associated with BPD symptoms, and ADHD symptoms were significantly related to these parenting dimensions. The direct effect of ADHD on BPD remained significant (estimate = 0.349, p = .010), indicating partial mediation (Table 3 and Fig. 3). Table 3 Path Estimates for the Paternal Parenting Mediation Model This table presents the path estimates for the mediation model examining paternal care (Pc) and paternal overprotection (Po) as mediators of the relationship between ADHD symptoms and BPD symptoms. Type Effect Estimate SE 95% CI β z p Lower Upper Indirect ADHD ⇒ Pc ⇒ BPD 0.166 0.0698 0.02969 0.3032 0.0901 2.39 .017* ADHD ⇒ Po ⇒ BPD 0.113 0.0547 0.00581 0.2204 0.0612 2.07 .039* Component ADHD ⇒ Pc 0.151 0.0552 0.04255 0.2588 0.2391 2.73 .006* Pc ⇒ BPD 1.105 0.2254 0.66266 1.5464 0.3769 4.90 < .001** ADHD ⇒ Po -0.127 0.0504 -0.22587 -0.0282 -0.2215 -2.52 .012* Po ⇒ BPD -0.890 0.2467 -1.37377 -0.4069 -0.2765 -3.61 < .001** Direct ADHD ⇒ BPD 0.349 0.1359 0.08223 0.6148 0.1887 2.57 .010* Total ADHD ⇒ BPD 0.610 0.1558 0.30414 0.9149 0.3303 3.91 < .001** Note. CI = confidence interval; β = standardized coefficient. Pc = Paternal Care; Po = Paternal Overprotection. * p < 0.05; ** p < 0.001 Structural model illustrating the associations between ADHD symptoms and BPD symptoms through paternal care and paternal overprotection. Solid arrows indicate significant paths ( p < .05), dashed arrows indicate non-significant paths. Values represent unstandardized estimates with corresponding p -values. Mentalisation Capacity as Mediators The mentalisation mediation model revealed a significant indirect effect of ADHD symptoms on BPD symptoms through mentalisation capacity (estimate = 0.160, p = .040). ADHD symptoms were associated with increased mentalisation capacity (estimate = 0.130, p = .029), which in turn was associated with higher BPD symptoms (estimate = 1.227, p < .001). The direct effect of ADHD on BPD remained significant (estimate = 0.450, p = .001), indicating partial mediation (Table 4 and Fig. 4). Table 4 Path Estimates for the Mentalisation Mediation Model This table presents the path estimates for the mediation model examining mentalisation capacity (Mz) as a mediator of the relationship between ADHD symptoms and BPD symptoms. Type Effect Estimate SE 95% CI β z p Lower Upper Indirect ADHD ⇒ Mz ⇒ BPD 0.160 0.0777 0.00741 0.312 0.0865 2.06 .040* Component ADHD ⇒ Mz 0.130 0.0595 0.01361 0.247 0.1914 2.19 .029* Mz ⇒ BPD 1.227 0.2052 0.82454 1.629 0.4520 5.98 < .001** Direct ADHD⇒ BPD 0.450 0.1396 0.17633 0.723 0.2438 3.22 .001* Total ADHD ⇒ BPD 0.610 0.1558 0.30414 0.915 0.3303 3.91 < .001** Note. CI = confidence interval; β = standardized coefficient. Mz = Mentalisation capacity. * p < 0.05; ** p < 0.001 Structural model illustrating the associations between ADHD symptoms and BPD symptoms through mentalisation capacity. Solid arrows indicate significant paths ( p < .05), dashed arrows indicate non-significant paths. Values represent unstandardized estimates with corresponding p -values. Discussion Prevalence of ADHD and BPD Symptoms ADHD (10.3%) and BPD (15.9%) symptoms were more common in this study than in earlier reports. These prevalence rates exceed both global and regional estimates, suggesting a potentially unique cultural or methodological influence. Globally, ADHD incidence averages approximately 8% in children and adolescents ( 4 ), with another review reporting 5.6% among adolescents aged 12–18 years ( 2 ). Local studies reported rates of 1.6–4.6% in younger samples ( 5 ). The prevalence of BPD in adolescents is typically approximately 3.0%, with higher rates in clinical populations ( 6 ); local data remain scarce. The elevated prevalence observed may reflect increased symptom expression or improved detection via adolescent self-reports, which can better capture the internal distress often overlooked by adult observers ( 2 , 6 ). Given the long-term burden of ADHD and BPD ( 26 , 27 ), early identification is crucial. In Malaysia, where routine school-based screening is limited, these findings highlight the need for stronger national policy and mental health investment ( 28 ). A feasible next step involves integrating school-based screening via validated tools such as the Behavior Rating Inventory of Executive Function (BRIEF), the Borderline Personality Features Scale for Children (BPFS), and the SNAP-IV combined with classroom observations to increase accuracy and support timely intervention ( 9 , 29 ). Correlation between ADHD and BPD Symptoms The association between ADHD and BPD is well documented, with both conditions sharing key features such as impulsivity and emotional dysregulation, which may complicate differential diagnosis ( 13 , 30 ). ADHD has also been linked to the later emergence of BPD symptoms ( 31 , 32 ), potentially reflecting overlapping deficits in emotion regulation ( 33 ). Consistent with previous research, the present study found a moderate association between ADHD and BPD symptoms among Malaysian adolescents, suggesting that adolescents exhibiting ADHD symptoms may be at elevated risk for BPD. Shared vulnerabilities, particularly impulsivity and emotional dysregulation, may underlie both conditions and indicate that ADHD could represent an early developmental pathway to BPD ( 34 , 35 ). In adolescent populations, comorbid ADHD has been associated with more severe clinical presentations of BPD, especially increased impulsivity ( 36 ). While much of the existing evidence is from Western contexts, our findings extend these associations to a Southeast Asian setting, enriching cross-cultural perspectives on ADHD–BPD comorbidity. These findings underscore the importance of assessing BPD symptoms in adolescents with ADHD, particularly when emotional instability and relational difficulties are present. Since parents often influence help-seeking, their recognition of symptoms is critical ( 37 ). However, many cases may remain undetected, highlighting the value of school-based screening for early detection ( 38 ). In practice, schools could improve early identification by training teachers and counselors to recognize emotional and interpersonal challenges associated with ADHD and early BPD signs. Training should include clear referral pathways to facilitate timely psychological support. Parenting Dimensions Maternal Care and Overprotection In contrast to expectations, maternal care and overprotection did not significantly mediate the relationship between ADHD and BPD symptoms. While both dimensions were associated with BPD symptoms, they were not significantly associated with ADHD symptoms. This contrasts with earlier research highlighting the role of maternal parenting in emotional dysregulation and BPD development ( 39 , 40 ), suggesting that maternal factors may not fully account for the ADHD–BPD co-occurrence in this context. One possible explanation lies in Malaysian cultural norms, where mothers are generally seen as nurturing but may not hold primary authority during adolescence ( 41 ). Relational enmeshment or social desirability may contribute to the underreporting of negative maternal behaviors. These findings contribute to a more nuanced understanding of parenting influences on adolescent psychopathology in collectivist contexts, complementing predominantly Western evidence. Despite the lack of mediation, parenting-focused interventions such as parenting wisely or the Triple P-Positive Parenting Program ( 42 ) may still offer benefits, particularly when adapted for adolescents and delivered through schools or community settings with engagement from both parents. Longitudinal or observational approaches may also be more sensitive in capturing the nuances of maternal impact over time. Paternal Care and Overprotection Paternal care and overprotection significantly mediated the association between adolescent ADHD and BPD symptoms. Unexpectedly, more ADHD symptoms were linked to greater paternal care, which in turn was associated with increased BPD symptoms. Conversely, lower paternal overprotection was related to both higher ADHD and BPD symptoms. These findings highlight complex and sometimes counterintuitive dynamics in paternal roles. This may reflect shifting norms of fatherhood in collectivist cultures such as Malaysia, where emotional involvement from fathers is increasing ( 43 ). Paternal warmth, responsiveness, and support have long been linked to adolescent outcomes ( 44 ). Adolescents’ perceptions of their fathers' behaviours may thus exert distinct and nuanced effects on mental health. Our findings support prior research underscoring fathers’ unique roles in adolescent development ( 45 , 46 ), yet fathers remain underrepresented in the parenting literature ( 47 ). In the Malaysian context, paternal emotional availability may be particularly impactful because of culturally shaped gender roles and expectations ( 41 ). These findings suggest that father-inclusive approaches warrant further exploration as a means of addressing potential shared ADHD-BPD vulnerabilities and could inform the design of culturally sensitive family support models. Schools and healthcare settings could take active steps to involve fathers, while policymakers consider developing and funding programmes that reduce structural and cultural barriers to their participation. Evidence-based interventions such as “ Dad’s Tuning in to Kids” have shown efficacy in improving paternal emotional responsiveness ( 48 ). However, engaging fathers in parenting programmes can be challenging due to practical constraints such as time demands, work commitments, and prevailing cultural norms ( 49 ). Offering digital or hybrid delivery formats guided by best-practice father-inclusive principles ( 50 ) may help overcome these barriers. Mentalisation Mentalisation emerged as a significant factor associated with both ADHD symptoms and BPD symptoms in adolescents and mediated the relationship between them. In contrast to some prior studies suggesting impaired mentalisation in ADHD patients, this study revealed that greater ADHD severity was linked to greater mentalisation capacity, which in turn predicted increased BPD symptoms. This finding indicates a more complex association between ADHD and mentalisation in this sample. These findings partially diverge from the established view that ADHD is typically characterized by hypo-mentalisation—defined as a diminished ability to understand others’ mental states and perspectives, particularly in adolescents with prominent inattention symptoms ( 51 ). In contrast, BPD is more commonly