Cognitive Behaviour Therapy for Children and Adolescents: Can Attachment Theory Contribute to Its Efficacy?

Does attachment anxiety mediate the persistence of anxiety and depressive symptoms from adolescence to early adulthood?

OBJECTIVES

Depression and anxiety often emerge in adolescence and persist into early adulthood. Developing a greater understanding of the factors that influence their persistence may inform psychological interventions. Their association with an insecure attachment style is well established although the mediating role of attachment anxiety in the persistence of depression and anxiety over time has not been examined. This study aimed to examine if anxious attachment mediated depression and anxiety from adolescence to early adulthood.

METHODS

Data from 3,436 participants in a longitudinal birth cohort study were examined. At 14-years and 21-years, participants completed the Achenbach Youth Self Report (YSR) and the Achenbach Young Adult Self-Report (YASR) respectively. At 21-years, participants completed the Attachment Style Questionnaire (ASQ). Attachment anxiety as a mediator for the persistence of anxiety/depressive symptoms from 14- to 21-years was examined.

RESULTS

Attachment anxiety accounted for approximately 60% of the persistence of anxiety and depressive symptoms at 14- and 21- years after adjusting for covariates. Results were similar when stratifying by males and females.

CONCLUSIONS

Attachment anxiety significantly contributes to the persistence of anxiety and depressive symptoms from adolescence into early adulthood for both males and females. Incorporating interventions that address attachment anxiety in adolescents may improve the response to therapy for anxiety and depression.

Identifying effective moderators of cognitive behavioural trauma treatment with caregiver involvement for youth with PTSD: a meta-analysis

Children can develop post-traumatic stress disorder (PTSD) and mental health symptoms after traumatic events. This meta-analysis evaluated the influence of moderators of cognitive behavioural trauma treatment (CBTT) with caregiver involvement in traumatized children. A total of 28 studies were included, with 23 independent samples and 332 effect sizes, representing the data of 1931 children (M age = 11.10 years, SD = 2.36). Results showed a significant medium overall effect (d = 0.55, t = 2.478, p = 0.014), indicating CBTT with caregiver involvement was effective in treating PTSD (d = 0.70), with somewhat smaller effect sizes for internalizing, externalizing, social, cognitive and total problems (0.35 < d > 0.48). The positive treatment effect was robust; we found somewhat smaller effect sizes at follow-up (d = 0.49) compared to post-test (d = 0.57) assessments. Furthermore, several sample (i.e. child's age, gender, and trauma event), programme (i.e. the duration of treatment, number of sessions), study (i.e. control condition, type of instrument, informant, type of sample), and publication (i.e. publication year and impact factor) characteristics moderated the treatment outcomes of the child. In sum, the results of our meta-analysis might help to improve the effectiveness of cognitive behavioural trauma treatment for youth with PTSD, and guide the development of innovative trauma interventions that involve caregivers. Implications for theory and practice are discussed.

Editorial Perspective: On the need for clarity about attachment terminology

Part of the appeal of attachment language is that it feels near to our everyday experience, as terms like 'attachment', 'security' or 'disorganisation' feel readily recognisable. Yet, not one of these terms is used by academic attachment researchers in line with ordinary language. This has hindered the evidence-based use of attachment in practice, the feedback loop from practice to research and the dialogue between attachment researchers in developmental psychology and in social psychology. This paper pinpoints the difficulties arising from the existence of multiple versions of 'attachment theory' that use exactly the same terms, held by communities that assume that they are referring to the same thing and with little infrastructure to help them discover otherwise. When we talk past one another, the different communities with a stake in knowledge of attachment are obstructed from genuinely learning from one another, drawing on their respective strengths and pursuing collaborations. One factor contributing to this situation has been the use of attachment terminology with technical meanings, but often without setting out clear definitions. We here introduce a guide to attachment terminology used by the academic community, which has recently been published on the website of the Society for Emotion and Attachment Studies. The guide is meant for researchers, clinicians and everyone concerned with attachment to increase understanding of the technical meaning of important terminology used by researchers, and support the quality of discussions between researchers, and between researchers and clinicians and other publics.

