Attachment organization in suicide prevention research: preliminary findings and future directions in a sample of inpatient adolescents

Non-suicidal Self-injurious Thoughts and Behaviors Among Adolescent Inpatients

Non-suicidal self-injury (NSSI) is a serious public health concern that typically onsets during early adolescence. Adolescents (N = 980, ages 12-19 years) admitted for acute, residential psychiatric treatment completed baseline clinical interviews assessing mental disorders and questionnaires measuring demographics, early life adversity, and symptom severity. Prevalence rates of NSSI for lifetime (thoughts: 78%; behaviors: 72%), past year (thoughts: 74%; behaviors: 65%), and past month (thoughts: 68%; behaviors: 51%) were high. Although effect sizes were modest, the presence of a lifetime depressive disorder, sexual abuse, and comorbidity (i.e., three or more current disorders) were significant correlates of experiencing NSSI thoughts and behaviors. Furthermore, lifetime depressive disorder, current anxiety disorder, and comorbidity were associated with a greater odds of persistent NSSI thoughts and/or behaviors. Longitudinal studies are needed to determine whether targeting these factors reduces the persistence of NSSI thoughts and behaviors.

Characteristics of single vs. multiple suicide attempters among adolescents: a systematic review and meta-analysis

There might be differential characteristics between those who have attempted suicide once in their lifetime (single attempters) and those who have attempted suicide two or more times (multiple attempters). We aimed to identify the factors that differentiate single and multiple attempters in child and adolescents. This study was conducted following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, and the review protocol was registered in PROSPERO. We conducted a systematic literature search in three databases to identify original studies exploring the characteristics of single attempters vs. multiple attempters among adolescents. We considered a wide range for the definition of adolescent, following most recent recommendations: 10-24 years. We carried out a meta-analysis. Fourteen studies were included in the systematic review and 13 in the meta-analysis with a total sample of with a total of 4286 participants. The factors statistically significantly associated with being a multiple attempter in the meta-analysis were: anxiety disorders, depression severity, alcohol abuse, substance abuse, aggressiveness, and hopelessness. Multiple attempters have a more severe clinical profile, with greater severity of symptoms. Knowledge of the risk factors associated with being a multiple attempter could help us to predict which patients are more likely to reattempt suicide and need further monitoring and a tailored treatment. Prevention programs tailored for the adolescent population, along with identification of early risk factors, could help to prevent suicidal behavior among this vulnerable population.

Family Factors Related to Suicidal Behavior in Adolescents

Objective: This research aims to investigate what type of family patterns (specifically attachment, bonding and family functioning) and stressful life events can trigger or protect adolescents from developing suicidal behavior. Methods: For these purposes, a case-control study (adolescents with suicidal behavior vs. paired adolescents with no suicidal behavior) was conducted with one hundred 12 to 17-year-old adolescents (50 controls, 50 cases, 74% females), assessed between 2018 and 2020. Results: Negligent (p < 0.001) or affection-less control bonding (p < 0.001), insecure attachment (p = 0.001) and stressful life events (p < 0.001) revealed to be significant risk factors for suicidal behavior. On the contrary, parents’ care (p < 0.001) and security (p < 0.001) were revealed as protective factors for suicidal behavior. Conclusions: Considering these results, family interventions and improving coping skills seem to be two essential targets for any suicide prevention intervention in adolescents.

The Relationship Between Attachment and Self-Injurious Behaviors in the Child and Adolescent Population: A Systematic Review of the Literature

Adolescents have high rates of self-injurious behavior (SIB), with suicide being the second leading cause of death. A consistent relationship between individual attachment and SIB was previously found in adult population; however, no such review has been undertaken for the child and adolescent population. A systematic search of PubMED, OVID, and PsychINFO up to March 31, 2020 was performed. Twenty-two articles met the inclusion criteria. Of the 22 articles, 21 found a positive association between attachment insecurity and SIB. Our results show a consistent relationship between attachment insecurity and SIB in children and adolescents, complementing the results found in the adult literature. These findings make a case for preventive strategies aimed at reducing self-injurious behaviors in youth by targeting attachment security.