associated with hyper-mentalisation—an overinterpretation of others’ intentions—which contributes to emotional instability and interpersonal difficulties ( 17 , 18 ). Impaired mentalisation in BPD patients also reflects reduced reflective functioning, a key developmental vulnerability ( 52 , 53 ). These findings suggest that mentalisation remains an important cognitive‒emotional mechanism linking ADHD and BPD symptoms. Mentalisation-based treatment (MBT) has demonstrated effectiveness in adolescents with BPD ( 54 , 55 ) and is emerging as a promising intervention for improving functioning in individuals with ADHD ( 56 ). However, given the distinct cognitive and attentional challenges in ADHD, MBT adaptations may be necessary to optimize outcomes. By targeting reflective functioning, MBT holds potential to address shared vulnerabilities across these disorders, although longitudinal studies are needed to evaluate its preventive potential and long-term effects. In summary, mentalisation represents a unifying developmental and clinical target, with the potential to inform early detection, refine prevention strategies, and guide culturally adaptable, mechanism-focused treatments for at-risk adolescents. Future research should further explore the nuanced relationship between ADHD and mentalisation, considering cultural, developmental, and measurement factors that may influence this association. Strengths and Limitations This study addresses a significant gap in Malaysian adolescent mental health research by examining the associations between ADHD and BPD symptoms and the mediating roles of parenting styles and mentalisation. Using well-established instruments (SNAP-IV, BSL-23, MentS-12, PBI), our mediation analysis revealed partial mediation by both paternal parenting dimensions and mentalisation. Moreover, recruiting participants from multiple schools in urban areas strengthens the ecological validity and generalizability of the findings to similar populations. Additionally, supervised data collection and the inclusion of parent-reported ADHD symptoms helped reduce bias from adolescent self-reports. However, several limitations should be acknowledged. These include a narrow age range (14- and 16-year-olds) and focus on urban government schools, which limits their applicability to other ages and settings. Reliance on adolescent self-reports introduces potential recall and social desirability bias, although this bias was partly mitigated by parent reports and data collection methods. Finally, the cross-sectional design precludes causal conclusions. Despite these limitations, this study advances understanding of ADHD–BPD co-occurrence in a non-Western setting and provides a foundation for future research and interventions tailored to Malaysian adolescents. Conclusions This study highlights the high prevalence of ADHD and BPD symptoms among Malaysian adolescents and highlights the interplay between neurodevelopmental traits, parenting (care and overprotection), and mentalisation. Paternal parenting and adolescents’ mentalizing capacity are key psychosocial mediators linking ADHD and BPD symptoms. By identifying these as modifiable targets, our findings lay the groundwork for culturally sensitive early intervention strategies that may reduce the long-term burden of ADHD and BPD in adolescents. These findings contribute novel evidence from a non-Western setting to a literature still dominated by Western samples and emphasize the value of integrating psychosocial factors into early screening and prevention frameworks. Our findings emphasize the need to address both biological and psychosocial factors in adolescent mental health. Family-focused and school-based interventions targeting parenting and mentalisation could strengthen early prevention. This research contributes to the regional literature and informs future studies, clinical work, and policy in Malaysia. Future research should involve more diverse adolescent samples across age groups, regions (including rural and private schools), and cultural contexts to enhance generalizability. Using multiple informants (e.g., teachers, parents, clinicians) would reduce self-report bias and improve validity. Longitudinal designs are recommended to clarify causal links between ADHD and BPD symptoms and to examine the mediating roles of parenting and mentalisation. Exploring additional psychosocial factors (e.g., peer influence, trauma, and family dynamics) and applying advanced methods such as structural equation modelling could further enrich the understanding of developmental risk pathways. Abbreviations ADHD attention deficit hyperactivity disorder BPD borderline personality disorder MBT Mentalisation–Based Treatment SNAP IV–Swanson, Nolan, and Pelham, version IV BSL 23–Borderline Symptom List, 23–item version PBI Parental Bonding Instrument MentS 12–Mentalisation Scale, 12–item version CI Confidence Interval SE Standard Error SD Standard Deviation β Standardized Coefficient Declarations Ethics approval and consent to participate: Ethical approval was obtained from the University of Malaya Medical Centre Ethics Committee (Ref: 20241114-14401). Written informed consent was obtained from all participants or their guardians. Consent for publication: Not applicable. Competing interests: The authors declare that they have no competing interests. Funding: This study was funded by the University of Malaya, subject to acceptance. Author Contribution Tan Yee Xin led the study design, data collection, analysis, and manuscript preparation. Chow Soon Ken provided conceptualization and supervision. Manveen Kaur and Fatin Liyana Binti Azhar contributed critical revisions and approved the final manuscript. Yit Han Ng provided suggestions for data analysis. Acknowledgement The authors thank the Ministry of Education Malaysia and the Selangor State Education Department for their cooperation and approval, the University of Malaya for institutional support, and the Department of Psychological Medicine for academic guidance. Special thanks to the child and adolescent psychiatry team for facilitating collaboration with the participating schools. The authors are grateful to the principals, teachers-in-charge, students, and parents of the participating schools for their contributions. Finally, they acknowledge their families for their understanding, encouragement, and support throughout this research. 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SNAP-IV teacher and parent rating scale 2018 [Available from: https://www.shared-care.ca/files/Scoring_for_SNAP_IV_Guide_26-item.pdf Jusoh AJ, Kadir NBA, Ahmad SB, Yunus RM, Ibrahim N. Cross–cultural translation and validation of the Malay version of the Swanson, Nolan and Pelham Parent Rating Scale of attention deficit hyperactivity disorders symptoms among Malaysian probands: A preliminary study. Asia–Pacific Psychiatry. 2020;13(2):e12414. Bohus M, Kleindienst N, Limberger MF, Stieglitz RD, Domsalla M, Chapman AL, et al. The short version of the Borderline Symptom List (BSL-23): development and initial data on psychometric properties. Psychopathology. 2009;42(1):32–9. Nicastro R, Prada P, Kung AL, Salamin V, Dayer A, Aubry JM, et al. Psychometric properties of the French borderline symptom list, short form (BSL-23). Borderline Personality Disorder Emot Dysregulation. 2016;3:4. Muhammad NA. Validation of the Malay Version of the Parental Bonding Instrument among Malaysian Youths Using Exploratory Factor Analysis. Malaysian J Med Sci. 2014;21:51–9. Dimitrijevic A, Hanak N, Altaras Dimitrijevic A, Jolic Marjanovic Z. The Mentalization Scale (MentS): A Self-Report Measure for the Assessment of Mentalizing Capacity. J Pers Assess. 2018;100(3):268–80. Rattay K, Robinson LR. Identifying Risk Factors for Attention-Deficit/Hyperactivity Disorder (ADHD): a Public Health Concern and Opportunity. Prev Sci. 2024;25(Suppl 2):195–202. Stone MH. Long-Term Course of Borderline Personality Disorder. Psychodyn Psychiatry. 2016;44(3):449–74. UNICEF and Ministry of Health Malaysia. Strengthening Mental Health and Psychosocial Support Systems and Services for Children and Adolescents in East Asia and Pacific Region: Malaysia Country Report. Kuala Lumpur; 2023. Musullulu H. Evaluating attention deficit and hyperactivity disorder (ADHD): a review of current methods and issues. Front Psychol. 2025;16:1466088. Franczak L, Podwalski P, Wysocki P, Dawidowski B, Jedrzejewski A, Jablonski M et al. Impulsivity in ADHD and Borderline Personality Disorder: A Systematic Review of Gray and White Matter Variations. J Clin Med. 2024;13(22). Carlotta D, Borroni S, Maffei C, Fossati A. On the relationship between retrospective childhood ADHD symptoms and adult BPD features: the mediating role of action-oriented personality traits. Compr Psychiatr. 2013;54(7):943–52. Tiger A, Ohlis A, Bjureberg J, Lundstrom S, Lichtenstein P, Larsson H, et al. Childhood symptoms of attention-deficit/hyperactivity disorder and borderline personality disorder. Acta psychiatrica Scandinavica. 2022;146(4):370–80. Rufenacht E, Euler S, Prada P, Nicastro R, Dieben K, Hasler R, et al. Emotion dysregulation in adults suffering from attention deficit hyperactivity disorder (ADHD), a comparison with borderline personality disorder (BPD). Borderline Personal Disord Emot Dysregul. 2019;6:11. Perroud N, Badoud D, Weibel S, Nicastro R, Hasler R, Kung AL, et al. Mentalization in adults with attention deficit hyperactivity disorder: Comparison with controls and patients with borderline personality disorder. Psychiatry Res. 2017;256:334–41. Storebo OJ, Simonsen E. Is ADHD an early stage in the development of borderline personality disorder? Nord J Psychiatry. 2014;68(5):289–95. Speranza M, Revah-Levy A, Cortese S, Falissard B, Pham-Scottez A, Corcos M. ADHD in adolescents with borderline personality disorder. BMC Psychiatry. 2011;11:158. Thurston IB, Phares V, Coates EE, Bogart LM. Child problem recognition and help-seeking intentions among black and white parents. J Clin Child Adolesc Psychol. 2015;44(4):604–15. Husky MM, Kaplan A, McGuire L, Flynn L, Chrostowski C, Olfson M. Identifying adolescents at risk through voluntary school-based mental health screening. J Adolesc. 2011;34(3):505–11. Eyden J, Winsper C, Wolke D, Broome MR, MacCallum F. A systematic review of the parenting and outcomes experienced by offspring of mothers with borderline personality pathology: Potential mechanisms and clinical implications. Clin Psychol Rev. 2016;47:85–105. Schuppert HM, Albers CJ, Minderaa RB, Emmelkamp PM, Nauta MH. Parental rearing and psychopathology in mothers of adolescents with and without borderline personality symptoms. Child Adolesc Psychiatry Ment Health. 