Attachment, Intellectual Disabilities and Mental Health: Research, Assessment and Intervention

A systematic review of attachment interventions for people with intellectual disability and their caregivers

OBJECTIVE

The current mixed-methods systematic review evaluated available literature to find out which attachment-based interventions have been implemented for people with intellectual disability and whether they are efficacious and acceptable.

METHODS

Five databases were searched (in July 2023 and April 2024), using terms related to intellectual disability and attachment-based interventions. The search yielded 793 papers; 15 papers (13 studies) met inclusion criteria. Relevant data was extracted from each study. Paper quality was appraised using the Mixed Methods Appraisal Tool. Findings were synthesised in an integrative review.

RESULTS

Of the included studies, 7 had people with intellectual disability as participants and 6 had their caregivers. Interventions included education, psychotherapy, technology assisted therapy, video interaction guidance/feedback and circle of security. Research methods varied.

CONCLUSIONS

Evidence for efficacy and acceptability of interventions was mixed but promising. Most studies had limited generalisability. Therefore, further research is required. Pre-registration with PROSPERO [351287].

Attachment behaviours in adults with intellectual disabilities in assisted living facilities: representations from direct-care staff

BACKGROUND

Studies on individuals with intellectual disabilities (IDs) indicate that primary care staff are potential attachment figures. Therefore, the ability to interpret and respond to attachment behaviours with sensitivity is crucial for professionals working with adults with IDs. However, little is known regarding representations and understanding of these attachment behaviours among professionals. This study investigated the representations of attachment behaviours among adults with IDs, as observed and interpreted by direct-care staff in assisted living facilities.

METHODS

Semi-structured interviews were conducted with 19 support workers in seven assisted living facilities in the French community of Belgium. A thematic content analysis was performed.

RESULTS

Professional discourse elicited various forms of attachment behaviours that were sometimes considered challenging. Staff reported difficulties in finding a balance between supporting selective attachment and maintaining 'the right distance' to prevent a negative impact on their work conditions.

CONCLUSIONS

This study gives insight to how using an attachment-informed framework may provide a new perspective on behaviours of adults with IDs in assisted living facilities, as well as the need to offer professionals the opportunity to reflect upon their practices in relation to this dimension.

Piloting attachment psychoeducation provided to parents of children with severe disabilities: Testing the feasibility of a digital micro-intervention

BackgroundA digital micro-intervention offering attachment psychoeducational videos was explored regarding its feasibility in parents of children with severe disabilities. Method: A mixed-methods study (including daily diaries and one-time questionnaires) with 16 parents (75.0% female) of children with severe disabilities (up to 10 years of age) was done during a three-week intervention. Results: Parents were positive about the video series and almost no drop-out occurred. The videos stimulated their learning and thinking and offered parents some personal meaning. Preliminary efficacy tests showed no major changes in parents' parenting self-efficacy (PSE) or perceptions of statements on parent-child attachment. Conclusions: The study showed promising results regarding the micro-interventions' acceptability and implementation. The limited efficacy testing did not show major changes in parents' PSE. Further research is needed to investigate the differential relevance of the micro-intervention, based on parents' needs, as well as its optimal embeddedness in a broader intervention trajectory.

People with intellectual disabilities living in care facilities engaging in virtual social contact: A systematic review of the feasibility and effects on well-being

BACKGROUND

During the initial phase of the COVID-19 pandemic, many people with disabilities living in home care facilities could not receive visitors. The use of virtual social contact has been recommended by health authorities. This systematic review examined the scientific evidence of the use and feasibility of information and communication technology (ICT) for social contact by people with intellectual disabilities living in care facilities, and potential effects on well-being.

METHODS

Five databases were searched using traditional systematic screening and machine-learning supported screening. Findings are presented in a narrative synthesis using thematic analysis.

RESULTS

Nine studies were included. We described three themes: means of ICT used for social contact; effects on well-being; and benefits, barriers, and preconditions.

CONCLUSIONS

Engaging in virtual social contact may be feasible for people with severe to mild intellectual disabilities, but there is little concrete evidence that this can be used as an alternative for in-person contact.

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.

Attachment representations among school-age children with intellectual disability

BACKGROUND

Research data documenting a high risk of insecure and disorganized attachment among children with intellectual disability (ID) in infancy and early childhood raises the question of mutual influences between ID and attachment in later childhood.

AIMS

The objectives of the present study were to examine attachment among school-age children with ID and whether attachment varies according to level of intellectual functioning, adaptative functioning, and presence of a genetic syndrome (i.e. Down syndrome).