Short version of the Inventory of Parental Representations, a self-report for attachment assessment among adolescents

BACKGROUND

 The Inventory of Parental Representations (IPR), a self-administered questionnaire, was developed primarily to identify styles of attachment in adolescence. However, it did not present stable psychometric properties in the various American studies carried out. The aim of this study was to adapt the IPR in French and to provide a shorter version with improved psychometric properties and sound content.

METHODS

The cross-cultural adaptation and content validity were carried out based on qualitative analysis by an Expert Committee and 10 non-clinical adolescents. For the quantitative analyses a cohort of 535 adolescent volunteers was enrolled, corresponding to 1070 responses, and divided into two groups: development and validation. The study of the metric properties of the adapted version of the IPR was realized in the development group, a sample of 275 responses. In case of mediocre results in the Confirmatory Factor Analysis, the development of a new and reduced IPR structure was planned using a mixed method including Classical Test Theory and Rasch Modelling in the development group. Subsequently, the study of the psychometric properties of the short, adapted version was confirmed in an independent sample of 795 responses (validation group).

RESULTS

Out of 62 items translated, 13 needed adaptations. The analysis of their metric properties produced mediocre results. Content and psychometric property analyses generated two Short version of the IPR in the development group: a paternal scale for Fathers (Short IPRF) with 15 items and a maternal scale for Mothers (Short IPRM) with 16 items. The sound content and good psychometric properties were confirmed in the validation group (Short IPRF: Comparative Fit Index = 0.987, Tucker-Lewis Index = 0.982, Root Mean Square Error of Approximation = 0.027; Short IPRM: Comparative Fit Index = 0.953, Trucker-Lewis Index = 0.927, Root Mean Square Error of Approximation = 0.068). Using Rasch modelling, the attachment was correctly measured overall especially for insecure attachment.

CONCLUSIONS

A step-by-step process involving led to the generation of two questionnaires: a paternal scale, the Short IPRF, and a maternal scale with the Short IPRM providing opportunities to use this self-questionnaire to assess attachment among adolescents. Further work will provide a solid rating for this new tool.

Attachment security as an outcome and predictor of response to trauma-focused cognitive-behavioral therapy among maltreated children with posttraumatic stress: A pilot study

Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) is a frontline intervention for posttraumatic stress disorder (PTSD) symptoms among maltreated children. Research suggests that active caregiver participation predicts positive treatment outcomes, but these studies are often based on the perception of the caregiver. Youth perceptions of the caregiver as a source of support who might help confront distressing memories (i.e., attachment security) and how they relate to TF-CBT treatment are unexplored. This paper uses data from a small randomized controlled feasibility trial of TF-CBT to conduct a pilot examination of whether (a) attachment security may improve through the course of TF-CBT, and (b) pre-treatment attachment security predicts response to TF-CBT for the amelioration of posttraumatic stress. Results favored the conclusion that those beginning treatment with attachment insecurity may demonstrate improvement for this outcome by the end of treatment (n = 8; t = 3.3, p = .013, Cohen's d = 1.17). However, although significant improvements were found over the course of treatment for PTSD, there was no evidence that pre-treatment attachment security predicted PTSD outcome (n = 29; ∆R² < .01, ∆F(1,26) = .001, p = .969). The limitations of the current pilot study are discussed, as well as directions for future research.

Extending the Biopsychosocial Conceptualisation of Chronic Post Surgical Pain in Children and Adolescents: The Family Systems Perspective

A substantial number of children and adolescents undergoing surgical procedures, as many as 40% in some estimates, will go on to develop chronic postsurgical pain (CPSP). Because of the significant negative impact of CPSP on social and emotional milestones, as well as the child's quality of life, it is important to identify modifiable factors that are associated with the onset and maintenance of the condition. Research has demonstrated that parent factors can play a role in pediatric chronic pain; however, there has been little examination of parent and family influences on the transition to CPSP. Family systems theories, which consider the influence of the family unit overall on the behavior of individuals members, have been applied to the eating disorders literature for decades. This narrative review proposes a novel application of family systems theory to pediatric CPSP and, in particular, highlights the role that parental dyadic factors may play in the development and maintenance of persistent pain following surgery in children and adolescents.