2012;6(1):29. Sumari M, Baharudin DF, Khalid NM, Ibrahim NH, Ahmed Tharbe IH. Family Functioning in a Collectivist Culture of Malaysia: A Qualitative Study. Family J. 2019;28(4):396–402. Sanders MR. Triple P-Positive Parenting Program: towards an empirically validated multilevel parenting and family support strategy for the prevention of behavior and emotional problems in children. Clin Child Fam Psychol Rev. 1999;2(2):71–90. Novianti RF, Novita S, Syaiful. Syaiful,. Parenting in Cultural Perspective: A Systematic Review of Paternal Role. J Ethnic Cult Stud. 2023;10(1):144–57. Lamb ME. The Role of the Father in Child Development. New York: Wiley; 1981. McMunn A, Martin P, Kelly Y, Sacker A. Fathers' Involvement: Correlates and Consequences for Child Socioemotional Behavior in the United Kingdom. J Fam Issues. 2017;38(8):1109–31. Su LP, Kubricht B, Miller R. The influence of father involvement in adolescents' overall development in Taiwan. J Adolesc. 2017;59:35–44. Mestermann S, Kleinoder JM, Arndt M, Kramer J, Eichler A, Kratz O. The Father's Part: A Pilot Evaluation of a Father-Centered Family Intervention Group in Child and Adolescent Psychiatry. Behav Sci (Basel). 2023;14(1). Havighurst SSW, Harley KR, Kehoe AE. C. E. Dads Tuning in to Kids: A randomized controlled trial of an emotion socialization parenting program for fathers. Soc Dev. 2019;28(4). Panter-Brick C, Burgess A, Eggerman M, McAllister F, Pruett K, Leckman JF. Practitioner review: Engaging fathers–recommendations for a game change in parenting interventions based on a systematic review of the global evidence. J Child Psychol Psychiatry. 2014;55(11):1187–212. Lechowicz ME, Jiang Y, Tully LA, Burn MT, Collins DAJ, Hawes DJ, et al. Enhancing Father Engagement in Parenting Programs: Translating Research into Practice Recommendations. Australian Psychol. 2020;54(2):83–9. Poznyak E, Samson JL, Barrios J, Rafi H, Hasler R, Perroud N, et al. Mentalizing in Adolescents and Young Adults with Attention Deficit Hyperactivity Disorder: Associations with Age and Attention Problems. Psychopathology. 2024;57(2):91–101. Bateman A, Fonagy P. Mentalization based treatment for borderline personality disorder. World Psychiatry. 2010;9(1):11–5. Fonagy P, Luyten P. A developmental, mentalization-based approach to the understanding and treatment of borderline personality disorder. Dev Psychopathol. 2009;21(4):1355–81. Rossouw TI, Fonagy P. Mentalization-based treatment for self-harm in adolescents: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry. 2012;51(12):1304–e133. Sharp C, Rossouw T. Mentalization-Based Treatment for Adolescents (MBT-A). Psychodyn Psychiatry. 2024;52(4):542–62. Kasper LA, Hauschild S, Schrauf LM, Taubner S. Enhancing mentalization by specific interventions within mentalization-based treatment of adolescents with conduct disorder. Front Psychol. 2023;14:1223040. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7484039","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":514926826,"identity":"37f459fb-578a-4bb3-8cfa-5d8821da7ae8","order_by":0,"name":"Yee Xin Tan","email":"","orcid":"","institution":"University of Malaya Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Yee","middleName":"Xin","lastName":"Tan","suffix":""},{"id":514926827,"identity":"096b0f7b-8440-48fa-8422-7bae7f4df91f","order_by":1,"name":"Soon Ken Chow","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvklEQVRIiWNgGAWjYJACxgYGBjkwi4cULcaka0lsIFqLfHvzsYczKu6kb7h2gPHB2zaGaIMDBLQYnDmWbrjhzLPcDbcTmA3ntjHkbiCoRSLHTPJh22GQFjZpXmK0yM8Aafl3ON3gdgL7b6K0MNwAatnYcDgBqIWNmSgtQL+kSc44dthw5u3EZsk55yRyZxJ0GDDEJHtqDsvz3U4++OFNmU1uH0GHIQAoehgkGBRI0AKzt4FkLaNgFIyCUTDMAQA5REgPOyUkagAAAABJRU5ErkJggg==","orcid":"","institution":"University of Malaya Medical Centre","correspondingAuthor":true,"prefix":"","firstName":"Soon","middleName":"Ken","lastName":"Chow","suffix":""},{"id":514926828,"identity":"17196e38-b2df-4c49-9fb6-0aeb4a4ebb00","order_by":2,"name":"Manveen Kaur","email":"","orcid":"","institution":"University of Malaya Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Manveen","middleName":"","lastName":"Kaur","suffix":""},{"id":514926829,"identity":"dd0ef885-9f14-48a7-8e85-ad4060974bfe","order_by":3,"name":"Fatin Liyana Azhar","email":"","orcid":"","institution":"University of Malaya Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Fatin","middleName":"Liyana","lastName":"Azhar","suffix":""},{"id":514926830,"identity":"a26bb179-120a-4d74-9931-2fe223eb8404","order_by":4,"name":"Yit Han Ng","email":"","orcid":"","institution":"Universiti Malaya","correspondingAuthor":false,"prefix":"","firstName":"Yit","middleName":"Han","lastName":"Ng","suffix":""}],"badges":[],"createdAt":"2025-08-29 02:08:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7484039/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7484039/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91357721,"identity":"9a628402-a4eb-440c-af56-2eff72b8e305","added_by":"auto","created_at":"2025-09-15 15:49:08","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":378082,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eLocation of the study area in urban Selangor.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2025.08.28BMCPsychiatryFig.1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7484039/v1/68be6a15e967f616ac062932.jpg"},{"id":91357727,"identity":"369751e8-b288-4865-a570-c86f0bf5239d","added_by":"auto","created_at":"2025-09-15 15:49:08","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":368492,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eModel of the Relationship between ADHD Symptoms and BPD Symptoms via Maternal Care and Overprotection\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2025.08.28BMCPsychiatryFig.2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7484039/v1/16130779ff87a0e51f2135a4.jpg"},{"id":91357733,"identity":"92ed4348-3a62-40b3-aedd-757d5bb6de37","added_by":"auto","created_at":"2025-09-15 15:49:08","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":370339,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eModel of the Relationship between ADHD Symptoms and BPD Symptoms via Paternal Care and Overprotection\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2025.08.28BMCPsychiatryFig.3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7484039/v1/51cb4d3ee50410c17cb56ab2.jpg"},{"id":91359084,"identity":"24e44e80-85c7-4c2e-8f66-b3f024b79d78","added_by":"auto","created_at":"2025-09-15 16:05:08","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":271549,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eModel of the Relationship between ADHD Symptoms and BPD Symptoms via Mentalisation Capacity\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2025.08.28BMCPsychiatryFig.4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7484039/v1/dc0f04285a0441eb4f4919ea.jpg"},{"id":91360564,"identity":"224c3d20-a58b-493f-b799-e6ef000a460a","added_by":"auto","created_at":"2025-09-15 16:21:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2759349,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7484039/v1/4cecbc74-d981-4fa1-900e-cc6652ae5a4f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Mediating Role of Parenting Dimensions and Mentalisation between ADHD and BPD in Adolescents: A Cross-Sectional Study","fulltext":[{"header":"Background","content":"\u003cp\u003eAdolescence is a key transitional stage marked by rapid physical, emotional, and cognitive changes (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) and often occurs when many mental health conditions become more pronounced or are first recognized. Attention deficit hyperactivity disorder (ADHD) and borderline personality disorder (BPD) are two such conditions. ADHD is characterized by inattention, hyperactivity, and impulsivity (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), with a global prevalence estimated between 5.8% and 8.0% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), whereas Malaysian rates are lower at 1.6\u0026ndash;4.6% (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). BPD involves emotional dysregulation, impulsivity, unstable relationships, and identity disturbance, affecting 3.0\u0026ndash;5.4% of adolescents (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). It is now recognized in this age group, with early detection considered crucial for timely intervention (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eLocal data on ADHD and BPD are scarce, and stigma along with diagnostic challenges hinders recognition, particularly within school settings (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). These conditions often cooccur, partly because of shared features such as impulsivity and emotional dysregulation (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). However, the psychosocial mechanisms underlying this association remain underexplored in non-Western populations. Parenting dimensions of care and overprotection (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) have been linked to difficulties observed in both disorders (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Mentalisation is the capacity to understand and reflect on one\u0026rsquo;s own and others\u0026rsquo; mental states; it is reduced in ADHD (hypo-mentalisation) and heightened in BPD (hyper-mentalisation) (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), yet empirical research in Malaysian adolescents is lacking.\u003c/p\u003e\u003cp\u003eThis study aimed to examine the association between ADHD and BPD symptoms among Malaysian adolescents and to investigate whether parenting dimensions and mentalisation mediate this relationship. Understanding these mechanisms may inform culturally sensitive interventions to support adolescents at risk of ADHD and BPD.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Setting\u003c/h2\u003e\u003cp\u003eThis cross-sectional study was conducted from March to July 2025 in three government secondary schools located in urban Selangor, a state bordering the capital, Kuala Lumpur (Fig.\u0026nbsp;1): SMK Damansara Jaya, SMK Taman Sea, and SMK Kota Damansara 10. Data were collected via self-administered questionnaires with parents completing the Swanson, Nolan, and Pelham Rating Scale\u0026ndash;Fourth Edition (SNAP-IV) and adolescents completing a sociodemographic questionnaire, Borderline Symptom List\u0026ndash;23 (BSL-23), Parental Bonding Instrument (PBI), and Mentalisation Scale (MentS-12).