METHODS

Attachment among 54 children with ID aged 8-12 years (30 with Down Syndrome, 24 with non-specific ID) was assessed using the Attachment Story Completion Task, and compared with that of 108 typically developing children, 54 of the same chronological age and 54 of the same mental age.

OUTCOMES

Results show (1) less security among children with ID than among same-age controls (2) more disorganization among children with ID compared to the two control groups, (3) a link between attachment disorganization and level of adaptive functioning among children with ID and (4) no difference in attachment between children with DS and children with non-specific ID.

CONCLUSIONS

Children with ID remain vulnerable to disorganization during late childhood. More research is needed to understand the factors underlying disorganized attachment representations.

Are people with an intellectual disability at increased risk of attachment difficulties? A critical review

Attachment difficulties are associated with a range of adverse outcomes in mental health, and people with intellectual disabilities (IDs) may be at greater risk of experiencing difficulties in their attachment relationships. This review critically evaluated recent research measuring the prevalence of attachment difficulties in people with ID. Eight studies met the inclusion criteria, and a higher prevalence of insecure and disorganized attachment classifications, and symptoms of attachment disorder, was found across a number of subgroups of people with diagnoses of ID. However, the validity and reliability of measures of attachment have not been empirically established in this population, and control groups were not always appropriate. These findings indicate the need to (1) develop reliable and standardized assessments of attachment for people with ID and (2) evaluate the efficacy of attachment-based interventions in relation to reducing psychological distress, mental health problems and expression of behaviours experienced by others as challenging.

Working alongside people with intellectual disabilities who have had difficult experiences: Reflections on trauma-informed care within a service context

People with intellectual disabilities are more likely to experience adverse childhood experiences than those in the general population. Additionally, the conceptualization of 'trauma' is far broader than traditionally understood in order to encompass the far reaching relational nature of people with intellectual disabilities traumatic experiences. This reflective account details the first steps one service took to embrace trauma-informed care as a whole systems approach. The paper is a response to calls following conference presentations about our work, to share the process of the beginning of this journey, it also aims to provide key learning points, practical considerations and questions for reflection in order to support other services to begin their own relationships with trauma-informed care.

Anxiety-associated and separation distress-associated behaviours in Angelman syndrome

BACKGROUND

Anxiety is considered a 'frequent' feature in the clinical criteria for Angelman syndrome; however, the nature and severity of anxiety symptoms have not been well characterised in this population. Anxiety behaviours, especially in response to separation from a preferred caregiver, have been described clinically but have not yet been explored empirically.

METHOD

This study used a combination of standardised and clinician-derived survey items to assess the frequency, nature and severity of behaviours associated with anxiety and separation distress in 100 individuals with Angelman syndrome. Family (e.g. income and maternal education) and individual (e.g. age, sex, genetic subtype, sleep difficulties and aggressive behaviours) variables were also gathered to assess possible predictors of higher anxiety levels. Approximately half of the sample was seen in clinic and assessed with standardised measures of development and daily functioning, allowing for an additional exploration of the association between anxiety symptoms and extent of cognitive impairment.

RESULTS

Anxiety concerns were reported in 40% of the sample, almost 70% were reported to have a preferred caregiver and over half displayed distress when separated from that caregiver. Individuals with the deletion subtype and individuals who are younger were less likely to have anxiety behaviours. Sleep difficulties and aggressive behaviour consistently significantly predicted total anxiety, the latter suggesting a need for future studies to tease apart differences between anxiety and aggression or anger in this population.

CONCLUSIONS

Anxiety concerns, especially separation distress, are common in individuals with Angelman syndrome and represent an area of unmet need for this population.

Comfort provided by parents versus strangers after eliciting stress in children with severe or profound intellectual disabilities: does it make a difference?

The relationships between children with severe or profound intellectual disabilities (ID) and their parents may fulfil attachment functions, such as regulating emotional responses to stress. This study examined the extent to which children with severe or profound ID differentiate between their parents and a stranger as a resource for stress-regulation. A home-based experimental paradigm was conducted and video-recorded in 38 families. Children (1-8 years) were exposed to four naturalistic stressors followed by comfort, randomly provided by the parents or the stranger. Emotional behaviour (arousal and valence) and the skin conductance level were simultaneously recorded. With regard to both emotional behaviour and skin conductance, children significantly differentiated between their parents as attachment figures and the stranger during stress and comfort, despite their impairments on various developmental domains. Behavioural observation and physiology show complementary manifestations of parent-child attachment in this population.