Attachment Representation Moderates the Effectiveness of Behavioral Parent Training Techniques for Children with ADHD: Evidence from a Randomized Controlled Microtrial

Behavioral parent training is an evidence-based intervention for children with attention-deficit/hyperactivity disorder (ADHD), but knowledge on the differential effects of behavioral techniques for specific subgroups of children is very limited. Attachment representations of children with ADHD may affect how receptive children are to changes in parenting. In this study, we investigated whether specific behavioral techniques were more or less effective for children with ADHD in relation to their attachment representations. We included parents of 74 children with ADHD (4-11 years, M = 8.15) who took part in a larger randomized controlled microtrial in which they were randomized to a two session training in antecedent-based techniques (i.e., stimulus control techniques: rules, instructions; n = 26), a two session training in consequent-based techniques (i.e., contingency management techniques: praise, rewards, ignoring; n = 25) or a waitlist control condition (n = 23). We examined whether attachment representation moderated the effectiveness of a) training versus waitlist, and b) antecedent- versus consequent-based techniques. Attachment representations were measured with a story stem task, the intervention outcome was daily parent-rated problem behaviors of the children. Attachment representation did not moderate the effects of the training compared to the waitlist. However, compared to antecedent-based techniques, consequent-based techniques were less effective for more securely and less disorganized attached children, and particularly effective for more disorganized attached children. This was the first study examining attachment as a moderator of behavioral techniques for ADHD. If replicated, the findings of this study can be used for treatment development and tailoring.

Attachment and the Development of Psychopathology: Introduction to the Special Issue

When Bowlby [...]

Exploring everyday state attachment dynamics in middle childhood

The current study explored dynamics of secure state attachment expectations in everyday life in middle childhood, specifically state attachment carry-over and reactivity to experiences of caregiver support in the context of stress. In two independent samples (one community sample, N = 123; one adoption sample, N = 69), children (8–12 years) daily reported on their state attachment for respectively 14 and 7 consecutive days. Additionally, they reported daily on their experiences of distress and subsequent experiences of caregiver support. Results in both samples indicated that secure state attachment on a day-to-day basis is characterized by a significant positive carry-over effect, suggesting that state attachment fluctuations are (partially) self-predictive. In Study 1, experiencing no support following distress significantly related to intraindividual decreases in secure state attachment; in Study 2, experiencing effective support during distress related to intra-individual increases in secure state attachment. Taken together, the current studies provide novel and important insights into how state attachment temporally evolves on a day-to-day basis in middle childhood.

Theories of Change and Mediators of Psychotherapy Effectiveness in Adolescents With Externalising Behaviours: A Systematic Review

BACKGROUND

Externalising behaviours are becoming a remarkably prevalent problem during adolescence, often precipitating both externalising and internalising disorders in later adulthood. Psychological treatments aim to increase the social functioning of adolescents in order for them to live a more balanced life and prevent these negative trajectories. However, little is known of the intervening variables and mediators involved in these treatments' change mechanisms. We conducted a systematic review, exploring the available evidence on mediators of psychological treatments for externalising behaviours and symptoms amongst adolescents (10 to 19 years old).

METHODS

A systematic search was performed on Medline and PsycINFO databases, which identified studies from inception to February 23, 2020. Eligible studies included randomised controlled trials that enrolled adolescents with externalising symptoms and behaviours as, at least, one of the primary outcomes. A group of 20 reviewers from the COST-Action TREATme (CA16102) were divided into 10 pairs. Each pair independently screened studies for inclusion, extracted information from the included studies, and assessed the methodological quality of the included studies and the requirements for mediators, following Kazdin's criteria. Risk of bias of RCTs was assessed by the Mixed Methods Appraisal Tool. Extracted data from the included studies were reported using a narrative synthesis.

RESULTS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA), after removing duplicates, 3,660 articles were screened. Disagreements were resolved by consensus. In a second stage, 965 full-text articles were assessed for eligibility. A total of 14 studies fulfilled all inclusion criteria. The majority were related to systemic psychological treatment approaches. Two types of mediators were identified as potentially being involved in the mechanisms of change for better social improvements of adolescents: to increase healthier parent-adolescent relationships and parental discipline. However, there were significant and non-significant results amongst the same mediators, which led to discussing the results tentatively.

CONCLUSIONS

Family variables were found to be the largest group of investigated mediators, followed by relational, behavioural, and emotional variables. No cognitive or treatment-specific mediators were identified. Both adequate behavioural control of adolescents' peer behaviour and a better positive balance in their relationships with their parents seemed to buffer the effects of externalising behaviours in adolescents. Several methodological limitations concerning mediation testing design, outcome measures, and mediator selection have been identified.