\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe map shows the urban study area in Selangor, Malaysia. Kuala Lumpur is shown in orange, the rest of Selangor in blue, and other parts of Peninsular Malaysia in grey.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eThe participants were 14- and 16-year-old students from the three selected schools. A convenience sampling method was used, recruiting students based on their availability and willingness to participate from the selected schools. The inclusion criteria included sufficient English proficiency, written assent, and parental consent; those lacking consent or with cognitive/language limitations were excluded.\u003c/p\u003e\u003cp\u003eThe required sample size was estimated using the Raosoft calculator, with a 95% confidence level, 5% margin of error, and an estimated ADHD prevalence of 5.6% among adolescents (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The calculation yielded a minimum of 82 participants:\u003c/p\u003e\u003cp\u003en = (1.96\u0026sup2; \u0026times; 0.056 \u0026times; (1\u0026thinsp;\u0026minus;\u0026thinsp;0.056)) / 0.05\u0026sup2; = 81.3\u003c/p\u003e\u003cp\u003e Based on the formula, the minimum required sample size was approximately 81 and was rounded up to 82 participants.\u003c/p\u003e\u003cp\u003eAmong the approximately 900 eligible students, 126 returned both complete consent and assent forms, yielding a response rate of approximately 14%.\u003c/p\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003cp\u003e was obtained from the University of Malaya Medical Centre Medical Research Ethics Committee (Ref: 20241114-14401), the Malaysian Ministry of Education (KPM.600-3/2/3-eras (23061)), and the Selangor State Education (JPNS. SPD 600-1/1/2 JLD.52(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)). All procedures were conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\u003c/p\u003e\u003cp\u003eThe principal investigator liaised with schoolteachers to distribute study information sheets, consent forms, and the SNAP-IV to parents via students; completed forms were returned to schools. Only students who provided parental consent were invited to participate. After receiving explanations and providing assent, the students completed questionnaires during school hours under supervision. Participation was voluntary and anonymous, with no incentives. No adverse events were reported, but a. referral protocol to school counsellors was in place in case of distress.\u003c/p\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eSociodemographic Questionnaire\u003c/h2\u003e\u003cp\u003eDeveloped by the research team, this questionnaire collected data on gender, age, ethnicity, religion, household composition, parental education and employment, income, and family history of physical or mental illness.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eSNAP-IV\u003c/h2\u003e\u003cp\u003eA parent-report scale assessing ADHD symptoms (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) across inattention (items 1\u0026ndash;9), hyperactivity/impulsivity (\u003cspan additionalcitationids=\"CR11 CR12 CR13 CR14 CR15 CR16 CR17\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), and oppositional symptoms (\u003cspan additionalcitationids=\"CR20 CR21 CR22 CR23 CR24 CR25\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) was used, with a 4-point Likert scale (0\u0026ndash;3). A score\u0026thinsp;\u0026ge;\u0026thinsp;13 on the inattention or hyperactivity subscale indicates mild ADHD symptoms (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The scale has been validated for Malaysian use (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eBSL-23\u003c/h3\u003e\n\u003cp\u003eSelf-reports assess BPD symptoms across domains such as emotional instability and impulsivity (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The items are rated on a 5-point scale (0\u0026ndash;4), with a total score ranging from 0\u0026ndash;92. A score\u0026thinsp;\u0026ge;\u0026thinsp;46 indicates clinically relevant BPD symptoms (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Although not locally validated, it is widely used cross-culturally.\u003c/p\u003e\n\u003ch3\u003ePBI\u003c/h3\u003e\n\u003cp\u003eA self-report assessing perceived parenting during childhood across two dimensions: Care and Overprotection. Higher Care scores reflect warmth; higher Overprotection scores reflect control (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The tool has been validated for Malaysian use (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eMentS-12\u003c/h2\u003e\u003cp\u003eA self-report scale is used to assess the capacity to reflect on one\u0026rsquo;s own and others' mental states (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The items are rated on a 5-point scale; total scores range from 12\u0026ndash;60, with higher scores indicating stronger mentalisation.\u003c/p\u003e\u003cp\u003eAll instruments were reviewed by an expert panel for adolescent suitability.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eDescriptive statistics and bivariate correlations were conducted via SPSS version 30. The prevalence of ADHD and BPD symptoms was calculated. Pearson correlations assessed the relationships between ADHD symptoms and BPD symptoms.\u003c/p\u003e\u003cp\u003eData were complete for all measures except for paternal PBI, which was missing for three participants due to absence of a father. Analyses were conducted using available data for each measure.\u003c/p\u003e\u003cp\u003eMediation analyses were performed in Jamovi version 2.6.26. Maternal care and overprotection and paternal care and overprotection were tested as paired mediators in separate models. Mentalisation was tested as an independent mediator. The results are presented in tables and figures; figures were prepared via Microsoft PowerPoint. Statistical significance was set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eSociodemographic Characteristics\u003c/h2\u003e\n \u003cp\u003eMost participants were female (54%), in Form 4 (81%), Malay (58%), or Muslim (60%). Nearly all (93%) had no personal history of mental illness. The majority (86%) were either unaware of or unsure about access to mental health services. Most parents were married (91%), and both were employed (60%). Most mothers (70%) and fathers (67%) had a college or university education. Few reported a history of family mental illness (7%). (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSociodemographic Characteristics of the Participants (N\u0026thinsp;=\u0026thinsp;126)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eFrequency (n)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePercentage (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e46.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e54.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eYear in School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eForm 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eForm 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e81.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003eEthnic Background\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMalay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e57.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChinese\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e31.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"5\"\u003e\n \u003cp\u003eReligion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIslam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e60.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBuddhist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChristian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHinduism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"6\"\u003e\n \u003cp\u003eParticipant\u0026rsquo;s Mental Illness History\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e117\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e92.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eADHD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBorderline PD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDepression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eAware of Mental Health access\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e28.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot sure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e57.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eParent\u0026apos;s Marital Status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e114\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e90.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDivorced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWidowed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"5\"\u003e\n \u003cp\u003eParental Employment Status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFather only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMother only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e17.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBoth working\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e59.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBoth not working\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot sure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"5\"\u003e\n \u003cp\u003eMother\u0026apos;s Education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo formal education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSecondary School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e20.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCollege/University Level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e69.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot sure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"5\"\u003e\n \u003cp\u003eFather\u0026apos;s Education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo formal education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePrimary School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSecondary School\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e17.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCollege/University Level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e66.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot sure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"3\"\u003e\n \u003cp\u003eFamily Mental Illness History\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e88.