Discovery awareness for staff supporting individuals with intellectual disabilities and challenging behaviour: is it helpful and does it increase self-efficacy?

Discovery awareness (DA) is an approach to using video within structured meetings to help staff become more mindful, aware and interested in a client they are supporting who has intellectual disabilities and challenging behaviour. The objective was to evaluate whether, and how, DA is helpful for staff in both inpatient and community settings, and whether it increases self-efficacy in working with people with challenging behaviour. A two-phase mixed method design was employed. For phase 1, forty staff who took part in one of seven single DA meetings completed the Challenging Behaviour Self-Efficacy Scale pre- and post-DA. In addition, post-DA, participants completed an Adapted Helpful Aspects of Therapy Scale (AHAT). For phase 2, six participants completed a follow-up Change Interview; 3-12 weeks after DA. Descriptive statistics reveal participants found events in the DA 'greatly helpful'. The changes identified varied in whether they were expected or not, but were unlikely to occur without DA and 'very important'. Statistical analysis showed no significant changes in self-efficacy following the DA. A thematic analysis on the qualitative data generated by the change interviews and AHAT identified three main themes: Impact on interaction; DA is unique and valuable; and the power of the process. The latter had three subthemes: a structure to facilitate change, making use of the content and reflective space to promote learning. Attendance at a single DA meeting does not increase staff perceptions of self-efficacy, however, staff find the process of DA helpful as it encourages reflection on their interactions with individuals with intellectual disability and challenging behaviour and attuning of their interactions, though further research is needed.

German Version of the Relationship Problems Questionnaire: Effective Screening for Attachment Disorder

INTRODUCTION

Attachment disorder (AD), including reactive AD and disinhibited social engagement disorder, is a prevalent, yet underdiagnosed disorder in severely maltreated children. Because the condition is associated with significant psychiatric morbidity over the entire lifespan, a valid and economic screening tool to identify children with clinical symptoms of AD is needed to avoid unspecific or ineffective treatment. The present study aimed to assess the effectiveness and efficiency of the German version of the Relationship Problems Questionnaire (RPQ).

METHODS

With a total of 135 children (mean age = 7.17 years, SD = 1.40, 63% male) from both general (34 children) and high-risk populations (69 in- and outpatients, 32 foster children), we investigated the sensitivity and specificity of the RPQ. AD was diagnosed using a standardized clinical interview (K-DIPS). 35 out of 135 children fulfilled the criteria for AD.

RESULTS

The RPQ identified 74% of the children who fulfilled the criteria for AD in the standardized clinical interview. The optimal cut-off score of the RPQ for identifying AD was 4.5 with a moderate sensitivity of 0.74 and specificity of 0.68.

CONCLUSIONS

The German version of the RPQ proved useful as a diagnostic indicator of clinical symptoms of AD. The tool is economic and suitable for the screening of AD in the general population as well as high-risk populations. We recommend the use of the RPQ in clinical and research settings, adding multi-method approaches after a positive screening.

Improving empathy and self-efficacy in caregivers of persons with intellectual disabilities, using m-learning (HiSense APP-ID): study protocol for a randomized controlled trial

Background

A secure attachment with one or more caregivers is one of the most important predictors of cognitive development and emotional wellbeing. Persons with intellectual disabilities (ID) have extra need for secure relationships with primary caregivers but can find making connections difficult. This study aims to explore the effect of a non-invasive m-learning intervention on the empathy and self-efficacy of caregivers, in view of improving attachment relationships with persons with ID.

Methods

A randomized controlled trial (RCT) will be conducted to assess the efficacy of the HiSense APP-ID. The study will include 100 parents/relatives and 100 professional caregivers of adults with mild or moderate ID (18 years and older). Of both groups of participants, half will complete the m-learning intervention. Data will be collected before the intervention starts, immediately after completion of the m-learning, and 1 month after the intervention. Participants will complete questionnaires concerning knowledge about attachment theory, empathy and self-efficacy (primary outcome measures) and social validity (secondary measures).

Discussion

The intervention aims to increase caregiver understanding of attachment theory and to improve empathy and self-efficacy, which may lead to better care and less stress in social interactions. The HiSense APP-ID is an m-learning intervention that can be done independently on any digital device. The course is therefore easily accessible for caregivers of persons with ID. The current study will provide insight into the effectiveness of the intervention for parents/family members and professional caregivers of persons with mild or moderate ID.