ETHICS AND DISSEMINATION

Ethical approval was not required. PROSPERO registration number: CRD42021231835.

A Learning Theory Approach to Attachment Theory: Exploring Clinical Applications

Although clinicians typically acknowledge the importance of insecure attachment as one factor that can contribute to children's psychopathology, translating attachment theory into clinical practice has proved a challenge. By specifying some of the mechanisms through which the child's attachment develops and changes, learning theory can enhance attachment based approaches to therapy. Specifically, interventions building on operant (parent management training) and classical (exposure therapy) learning can be used to stimulate new learning that increases the child's security and confidence in the parent's availability and responsiveness. To explore the clinical application and utility of a Learning Theory of Attachment (LTA), we focus on two attachment-focused interventions: Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline (VIPP-SD) and Middle Childhood Attachment-based Family Therapy (MCAT). VIPP-SD is an evidence-based parent management training designed to promote sensitive parenting and secure attachment in early childhood. MCAT is a recently developed intervention that uses exposure to stimulate secure attachment in middle childhood. LTA sheds light on the mechanisms set in train by VIPP-SD and MCAT facilitating the induction of professionals in clinical applications.

An empirical test of prototype and revisionist models of attachment stability and change from middle childhood to adolescence: A 6-year longitudinal study

We examined the prototype v. revisionist models of attachment stability with a five-wave, 6-year, longitudinal study of attachment security from middle childhood to adolescence in a White Western European sample (N = 157; Wave 1 M_age  = 10.91, SD = 0.87; 52% female). Attachment was assessed using both questionnaire (Experiences in Close Relationships) and narrative-based measures (Attachment Script Assessment). In addition, a set of potential moderators of prototype-like stability were examined. Results indicated that data from both attachment assessments best fit the prototype model. Moderator analyses indicated that male sex significantly undermined the influence of an attachment prototype and parent-child conflict and parental divorce enhanced the influence of an attachment prototype on stability.

A Lifespan Development Theory of Insecure Attachment and Internalizing Symptoms: Integrating Meta-Analytic Evidence via a Testable Evolutionary Mis/Match Hypothesis

Attachment scholars have long argued that insecure attachment patterns are associated with vulnerability to internalizing symptoms, such as depression and anxiety symptoms. However, accumulating evidence from the past four decades, summarized in four large meta-analyses evaluating the link between insecure attachment subtypes and internalizing symptoms, provide divergent evidence for this claim. This divergent evidence may be accounted for, at least in part, by the developmental period under examination. Specifically, children with histories of deactivating (i.e., insecure/avoidant) but not hyperactivating (i.e., insecure/resistant) attachment patterns in infancy and early childhood showed elevated internalizing symptoms. In contrast, adolescents and adults with hyperactivating (i.e., insecure/preoccupied) but not deactivating (i.e., insecure/dismissing) attachment classifications showed elevated internalizing symptoms. In this paper, we summarize findings from four large meta-analyses and highlight the divergent meta-analytic findings that emerge across different developmental periods. We first present several potential methodological issues that may have contributed to these divergent findings. Then, we leverage clinical, developmental, and evolutionary perspectives to propose a testable lifespan development theory of attachment and internalizing symptoms that integrates findings across meta-analyses. According to this theory, subtypes of insecure attachment patterns may be differentially linked to internalizing symptoms depending on their mis/match with the developmentally appropriate orientation tendency toward caregivers (in childhood) or away from them (i.e., toward greater independence in post-childhood). Lastly, we offer future research directions to test this theory.