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNot sure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cem\u003eThis table summarizes the sociodemographic characteristics of the 126 adolescent participants and their parents. Percentages may not total 100% due to rounding or missing responses.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eDescriptive Statistics\u003c/h2\u003e\n \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\n \u003ch2\u003ePrevalence of ADHD and BPD Symptoms\u003c/h2\u003e\n \u003cp\u003eClinically significant ADHD symptoms were identified in 13 participants (10.3%) based on a SNAP-IV subscale score\u0026thinsp;\u0026ge;\u0026thinsp;13 for Inattention or Hyperactivity/Impulsivity. For BPD, 20 participants (15.9%) scored\u0026thinsp;\u0026ge;\u0026thinsp;46 on the BSL-23, indicating clinically significant symptoms (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003ch2\u003eParenting Dimensions\u003c/h2\u003e\n \u003cp\u003eThe mean scores were 10.44 (SD\u0026thinsp;=\u0026thinsp;6.49) for maternal care and 25.49 (SD\u0026thinsp;=\u0026thinsp;5.57) for maternal overprotection. For the paternal dimensions, the mean level of care was 14.57 (SD\u0026thinsp;=\u0026thinsp;7.13), and that of overprotection was 26.56 (SD\u0026thinsp;=\u0026thinsp;6.49).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\n \u003ch2\u003eMentalisation Capacity\u003c/h2\u003e\n \u003cp\u003eThe total mentalisation score was calculated by summing all 12 items of the MentS-12. The scores ranged from 12.00 to 57.00, with a mean of 40.21 (SD\u0026thinsp;=\u0026thinsp;7.65).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n \u003ch2\u003eCorrelation between ADHD and BPD Symptoms\u003c/h2\u003e\n \u003cp\u003ePearson correlation analysis indicated a significant moderate positive association between ADHD and BPD symptoms. (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.33, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\n \u003ch2\u003eMediation Analysis\u003c/h2\u003e\n \u003cp\u003eMediation analyses examined maternal and paternal care and overprotection (each pair in separate models) and mentalisation as independent mediators of the ADHD\u0026ndash;BPD association.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\n \u003ch2\u003eMaternal Parenting Dimension as a Mediator\u003c/h2\u003e\n \u003cp\u003eADHD symptoms had a significant total effect on BPD symptoms (estimate\u0026thinsp;=\u0026thinsp;0.6095, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Maternal care and maternal overprotection each significantly predicted BPD symptoms when controlling for ADHD (estimate\u0026thinsp;=\u0026thinsp;0.7598, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.007; estimate\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.7799, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.017), although their indirect effects were not significant. The direct effect of ADHD on BPD remained significant (estimate\u0026thinsp;=\u0026thinsp;0.4888, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e and Fig. 2).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cstrong\u003ePath Estimates for the Maternal Parenting Mediation Model\u003c/strong\u003e \u003cem\u003eThis table presents the path estimates for the mediation model examining maternal care (Mc) and maternal overprotection (Mo) as mediators of the relationship between ADHD symptoms and BPD symptoms.\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eType\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eEffect\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eEstimate\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eSE\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026beta;\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003ez\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLower\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eUpper\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eIndirect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eADHD \u0026rArr; Mc \u0026rArr; BPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0700\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0464\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.02093\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.1609\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0379\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.131\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eADHD \u0026rArr; Mo \u0026rArr; BPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0507\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0401\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.02793\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.1294\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0275\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.206\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003eComponent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eADHD \u0026rArr; Mc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0921\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0507\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.00726\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.1914\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.1598\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.069\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMc \u0026rArr; BPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.7598\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.2806\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.20984\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.3097\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.2373\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.007*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eADHD \u0026rArr; Mo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.0650\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0437\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.15073\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0207\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.1314\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-1.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.137\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMo \u0026rArr; BPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.7799\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.3253\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-1.41751\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.1423\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.2092\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-2.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.017*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDirect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eADHD \u0026rArr; BPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.4888\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.1445\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.20572\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.7720\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.2649\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eADHD \u0026rArr; BPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.6095\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.1558\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.30414\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.9149\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.3303\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\"\u003eNote. CI\u0026thinsp;=\u0026thinsp;confidence interval; \u0026beta;\u0026thinsp;=\u0026thinsp;standardized coefficient. Mc\u0026thinsp;=\u0026thinsp;maternal care; Mo\u0026thinsp;=\u0026thinsp;maternal overprotection.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\"\u003e*\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05; **\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cem\u003eStructural model illustrating the associations between ADHD symptoms and BPD symptoms through maternal care and maternal overprotection. Solid arrows indicate significant paths (p\u0026thinsp;\u0026lt;\u0026thinsp;.05), dashed arrows indicate non-significant paths. Values represent unstandardized estimates with corresponding p-values.\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\n \u003ch2\u003ePaternal Parenting Dimensions as Mediators\u003c/h2\u003e\n \u003cp\u003eThis model revealed significant indirect effects of ADHD symptoms on BPD symptoms through paternal care (estimate\u0026thinsp;=\u0026thinsp;0.166, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.017) and paternal overprotection (estimate\u0026thinsp;=\u0026thinsp;0.113, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.039). Both paternal care and overprotection were significantly associated with BPD symptoms, and ADHD symptoms were significantly related to these parenting dimensions. The direct effect of ADHD on BPD remained significant (estimate\u0026thinsp;=\u0026thinsp;0.349, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.010), indicating partial mediation (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e and Fig. 3).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cstrong\u003ePath Estimates for the Paternal Parenting Mediation Model\u003c/strong\u003e \u003cem\u003eThis table presents the path estimates for the mediation model examining paternal care (Pc) and paternal overprotection (Po) as mediators of the relationship between ADHD symptoms and BPD symptoms.