Trial registration

Nederlands Trial Register, NTR 6944. Registered on 16 December 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2772-7) contains supplementary material, which is available to authorized users.

Young children with significant developmental delay differentiate home observed attachment behaviour towards their parents

BACKGROUND

The hallmark of attachment is that contact, proximity and relief from stress are sought from specific individuals, laying important groundwork for healthy socioemotional functioning. This study investigated the extent to which differentiated attachment behaviour can be observed in young children with significant developmental delay (DD).

METHOD

Video-taped observations of the parent-child and stranger-child interaction were conducted at home and complemented with questionnaires in 20 families with a child with significant DD (age 2-7 years with an average DD of 49 months).

RESULTS

Children displayed more intense and persistent contact-seeking, contact-maintaining and resistant behaviour in the episodes with their parent compared to the episodes with the stranger. Parent-reported secure attachment behaviour was slightly more characteristic towards mother compared to father.

CONCLUSIONS

Even children with significant DD develop differentiated attachment behaviour. Detailed observations may support parents in identifying the interactions that make the attachment relationship with their child special.

Changing Relationships through Interactions: Preliminary Accounts of Parent-Child Interactions after Undertaking Individual Parent Training

Parent and child interaction training has been increasingly investigated over recent years. However, the mechanisms of change within individual training programmes are not well understood. To explore the factors that can facilitate or inhibit meaningful changes in interactions and ultimately relationships, the current study employed semi-structured interviews to obtain first person accounts from parents who had undertaken an individualised parent-training programme. Three participants provided accounts of the training programme and their perceived impact upon interactions with their children were analysed using inductive thematic analysis. The analysis resulted in three themes, which illustrate how participants adjusted their interactional style with their child to varying degrees through enhanced personal awareness, increased understanding of their child's emotional and interactional needs, and accepting the reciprocity of interactional accountability. Changes in interactional style enabled participants to alter their perceptions of their own behaviours, their child's behaviours, and how they influenced one another through interactions. Recommendations for future research and therapeutic practice are discussed in the context of the findings and the existing evidence base.

Attachment quality of children with ID and its link to maternal sensitivity and structuring

BACKGROUND

Attachment theory produced a fertile field of research and clinical application. Although the topic of attachment of children with intellectual disability (ID) has received increasing research attention over the past 15 years, the empirical evidence is still limited.

AIMS

We applied theoretical and empirical knowledge of parenting typically developing children to examine the mother-child relationship in the ID population. The aim was to examine maternal sensitivity and structuring and its association with children's attachment classification and their disability.

METHODS

Forty preschool children (mean age 47.25, range 26-75 months) with non-specific ID and their mothers participated in the study. The mean developmental age was 25.92 months (SD = 10.89), The DQ mean score was 55.45 (SD = 17.28). We assessed children's quality of attachment using the SSP and maternal interactive behavior using the Emotional Availability Scales.

OUTCOMES

Forty percent of children showed secure attachment, and 32.5% showed disorganized attachment. Attachment classifications correlated significantly with maternal sensitivity and maternal structuring but not with the child's cognitive disability.

CONCLUSIONS

The results point to the importance of maternal interactive behavior for children with ID. Clinical implication may consider interventions aiming to enhance maternal sensitivity and structuring to improve children's quality of attachment.

Self-concept in institutionalized children with disturbed attachment: The mediating role of exploratory behaviours

BACKGROUND

Self-concept is seen as both an outcome of sociocognitive and emotional development, and a factor in social and mental health outcomes. Although the contribution of attachment experiences to self-concept has been limited to quality of primary attachment relationships, little is known of the effects of disturbed attachment on self-concept in institutionalized children. Thus, the current study examined associations between disturbed attachment behaviours in institutionalized children and self-concept, testing limited exploration as an explanatory factor.

METHODS

Thirty-three institutionalized children, aged 4-12, participated in a multimethod and multi-informant assessment of disturbed attachment behaviours (i.e., Disturbances of Attachment Interview and Behavioral Signs of Disturbed Attachment in Young Children), self-concept (i.e., Pictorial Scale of Perceived Competence and Social Acceptance for Young Children), and exploratory behaviours (i.e., Student Exploratory Behaviours Observation Scale). Analyses were conducted using bootstrapping techniques.

RESULTS

Global self-concept converged with teacher-rated children's self-concept, except for physical competence domain. Disturbed attachment behaviours were identified in 62.5% of the children, and this was associated with lower levels of exploration and lower scores on self-concept, compared with children without disturbed attachment behaviours. Furthermore, exploratory behaviours mediated the effects of disturbed attachment behaviours on self-concept.