Attachment and the Development of Depressive Symptoms in Adolescence: The Role of Regulating Positive and Negative Affect

Although widely accepted, attachment theory's hypothesis that insecure attachment is associated with the development of depressive symptoms through emotion regulation strategies has never been longitudinally tested in adolescence. Additionally, previous research only focused on strategies for regulating negative affect, whereas strategies for regulating positive affect may also serve as a mechanism linking insecure attachment to depressive symptoms. This study aimed to fill these research gaps by testing whether the association between attachment and change in depressive symptoms over time is explained by strategies for regulating negative and positive affect in adolescence. Adolescents (N = 1706; 53% girls; Mage = 12.78 years, SDage = 1.54 at Time 1) were tested three times, with a 1-year interval between measurement times. They reported on their attachment anxiety and avoidance at Time 1, depressive symptoms at Times 1 and 3, and regulation of negative affect (brooding and dampening) and positive affect (focusing and reflection) at Time 2. The results from multiple mediation analyses showed that more anxiously attached adolescents developed more depressive symptoms via increased brooding and dampening. More avoidantly attached adolescents developed more depressive symptoms via decreased focusing. These findings provide longitudinal support for attachment theory's emotion regulation hypothesis, and show that the regulation of both negative and positive affect is important.

The Relation Between Attachment and Depression in Children and Adolescents: A Multilevel Meta-Analysis

Insecure attachment to primary caregivers is associated with the development of depression symptoms in children and youth. This association has been shown by individual studies testing the relation between attachment and depression and by meta-analyses focusing on broad internalizing problems instead of depression or adult samples only. We therefore meta-analytically examined the associations between attachment security and depression in children and adolescents, using a multilevel approach. In total, 643 effect sizes were extracted from 123 independent samples. A significant moderate overall effect size was found (r = .31), indicating that insecure attachment to primary caregivers is associated with depression. Multivariate analysis of the significant moderators that impacted on the strength of the association between attachment security and depression showed that country of the study, study design, gender, the type of attachment, and the type of instrument to assess attachment uniquely contributed to the explanation of variance. This study suggests that insecure attachment may be a predictor of the development of depression in children and adolescents. When treating depression in children, attachment should therefore be addressed.

Treatment Refractory Internalizing Behaviour Across Disorders: An Aetiological Model for Severe Emotion Dysregulation in Adolescence

Auto-aggressive behaviour, especially treatment refractory suicidality in adolescents with psychiatric disorders, may be challenging to clinicians. In search of therapeutic possibilities, we have integrated current opinions regarding causality and interdependency of suicidality and auto-aggressive behaviour across disorders within the HiTOP framework. We propose a developmental model regarding these unsettling behaviours in youths that may help to guide future directions for research and interventions. We argue that the interdependent development of biologic factors, attachment, moral reasoning and emotion regulation in an overprotective environment may lead to social anxiety and later during development to emotion dysregulation and severe internalizing behaviour disorders. To optimize treatment efficacy for both internalizing and externalizing behaviour, we emphasize the importance transdiagnostic interventions, such as addressing non-compliance, restoration of trust between parents and their child, and limitation of avoidance behaviour. These may be seen as higher order interventions within the HiTOP framework.

Six attachment discourses: convergence, divergence and relay

Attachment concepts are used in diverging ways, which has caused confusion in communication among researchers, among practitioners, and between researchers and practitioners, and hinders their potential for collaboration. In this essay we explore how attachment concepts may vary in meaning across six different domains: popular discourses, developmental science, social psychological science, psychiatric diagnosis, psychotherapy, and child welfare practice. We attempt to typify these forms of attachment discourse by highlighting points of convergence, divergence, and relay between the different domains. Our general conclusions are that diversity in the use of attachment concepts across different domains of application has been largely unrecognised, and that recognition of these differences would reduce confusion, help identify sites where infrastructure needs to be developed to support coordination, and strengthen opportunities for collaboration to mutual benefit. We suggest that academic attachment discourse would benefit from clarification of core terminology, including: "attachment", "internal working model", "trauma", and "dysregulation".

Do risk profiles moderate the relation between age of onset of disruptive behaviour and two types of externalising problems among adolescents admitted to secure residential care?

BACKGROUND

Adolescents with externalising problems in secure residential care differ in age of onset of disruptive behaviour and in cumulative risks in several domains. In order to reduce negative consequences of externalising behaviour for society and the adolescents themselves, it is important to gain more insight into the complexity and heterogeneity of disruptive behaviour in these adolescents. To look beyond the influence of single risk factors, the aim of this study is to investigate the moderator effect of co-occurring risk factors in multiple domains on the relation between age of onset of disruptive behaviour and two types of externalising problems in adolescence.