\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eType\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eEffect\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eEstimate\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eSE\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026beta;\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003ez\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLower\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eUpper\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eIndirect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eADHD \u0026rArr; Pc \u0026rArr; BPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.166\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0698\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.02969\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.3032\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0901\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.017*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eADHD \u0026rArr; Po \u0026rArr; BPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.113\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0547\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00581\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.2204\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0612\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.039*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"4\"\u003e\n \u003cp\u003eComponent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eADHD \u0026rArr; Pc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.151\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0552\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.04255\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.2588\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.2391\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.006*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePc \u0026rArr; BPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.2254\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.66266\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.5464\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.3769\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eADHD \u0026rArr; Po\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.127\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0504\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.22587\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.0282\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.2215\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-2.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.012*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePo \u0026rArr; BPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.890\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.2467\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-1.37377\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.4069\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-0.2765\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e-3.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDirect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eADHD \u0026rArr; BPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.349\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.1359\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.08223\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.6148\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.1887\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.010*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eADHD \u0026rArr; BPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.610\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.1558\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.30414\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.9149\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.3303\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\"\u003eNote. CI\u0026thinsp;=\u0026thinsp;confidence interval; \u0026beta;\u0026thinsp;=\u0026thinsp;standardized coefficient. Pc\u0026thinsp;=\u0026thinsp;Paternal Care; Po\u0026thinsp;=\u0026thinsp;Paternal Overprotection.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\"\u003e*\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05; **\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cem\u003eStructural model illustrating the associations between ADHD symptoms and BPD symptoms through paternal care and paternal overprotection. Solid arrows indicate significant paths (\u003c/em\u003ep\u0026thinsp;\u003cem\u003e\u0026lt;\u0026thinsp;.05), dashed arrows indicate non-significant paths. Values represent unstandardized estimates with corresponding\u003c/em\u003e p\u003cem\u003e-values.\u003c/em\u003e\u003c/p\u003e\n \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\n \u003ch2\u003eMentalisation Capacity as Mediators\u003c/h2\u003e\n \u003cp\u003eThe mentalisation mediation model revealed a significant indirect effect of ADHD symptoms on BPD symptoms through mentalisation capacity (estimate\u0026thinsp;=\u0026thinsp;0.160, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.040). ADHD symptoms were associated with increased mentalisation capacity (estimate\u0026thinsp;=\u0026thinsp;0.130, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.029), which in turn was associated with higher BPD symptoms (estimate\u0026thinsp;=\u0026thinsp;1.227, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). The direct effect of ADHD on BPD remained significant (estimate\u0026thinsp;=\u0026thinsp;0.450, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.001), indicating partial mediation (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e and Fig. 4).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab4\" border=\"1\" class=\"fr-table-selection-hover\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003e\u003cstrong\u003ePath Estimates for the Mentalisation Mediation Model\u003c/strong\u003e \u003cem\u003eThis table presents the path estimates for the mediation model examining mentalisation capacity (Mz) as a mediator of the relationship between ADHD symptoms and BPD symptoms.\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eType\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eEffect\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eEstimate\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eSE\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e95% CI\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026beta;\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003ez\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eLower\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eUpper\u003c/strong\u003e\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndirect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eADHD \u0026rArr; Mz \u0026rArr; BPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.160\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0777\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.00741\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.312\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0865\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.040*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eComponent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eADHD \u0026rArr; Mz\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.130\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0595\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.01361\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.247\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.1914\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.029*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMz \u0026rArr; BPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.227\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.2052\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.82454\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.629\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.4520\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDirect\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eADHD\u0026rArr; BPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.450\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.1396\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.17633\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.723\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.2438\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eADHD \u0026rArr; BPD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.610\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.1558\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.30414\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.915\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.3303\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\"\u003eNote. CI\u0026thinsp;=\u0026thinsp;confidence interval; \u0026beta;\u0026thinsp;=\u0026thinsp;standardized coefficient. Mz\u0026thinsp;=\u0026thinsp;Mentalisation capacity.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\"\u003e*\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05; **\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e\u003cem\u003eStructural model illustrating the associations between ADHD symptoms and BPD symptoms through mentalisation capacity. Solid arrows indicate significant paths (\u003c/em\u003ep\u0026thinsp;\u003cem\u003e\u0026lt;\u0026thinsp;.05), dashed arrows indicate non-significant paths. Values represent unstandardized estimates with corresponding\u003c/em\u003e p\u003cem\u003e-values.\u003c/em\u003e\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec25\" class=\"Section2\"\u003e\u003ch2\u003ePrevalence of ADHD and BPD Symptoms\u003c/h2\u003e\u003cp\u003eADHD (10.3%) and BPD (15.9%) symptoms were more common in this study than in earlier reports. These prevalence rates exceed both global and regional estimates, suggesting a potentially unique cultural or methodological influence. Globally, ADHD incidence averages approximately 8% in children and adolescents (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), with another review reporting 5.6% among adolescents aged 12\u0026ndash;18 years (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Local studies reported rates of 1.6\u0026ndash;4.6% in younger samples (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The prevalence of BPD in adolescents is typically approximately 3.0%, with higher rates in clinical populations (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e); local data remain scarce.