Advancement in the child attachment interview and the child and adolescent reflective functioning scale using a PDM-2 framework: case reports

The Child Attachment Interview (CAI) is a well-established semi-structured interview, widely used to identify attachment representations in middle childhood and adolescence. The application of the Child and Adolescent Reflective Functioning Scale (CRFS) to CAI narratives allows for an assessment of child mentalization, considered a strong predictor of attachment security. The 2^nd edition of the Psychodynamic Diagnostic Manual (PDM-2) includes CAI and CRFS as valid and reliable assessment measures in order to assess the dominion of the Mental Functioning axis. The aim of the present paper is to investigate the informative power of CAI and CRFS for the overall understanding of mental functioning and personality in a PDM-2 framework. The present report includes the discussion of two clinical cases of school-aged children in applying the Psychodiagnostic Chart-Second Edition (PDC-2) to the CAI transcript. The first case concerns a young male, aged 10, suffering from Oppositional-Provocative Disorder (externalizing disorder), while the second case concerns a young female, aged 15, suffering from Somatic Symptoms Disorder (internalizing disorder). PDC-2 for children and adolescents was used. Data from the scoring of CAI and CRFS were combined with a systematic evaluation of the qualitative contents emerging from CAI transcripts. A detailed analysis suggests that both the CAI and CRFS are useful attachment-oriented measures, able to explore child’s mental states, and together with the application of PDC-2 they provide an essential contribution in the understanding of developmental psychopathology. Implications of this innovative approach for clinical assessment, treatment design, and interventions are further discussed.

Attachment Style and Mental Health Profiles of Parents Caring for a Child with Autism: Suicidal Ideation, Depression and Anxiety

The study investigated association between attachment style of parents with a child diagnosed with Autism and mental health. A cross-sectional web-based survey collected data from 184 parents of individuals with autism. Findings from the study indicated association between an avoidant and anxious attachment style and mental health. Mainly, a link between avoidant attachment style and parents' levels of suicidal ideation and depression, an association between anxious attachment style and the parent's level of suicidal ideation, depression and anxiety. Several sociodemographic variables were associated with suicidal ideation and mental health. Specifically, we identified impacts of child's race on suicidal ideation, marital status on depression as well as impact of education on anxiety. Implication for future research, assessment and treatment are presented.

Psychometric Properties of the Child Attachment Interview in Italian Context: A Focus on Normative and Specific Clinical Groups in School-Aged Children

While attachment assessments developed for infancy and adulthood are well established, no such gold standard measure exists for school years, where measures are not yet sufficiently robust. Nevertheless, the last decade has witnessed some progress in this field with the development of the Child Attachment Interview (CAI), a semistructured interview designed to access children's mental representations of their attachment relationships. This study aimed to test the validity and reliability of the CAI for an Italian population, using a normative group and a clinical group of disruptive behavior disorder and somatic symptom disorder patients. A total sample of 311 Italian children (213 normative and 98 clinical) aged 8 to 15 years completed a battery of measures assessing attachment, verbal IQ, and symptomatology. The psychometric properties of the CAI alongside other children (Kerns Security Scale, Inventory of Parent and Peer Attachment) and parents (Adult Attachment Interview) attachment measures in normative sample, as well as the distribution of attachment patterns in normative and clinical samples, were examined. The results revealed the CAI to have adequate interrater and test-retest reliability, as well as discriminant, and convergent validity. Significant differences in the CAI's distribution of attachment patterns for normative and specific clinical groups were found. Taken together, the findings show that the CAI Italian version is a reliable and valid measure for assessing attachment in school years and beyond.

The Quest for Meaning Around Self-Injurious and Suicidal Acts: A Qualitative Study Among Adolescent Girls

Introduction: Suicide and non-suicidal self-injury (NSSI) are major problems in adolescent psychiatry and share numerous clinical characteristics. The principal objective of this study is to describe the subjective experience of adolescent girls and young women who present NSSI and/or suicidal behaviors and to determine the common aspects and the specificities of each experience. Method: This exploratory study is based on a procedure that is qualitative, phenomenological, and inductive. The data were collected from two semi-structured interviews each of 18 girls and young women aged 12-21 years, who were receiving care from a psychiatrist specializing in adolescents and who at least once had harmed themselves by NSSI or attempted suicide, or both. The thematic data analysis was performed by applying the methods of interpretative phenomenological analysis. Results: The results are described around four superordinate themes: relationships with the self, with others/otherness, with the body, and with death; they are then subdivided into 13 themes. Several themes appeared common to both types of behavior, especially the relational dimension of self-harming acts. The process of separation-individuation seems complex for these youth. Conclusion: The results underline the relational aspects of the self-harming behavior (NSSI or suicidal) among adolescent girls. These aspects also appear to be expressed in the family sphere, the social sphere, in contact with peers, and also at a societal level when the community no longer addresses adolescents' difficulties. When the process of subjectification does not appear to reach completion, self-aggressive behavior is seen as an ultimate attempt to regain a feeling of autonomy.