METHODS

Retrospectively collected data of 225 adolescents admitted to secure residential care were analysed. The four risk profiles were based on co-occurring pre-admission risk factors in four domains, which were identified in a previous study by latent class analysis. Multiple regression models were used to test whether the independent variable age of onset and dummy-coded moderator variable risk profiles had statistically significant associations with aggressive behaviour and rule-breaking behaviour of the adolescents, as reported by professional caregivers in the first months of admission.

RESULTS

Risk profiles moderated the relation between age of onset of disruptive behaviour and rule-breaking behaviour. Adolescents with childhood-onset disruptive behaviour within the risk profile with mainly family risks showed more rule-breaking behaviour in the first months of their admission to secure residential care than adolescents with an onset in adolescence within the same risk profile. Risk profiles, however, did not moderate the relation between age of onset of disruptive behaviour and aggressive behaviour.

CONCLUSION

Heterogeneity of aggressive and rule-breaking behaviour was established in this study by finding differences on these two types of externalising behaviour between the childhood- and adolescence-onset groups and between the four risk profiles. Furthermore, risk profiles moderated the effect between age of onset of disruptive behaviour and rule-breaking behaviour-not aggressive behaviour-in adolescents admitted to secure residential care. While respecting the limitations, adolescents' childhood-onset disruptive behaviour within a profile with mainly family risk factors appear to be distinctive from adolescents with adolescence-onset disruptive behaviour within the same risk profile.

Parent-Child Attachment: A Principle-Based Concept Analysis

INTRODUCTION

Extensive evidence indicates that the quality of parent-child attachment is related to later socio-emotional and physical health outcomes. Yet, despite its clinical relevance, the parent-child attachment concept has been inconsistently applied across the disciplines of nursing, medicine and psychology and is often conflated with parent-child bonding in nursing literature.

OBJECTIVES

To provide readers with a critical analysis of the concept of parent-child attachment. Using a principle-based concept analysis, we clarify how parent-child attachment is understood from a multidisciplinary perspective to advance the use of this concept in nursing practice.Concept Description: Attachment is an affectionate, mutually satisfying relationship between a child and a caregiver that serves the purpose of making the child feel safe, secure, and protected.

DISCUSSION

In this principle-based concept analysis, each definitional (i.e., epistemological, pragmatic, linguistic, and logical) principle contributes to an understanding of the strengths and limitations of the state of science about this concept. The discussion highlights how applying the concept of parent-child attachment security may offer exciting and promising opportunities for nursing clinical work with families.

CONCLUSION

The understanding of the concept of parent-child attachment differs among disciplines of nursing, medicine and psychology and offers exciting and promising opportunities for clarity and collaborative, multi-disciplinary work.

Criminogenic Needs as Intervening Factors in the Relation Between Insecure Attachments and Youth Sexual Violence

There is a strong theoretical and research base demonstrating the link between attachment styles and adolescent sexual offending. However, this relationship may be best explained by deficit-based mediational pathways including criminogenic needs such as emotional or affect regulation and callousness. Grady, Levenson, and Bolder propose a framework that details criminogenic needs as intermediary variables in the attachment-sexual offending relationship. Using data on adolescents adjudicated of sexual and nonsexual crimes in a Western state (N = 200), two structural equation models (SEM) tested direct and indirect relationships between ambivalent and avoidant attachment styles (in separate models), dysregulation including cognitive and behavioral transitions, emotional control, and inhibited/impulsive behaviors, callousness, delinquency, and offending type (sexual or nonsexual offending). Results revealed statistically significant direct pathways between variables of interest and a multimediational effect of dysregulation and callousness in the relationship between insecure attachments and sexual offending. Treatment, policy, and research implications are discussed.

Combining oxytocin and cognitive bias modification training in a randomized controlled trial: Effects on trust in maternal support

BACKGROUND AND OBJECTIVES

Research on the social effects of intranasal oxytocin in children is scarce. Oxytocin has been proposed to have clearer beneficial effects when added to social learning paradigms. The current study tested this proposition in middle childhood by assessing effects of cognitive bias modification (CBM) training and oxytocin on trust in maternal support.

METHODS

Children (N = 100, 8-12 years) were randomly assigned to one of two training conditions: CBM training aimed at increasing trust or neutral placebo training. Within each training condition, half the participants received oxytocin and half a placebo. Main and interaction effects were assessed on measures of trust-related interpretation bias and trust. We explored whether child characteristics moderated intervention effects.