\u003c/p\u003e\u003cp\u003eThe elevated prevalence observed may reflect increased symptom expression or improved detection via adolescent self-reports, which can better capture the internal distress often overlooked by adult observers (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Given the long-term burden of ADHD and BPD (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), early identification is crucial. In Malaysia, where routine school-based screening is limited, these findings highlight the need for stronger national policy and mental health investment (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eA feasible next step involves integrating school-based screening via validated tools such as the Behavior Rating Inventory of Executive Function (BRIEF), the Borderline Personality Features Scale for Children (BPFS), and the SNAP-IV combined with classroom observations to increase accuracy and support timely intervention (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\u003ch2\u003eCorrelation between ADHD and BPD Symptoms\u003c/h2\u003e\u003cp\u003eThe association between ADHD and BPD is well documented, with both conditions sharing key features such as impulsivity and emotional dysregulation, which may complicate differential diagnosis (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). ADHD has also been linked to the later emergence of BPD symptoms (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), potentially reflecting overlapping deficits in emotion regulation (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eConsistent with previous research, the present study found a moderate association between ADHD and BPD symptoms among Malaysian adolescents, suggesting that adolescents exhibiting ADHD symptoms may be at elevated risk for BPD. Shared vulnerabilities, particularly impulsivity and emotional dysregulation, may underlie both conditions and indicate that ADHD could represent an early developmental pathway to BPD (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn adolescent populations, comorbid ADHD has been associated with more severe clinical presentations of BPD, especially increased impulsivity (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). While much of the existing evidence is from Western contexts, our findings extend these associations to a Southeast Asian setting, enriching cross-cultural perspectives on ADHD\u0026ndash;BPD comorbidity.\u003c/p\u003e\u003cp\u003eThese findings underscore the importance of assessing BPD symptoms in adolescents with ADHD, particularly when emotional instability and relational difficulties are present. Since parents often influence help-seeking, their recognition of symptoms is critical (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). However, many cases may remain undetected, highlighting the value of school-based screening for early detection (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn practice, schools could improve early identification by training teachers and counselors to recognize emotional and interpersonal challenges associated with ADHD and early BPD signs. Training should include clear referral pathways to facilitate timely psychological support.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\u003ch2\u003eParenting Dimensions\u003c/h2\u003e\u003cdiv id=\"Sec28\" class=\"Section4\"\u003e\u003ch2\u003eMaternal Care and Overprotection\u003c/h2\u003e\u003cp\u003eIn contrast to expectations, maternal care and overprotection did not significantly mediate the relationship between ADHD and BPD symptoms. While both dimensions were associated with BPD symptoms, they were not significantly associated with ADHD symptoms. This contrasts with earlier research highlighting the role of maternal parenting in emotional dysregulation and BPD development (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e), suggesting that maternal factors may not fully account for the ADHD\u0026ndash;BPD co-occurrence in this context.\u003c/p\u003e\u003cp\u003eOne possible explanation lies in Malaysian cultural norms, where mothers are generally seen as nurturing but may not hold primary authority during adolescence (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Relational enmeshment or social desirability may contribute to the underreporting of negative maternal behaviors. These findings contribute to a more nuanced understanding of parenting influences on adolescent psychopathology in collectivist contexts, complementing predominantly Western evidence.\u003c/p\u003e\u003cp\u003eDespite the lack of mediation, parenting-focused interventions such as parenting wisely or the Triple P-Positive Parenting Program (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e) may still offer benefits, particularly when adapted for adolescents and delivered through schools or community settings with engagement from both parents. Longitudinal or observational approaches may also be more sensitive in capturing the nuances of maternal impact over time.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e\u003ch2\u003ePaternal Care and Overprotection\u003c/h2\u003e\u003cp\u003ePaternal care and overprotection significantly mediated the association between adolescent ADHD and BPD symptoms. Unexpectedly, \u003cb\u003emore\u003c/b\u003e ADHD symptoms were linked to greater paternal care, which in turn was associated with increased BPD symptoms. Conversely, lower paternal overprotection was related to both higher ADHD and BPD symptoms. These findings highlight complex and sometimes counterintuitive dynamics in paternal roles.\u003c/p\u003e\u003cp\u003eThis may reflect shifting norms of fatherhood in collectivist cultures such as Malaysia, where emotional involvement from fathers is increasing (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Paternal warmth, responsiveness, and support have long been linked to adolescent outcomes (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Adolescents\u0026rsquo; perceptions of their fathers' behaviours may thus exert distinct and nuanced effects on mental health.\u003c/p\u003e\u003cp\u003eOur findings support prior research underscoring fathers\u0026rsquo; unique roles in adolescent development (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e), yet fathers remain underrepresented in the parenting literature (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). In the Malaysian context, paternal emotional availability may be particularly impactful because of culturally shaped gender roles and expectations (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThese findings suggest that father-inclusive approaches warrant further exploration as a means of addressing potential shared ADHD-BPD vulnerabilities and could inform the design of culturally sensitive family support models. Schools and healthcare settings could take active steps to involve fathers, while policymakers consider developing and funding programmes that reduce structural and cultural barriers to their participation.\u003c/p\u003e\u003cp\u003eEvidence-based interventions such as \u0026ldquo;\u003cem\u003eDad\u0026rsquo;s Tuning in to Kids\u0026rdquo;\u003c/em\u003e have shown efficacy in improving paternal emotional responsiveness (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). However, engaging fathers in parenting programmes can be challenging due to practical constraints such as time demands, work commitments, and prevailing cultural norms (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). Offering digital or hybrid delivery formats guided by best-practice father-inclusive principles (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e) may help overcome these barriers.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eMentalisation\u003c/h3\u003e\n\u003cp\u003eMentalisation emerged as a significant factor associated with both ADHD symptoms and BPD symptoms in adolescents and mediated the relationship between them. In contrast to some prior studies suggesting impaired mentalisation in ADHD patients, this study revealed that greater ADHD severity was linked to greater mentalisation capacity, which in turn predicted increased BPD symptoms. This finding indicates a more complex association between ADHD and mentalisation in this sample.\u003c/p\u003e\u003cp\u003eThese findings partially diverge from the established view that ADHD is typically characterized by hypo-mentalisation\u0026mdash;defined as a diminished ability to understand others\u0026rsquo; mental states and perspectives, particularly in adolescents with prominent inattention symptoms (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn contrast, BPD is more commonly associated with hyper-mentalisation\u0026mdash;an overinterpretation of others\u0026rsquo; intentions\u0026mdash;which contributes to emotional instability and interpersonal difficulties (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Impaired mentalisation in BPD patients also reflects reduced reflective functioning, a key developmental vulnerability (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThese findings suggest that mentalisation remains an important cognitive‒emotional mechanism linking ADHD and BPD symptoms. Mentalisation-based treatment (MBT) has demonstrated effectiveness in adolescents with BPD (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e) and is emerging as a promising intervention for improving functioning in individuals with ADHD (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e). However, given the distinct cognitive and attentional challenges in ADHD, MBT adaptations may be necessary to optimize outcomes. By targeting reflective functioning, MBT holds potential to address shared vulnerabilities across these disorders, although longitudinal studies are needed to evaluate its preventive potential and long-term effects.\u003c/p\u003e\u003cp\u003e In summary, mentalisation represents a unifying developmental and clinical target, with the potential to inform early detection, refine prevention strategies, and guide culturally adaptable, mechanism-focused treatments for at-risk adolescents. Future research should further explore the nuanced relationship between ADHD and mentalisation, considering cultural, developmental, and measurement factors that may influence this association.\u003c/p\u003e\u003cdiv id=\"Sec31\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and Limitations\u003c/h2\u003e\u003cp\u003eThis study addresses a significant gap in Malaysian adolescent mental health research by examining the associations between ADHD and BPD symptoms and the mediating roles of parenting styles and mentalisation. Using well-established instruments (SNAP-IV, BSL-23, MentS-12, PBI), our mediation analysis revealed partial mediation by both paternal parenting dimensions and mentalisation.\u003c/p\u003e\u003cp\u003eMoreover, recruiting participants from multiple schools in urban areas strengthens the ecological validity and generalizability of the findings to similar populations. Additionally, supervised data collection and the inclusion of parent-reported ADHD symptoms helped reduce bias from adolescent self-reports.