The Suicide Narrative Interview: adolescents' attachment expectancies and symptom severity in a clinical sample

Insecure attachment styles have consistently been identified as risk factors for adolescent psychopathology and, more specifically, suicidal ideation. However, much less is known about the mechanisms that account for the relationship between attachment styles and severity of suicidal ideation within clinical samples. In the current study, adolescents' expectancies for caregiver availability and responsiveness were coded from transcripts of the Suicide Narrative Interview in a clinical sample of 129 depressed and suicidal adolescents. Results indicated that negative expectancies for caregiver availability in the Suicide Narrative Interview were associated both with attachment insecurity and with the intensity of adolescents' suicidal ideation. The implications of adolescents' expectancies for caregiver availability as targets for clinical intervention are discussed.

The Child Attachment Interview: A Narrative Review

Attachment theory promoted an impressive body of research on the psychic developmental processes, resulting in studies on both typical and atypical development. Much of the diffusion of the attachment theory in the clinical field was related to the design of reliable instruments to evaluate the organization of attachment in infancy as well as in adulthood. Until recently, the lack of a suitable instrument to assess attachment in middle childhood as well as in adolescence hindered the expansion of research in these developmental phases during which the parent-child relationship takes on a different, albeit still crucial, role. The Child Attachment Interview (CAI), a measure that was recently designed to assess attachment at a representational level in middle childhood and adolescence, filled the measurement gap. The aim of the current review was to summarize previous empirical investigations concerning CAI in order to (a) provide an overview of the state of current research, (b) identify unanswered questions, and (c) propose future research directions. A narrative review was conducted to map the current research findings by searching for the term “Child Attachment Interview” in the Medline, Scopus, Web of Science, and PsychINFO databases, followed by a search in Mendeley. Limits were set to exclude dissertations, chapters in books, and qualitative or theoretical papers, while empirical studies were included if they used the CAI and were published in English language, peer-reviewed journals by July, 2016. The review, which ultimately included 39 studies meeting the criteria, showed that the CAI is a reliable instrument to assess attachment organization in clinical and non-clinical samples, thus providing a worthwhile contribution to the investigation of the influence of the parent-child relationship beyond infancy and early childhood. Nevertheless, the review pointed out a number of relevant open issues, the most critical of which concerned the CAI coding and classification system. In particular, some relevant questions arose about (a) how opportune it would be to maintain a distinct classification for mother and father, (b) coding challenges regarding both the father and the Preoccupied and Disorganized classification, and finally (c) the advantage of a dimensional vs. a categorical approach.

Attachment Styles and Suicide-Related Behaviors in Adolescence: The Mediating Role of Self-Criticism and Dependency

Insecure attachment and the personality dimensions of self-criticism and dependency have been proposed as risk factors for suicide in adolescents. The present study examines whether self-criticism and dependency mediate the relationship between insecure attachment styles and suicidality. A sample of 340 high-school students (73.2% females), ranging in age from 13 to 20 years (M = 16.47, SD = 1.52), completed the Depressive Experiences Questionnaire for Adolescents, the Depressive Experiences Questionnaire for Adolescents, the Attachment Style Questionnaire, and the Suicidal Behaviors Questionnaire-Revised. The results partially support the expected mediation effects. Self-criticism, but not dependency, mediates the link between insecure attachment (anxiety and avoidance) and suicide-related behaviors. Implications for suicide risk assessment and management are discussed.

Parents of youth who self-injure: a review of the literature and implications for mental health professionals

Non-suicidal self-injury (NSSI) is a common mental health concern among youth, and parents can be valuable supports for these youth. However, youth NSSI can have a significant impact on parents' wellbeing, which may in turn alter parents' ability to support the youth. To date, no single article has consolidated the research on parents of youth who self-injure. This review synthesizes the literature on parent factors implicated in youth NSSI risk, the role of parents in help-seeking and intervention for youth NSSI, and the impact of youth NSSI on parent wellbeing and parenting. Clinical implications for supporting parents as they support the youth are also discussed, and recommendations for future research are outlined.