RESULTS

Children in the CBM training were faster to interpret maternal behaviour securely versus insecurely. Effects did not generalize to interpretation bias measures or trust. There were no main or interaction effects of oxytocin. Exploratory moderation analyses indicated that combining CBM training with oxytocin had less positive effects on trust for children with more internalizing problems.

LIMITATIONS

As this was the first study combining CBM and oxytocin, replication of the results is needed.

CONCLUSIONS

This study combined a social learning paradigm with oxytocin in children. CBM training was effective at an automatic level of processing. Oxytocin did not enhance CBM effects or independently exert effects. Research in larger samples specifying when oxytocin might have beneficial effects is necessary before oxytocin can be used as intervention option in children.

Intensive home treatment for adolescents in psychiatric crisis

BACKGROUND

Adolescents with acute psychiatric disorders are typically treated with long-term clinical admission. However, long term admission may be associated with a variety of negative outcomes. This pilot study presents a new model of care, that is, the combined application of intensive home treatment and the possibility of short term stay at a psychiatric high & intensive care.

METHODS

In total 112 referred adolescents with mixed diagnoses participated in this longitudinal observational design. Clinical outcome was measured by the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) which measures the severity of multiple mental health problems. The HoNOSCA was clinician-rated at intake, after two months and after four months at discharge. Change in HoNOSCA total score was analysed with paired t-tests. Outcome moderators were gender, age, primary diagnosis, clinical admission, home treatment-time, medication and additional therapies. Follow up data were completed for 62 patients after two months and for 53 after four months.

RESULTS

Participants aged between 11 and 18 years (M = 14.8 years, SD = 0.3; 52% female). Mean HoNOSCA total score at intake was 18.8 (SD = 5.2), after two months 13.0 (SD = 5.0); after four months resulting in a score of 9.3 (SD = 5.2). None of the moderators tested showed a significant effect on HoNOSCA scores. However, a control group could not be used because of the severe psychopathology and high risk for suicidality and the lack of an effective treatment intervention for a comparable study group.

CONCLUSION

With a symptom decrease of over 50% within four months as measured by the HoNOSCA, including less risk for hospitalization, this new model appears promising and of clinical relevance. Nevertheless, further research regarding stability of treatment outcome is warranted and evaluation of long-term effects of this model in follow-up studies is needed.

Trust development as an expectancy-learning process: Testing contingency effects

Trust in parental support and subsequent support seeking behavior, a hallmark of secure attachment, result from experiences with sensitive parents during distress. However, the underlying developmental mechanism remains unclear. We tested the hypothesis that trust is the result of an expectancy-learning process condtional upon contingency (the probability that caregiver support has a positive outcome). We developed a new paradigm in which a novel caregiver provides help to solve a problem. Contingency of the caregiver's support was manipulated and participants' trust in the caregiver and their help seeking behavior was measured in three independent samples. The hypothesis was supported suggesting that trust and support seeking result from an expectancy-learning process. These findings' potential contribution to attachment theory is discussed.

A Further Validation of the Cognitive Bias Modification Effect on Trust in Middle Childhood

Recent middle childhood research suggests that children's trust in maternal support can be manipulated using Cognitive Bias Modification (CBM) aimed at changing children's interpretation of ambiguous maternal support-related behavior. The current study with 60 children (40 girls, M_age = 10.62, SD_age = 1.20) aimed to replicate previous research and to test whether the CBM effect is specific to trust or generalizes to other child evaluations of maternal behavior. More specifically, CBM effects on children's evaluation of parenting behavior were tested. Trust and maternal parenting behaviors were assessed using children's self-report. Results largely replicated previous findings, including the positive effect of CBM on children's trust in maternal support. Suggesting that this effect was specific for trust, the CBM manipulation did not affect children's appraisal of maternal parenting behavior. This finding supports the validity of CBM effects.