\u003c/p\u003e\u003cp\u003eHowever, several limitations should be acknowledged. These include a narrow age range (14- and 16-year-olds) and focus on urban government schools, which limits their applicability to other ages and settings. Reliance on adolescent self-reports introduces potential recall and social desirability bias, although this bias was partly mitigated by parent reports and data collection methods. Finally, the cross-sectional design precludes causal conclusions.\u003c/p\u003e\u003cp\u003eDespite these limitations, this study advances understanding of ADHD\u0026ndash;BPD co-occurrence in a non-Western setting and provides a foundation for future research and interventions tailored to Malaysian adolescents.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study highlights the high prevalence of ADHD and BPD symptoms among Malaysian adolescents and highlights the interplay between neurodevelopmental traits, parenting (care and overprotection), and mentalisation. Paternal parenting and adolescents\u0026rsquo; mentalizing capacity are key psychosocial mediators linking ADHD and BPD symptoms. By identifying these as modifiable targets, our findings lay the groundwork for culturally sensitive early intervention strategies that may reduce the long-term burden of ADHD and BPD in adolescents. These findings contribute novel evidence from a non-Western setting to a literature still dominated by Western samples and emphasize the value of integrating psychosocial factors into early screening and prevention frameworks.\u003c/p\u003e\u003cp\u003eOur findings emphasize the need to address both biological and psychosocial factors in adolescent mental health. Family-focused and school-based interventions targeting parenting and mentalisation could strengthen early prevention. This research contributes to the regional literature and informs future studies, clinical work, and policy in Malaysia.\u003c/p\u003e\u003cp\u003eFuture research should involve more diverse adolescent samples across age groups, regions (including rural and private schools), and cultural contexts to enhance generalizability. Using multiple informants (e.g., teachers, parents, clinicians) would reduce self-report bias and improve validity.\u003c/p\u003e\u003cp\u003eLongitudinal designs are recommended to clarify causal links between ADHD and BPD symptoms and to examine the mediating roles of parenting and mentalisation. Exploring additional psychosocial factors (e.g., peer influence, trauma, and family dynamics) and applying advanced methods such as structural equation modelling could further enrich the understanding of developmental risk pathways.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eADHD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eattention deficit hyperactivity disorder\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBPD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eborderline personality disorder\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMBT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMentalisation\u0026ndash;Based Treatment\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSNAP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIV\u0026ndash;Swanson, Nolan, and Pelham, version IV\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBSL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e23\u0026ndash;Borderline Symptom List, 23\u0026ndash;item version\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePBI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eParental Bonding Instrument\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMentS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003e12\u0026ndash;Mentalisation Scale, 12\u0026ndash;item version\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eConfidence Interval\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStandard Error\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStandard Deviation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eβ\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStandardized Coefficient\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003cp\u003e Ethical approval was obtained from the University of Malaya Medical Centre Ethics Committee (Ref: 20241114-14401). Written informed consent was obtained from all participants or their guardians.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eThis study was funded by the University of Malaya, subject to acceptance.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eTan Yee Xin led the study design, data collection, analysis, and manuscript preparation. Chow Soon Ken provided conceptualization and supervision. Manveen Kaur and Fatin Liyana Binti Azhar contributed critical revisions and approved the final manuscript. Yit Han Ng provided suggestions for data analysis.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003e The authors thank the Ministry of Education Malaysia and the Selangor State Education Department for their cooperation and approval, the University of Malaya for institutional support, and the Department of Psychological Medicine for academic guidance. Special thanks to the child and adolescent psychiatry team for facilitating collaboration with the participating schools. The authors are grateful to the principals, teachers-in-charge, students, and parents of the participating schools for their contributions. Finally, they acknowledge their families for their understanding, encouragement, and support throughout this research.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eUNICEF. Parenting adolescents: A regional study on parenting adolescents and parenting support programmes in Belarus, Bulgaria, Georgia, Moldova, Montenegro and Romania. Switzerland: Geneva; 2018.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSalari N, Ghasemi H, Abdoli N, Rahmani A, Shiri MH, Hashemian AH, et al. The global prevalence of ADHD in children and adolescents: a systematic review and meta-analysis. 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A developmental, mentalization-based approach to the understanding and treatment of borderline personality disorder. Dev Psychopathol. 2009;21(4):1355\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRossouw TI, Fonagy P. Mentalization-based treatment for self-harm in adolescents: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry. 2012;51(12):1304\u0026ndash;e133.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSharp C, Rossouw T. Mentalization-Based Treatment for Adolescents (MBT-A). Psychodyn Psychiatry. 2024;52(4):542\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKasper LA, Hauschild S, Schrauf LM, Taubner S. Enhancing mentalization by specific interventions within mentalization-based treatment of adolescents with conduct disorder. Front Psychol. 2023;14:1223040.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Attention-deficit/hyperactivity disorder (ADHD), borderline personality disorder (BPD), adolescents, parenting dimensions, mentalisation, mediation analysis, cross-sectional study, Malaysia","lastPublishedDoi":"10.21203/rs.3.rs-7484039/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7484039/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAttention-deficit/hyperactivity disorder (ADHD) and borderline personality disorder (BPD) share overlapping features such as impulsivity and emotional dysregulation, yet their co-occurrence in adolescents is rarely examined outside Western settings. In Southeast Asia, where parenting practices and cultural norms may shape developmental pathways differently, this relationship remains underexplored. Evidence is also limited on how parenting dimensions and mentalisation contribute to the ADHD\u0026ndash;BPD link. This study addresses these gaps by examining Malaysian adolescents, providing cross-cultural insights into early psychosocial risk factors that may inform targeted interventions.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA cross-sectional study was conducted from March to July 2025 in three government secondary schools in urban Selangor, Malaysia, involving 126 adolescents aged 14 to 16 years. ADHD symptoms were assessed using the parent-rated Swanson, Nolan, and Pelham Rating Scale\u0026ndash;Fourth Edition (SNAP-IV), while adolescents completed a sociodemographic questionnaire, the Borderline Symptom List\u0026ndash;23 (BSL-23), the Parental Bonding Instrument (PBI), and the Mentalisation Scale\u0026ndash;12 (MentS\u0026ndash;12). Descriptive statistics and bivariate correlations were conducted using SPSS version 30, and mediation analyses were performed using Jamovi version 2.6.26.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eClinically significant ADHD and BPD symptoms were present in 10.3% and 15.9% of adolescents, respectively. ADHD and BPD symptoms were moderately correlated (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.33, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Mediation analyses revealed that paternal parenting dimensions and lower adolescent mentalisation capacity significantly mediated the association between ADHD and BPD symptoms.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThese findings suggest that paternal parenting and mentalisation capacity may play important roles in the co-occurrence of ADHD and BPD symptoms among adolescents. Longitudinal research is warranted to clarify the causal pathways involved.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTrial registration:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"The Mediating Role of Parenting Dimensions and Mentalisation between ADHD and BPD in Adolescents: A Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-15 15:49:04","doi":"10.21203/rs.3.rs-7484039/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-10-03T00:13:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"120564484954652554864829684533381565312","date":"2025-09-11T18:54:23+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-02T05:46:49+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-01T21:12:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-29T04:48:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-29T04:48:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychiatry","date":"2025-08-29T02:00:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"43757a65-40ff-4221-8602-6a98a35bf5b3","owner":[],"postedDate":"September 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-15T15:49:04+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-15 15:49:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7484039","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7484039","identity":"rs-7484039","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}