Unraveling middle childhood attachment-related behavior sequences using a micro-coding approach

Attachment theory states that children learn to trust in their parent's availability and support if they repeatedly experience that their parents respond sensitively to their needs during distress. Attachment is thus developed and shaped by day-to-day interactions, while at the same time, each interaction is a momentary expression of the attachment relation. How attachment-related behaviors of mother and child follow upon each other during interactions in middle childhood, and how these sequences differ in function of attachment quality, has hardly been studied up to now. To fill this gap, we analyzed the micro-coded interaction of 55 mother-child dyads (27 girls, 28 boys, mean age: 10.3) after a standardized stress-induction. Results reveal that all mother-child dyads show a loop between positive mother and child behaviors. This pattern is complemented with a loop of negative mother and child behaviors in low-trust and more avoidantly attached children: these children tend to handle negative mother behavior less well as they show more negative behavior and less positive behavior in response to negative maternal behavior. More anxiously attached children also show less positive behavior, but react positively on collaborative interactions. The micro-coded interactions thus reveal important insights that inform practitioners and advance attachment theory.

Adult attachment representations and depressive symptoms: A meta-analysis

BACKGROUND

Attachment theory has long argued that insecure and disorganized attachment representations are associated with vulnerability to psychopathology in general, and depressive symptoms in particular. However, studies assessing the link between insecure and disorganized attachment and depressive symptoms report inconsistent results. The primary aim of this meta-analysis was to examine the extent to which adult attachment representations are associated with depressive symptoms.

METHODS

We conducted a literature search for published studies using PsycINFO, MEDLINE, and ProQuest in March 2017, identifying 55 samples (N = 4,386). Eligible studies assessed depression using a well-validated self-report or clinical diagnostic measure of depression and attachment using the Adult Attachment Interview.

RESULTS

Results demonstrated that insecure individuals had higher levels of depression than secure-autonomous individuals (d = 0.21, 95% CI [0.08-0.33]). Specifically, insecure-preoccupied individuals (d = 0.48, 95% CI [0.30-0.65]), but not insecure-dismissing individuals (d = 0.09, 95% CI [-0.03-0.22]), exhibited significantly more depressive symptoms than the secure-autonomous individuals. Additionally, unresolved adults had higher levels of depression than adults with organized attachment classifications (d = 0.29, 95% CI [0.13-0.44]).

LIMITATIONS

Due to the nature of the studies reviewed, causal inferences regarding the links found between adult attachment representations and depressive symptoms may not be drawn. Further, the aggregate effect sizes do not solely reflect the magnitude of the association between attachment representations and clinically-diagnosed major depressive disorder.

CONCLUSIONS

The results of this meta-analysis have important conceptual and practical implications for attachment-based prevention and intervention efforts, as they suggest that attachment representations, specifically insecure-preoccupied and unresolved, are associated with depressive symptoms in adulthood. Future research using longitudinal and intervention-based designs should examine the extent to which insecure-preoccupied and unresolved attachment lead to increased depressive symptoms, as well as the mechanisms by which these attachment patterns across the life span may increase vulnerability to depressive symptoms in adulthood.

NR3C1 methylation as a moderator of the effects of maternal support and stress on insecure attachment development

We examined the prediction that the interaction between Glucocorticoid Receptor Gene (NR3C1) methylation, stress, and experienced maternal support predicts anxious and avoidant attachment development. This was tested in a general population sample of 487 children and adolescents (44% boys, Mage = 11.84, SDage = 2.4). These children were followed over a period of 18 months. In line with the prediction, we found that NR3C1 methylation moderates the effect of maternal support during stress on anxious attachment development 18 months later. More stressed children who experienced less maternal support reported increased anxious attachment when their NR3C1 gene was highly methylated. This effect could not be explained by children's level of psychopathology. No effects were found for attachment avoidance. These data provide the first prospective evidence that epigenetic processes are involved in attachment development. (PsycINFO Database Record

Angststörungen

Zusammenfassung. Angststörungen zählen zu den häufigsten psychischen Störungen des Kindes- und Jugendalters. Bei der Entwicklung von Ängsten kommt dem frühkindlichen Temperament, der elterlichen Psychopathologie und der genetischen Disposition eine zentrale Rolle zu. Aspekte der Emotionsregulation und Auffälligkeiten im Bindungsmuster werden zunehmend diskutiert. Gemeinsam mit den Angststörungen treten sowohl weitere internalisierende Störungen (z. B. die Depression) als auch externalisierende Auffälligkeiten (z. B. aggressives Verhalten) auf. In der Behandlung von Angststörungen scheint eine transdiagnostische Sichtweise besonders erfolgversprechend.