CONCLUSIONS

Institution-reared children with disturbed attachment behaviours were likely to have a negative perception of self and one's own competences. Limited exploratory behaviours explained this linkage. Targeting disordered attachment in children reared in institutions and their caregivers should become a high priority as a means for preventing socioemotional development issues.

Systemic-attachment formulation for families of children with autism

Purpose

Case formulation has gained increasing prominence as a guide to intervention across a range of clinical problems. It offers a contrasting orientation to diagnosis and its value is considered in the context of clinical work with autistic spectrum disorders (ASD). The purpose of this paper is to argue that case formulation integrating attachment, systemic and narrative perspectives offers a valuable way forward in assisting people with the diagnosis and their families.

Design/methodology/approach

The literature on ASD and related conditions is reviewed to examine levels of co-morbidity, consider the role of parental mental health difficulties and explore the issues inherent with current approaches to diagnosis.

Findings

ASD is found to have a high level of co-morbidity with other difficulties, such as anxiety and insecure attachment. Research findings, alongside the authors own clinical experience, are developed to suggest that formulation can allow the possibility of early intervention based on a holistic appraisal of the array of difficulties present prior to a diagnosis.

Originality/value

It is argued that the use of this systemic-attachment formulation approach could offset the exacerbation in ASD and related conditions, and deterioration in families’ mental health, whilst they face long waiting times for a diagnosis.

A Systematic Review of the Literature on Parenting of Young Children with Visual Impairments and the Adaptions for Video-Feedback Intervention to Promote Positive Parenting (VIPP)

Secure parent-child attachment may help children to overcome the challenges of growing up with a visual or visual-and-intellectual impairment. A large literature exists that provides a blueprint for interventions that promote parental sensitivity and secure attachment. The Video-feedback Intervention to promote Positive Parenting (VIPP) is based on that blueprint. While it has been adapted to several specific at risk populations, children with visual impairment may require additional adjustments. This study aimed to identify the themes that should be addressed in adapting VIPP and similar interventions. A Delphi-consultation was conducted with 13 professionals in the field of visual impairment to select the themes for relationship-focused intervention. These themes informed a systematic literature search. Interaction, intersubjectivity, joint attention, exploration, play and specific behavior were the themes mentioned in the Delphi-group. Paired with visual impairment or vision disorders, infants or young children (and their parents) the search yielded 74 articles, making the six themes for intervention adaptation more specific and concrete. The rich literature on six visual impairment specific themes was dominated by the themes interaction, intersubjectivity, and joint attention. These themes need to be addressed in adapting intervention programs developed for other populations, such as VIPP which currently focuses on higher order constructs of sensitivity and attachment.

Practice Parameter for the Assessment and Treatment of Children and Adolescents With Reactive Attachment Disorder and Disinhibited Social Engagement Disorder

This Practice Parameter is a revision of a previous Parameter addressing reactive attachment disorder that was published in 2005. It reviews the current status of reactive attachment disorder (RAD) and disinhibited social engagement disorder (DESD) with regard to assessment and treatment. Attachment is a central component of social and emotional development in early childhood, and disordered attachment is defined by specific patterns of abnormal social behavior in the context of "insufficient care" or social neglect. Assessment requires direct observation of the child in the context of his or her relationships with primary caregivers. Treatment requires establishing an attachment relationship for the child when none exists and ameliorating disturbed social relatedness with non-caregivers when evident.

The effectiveness of VIPP-V parenting training for parents of young children with a visual or visual-and-intellectual disability: study protocol of a multicenter randomized controlled trial

BACKGROUND

Visual or visual-and-intellectual disabilities of children make daily interactions more difficult for their parents and may impact the quality of the parent-child relationship. To support these parents, an existing intervention (Video-feedback Intervention to promote Positive Parenting; VIPP; Juffer F, Bakermans-Kranenburg MJ, van IJzendoorn MH, 2008. Promoting positive parenting; an attachment-based intervention. Mahwah, NJ: Lawrence Erlbaum Associates; 2008) was adapted for use with parents of children with a visual or visual-and-intellectual disability (VIPP-V). This attachment-based intervention was hypothesized to support parents' interpretation and understanding of the behavior of their child with a visual or visual-and-intellectual disability and respond to their child's signals in a sensitive way to improve parent-child interaction quality.

METHODS/DESIGN

A randomized controlled trial (RCT) will be conducted to assess the effectiveness of the adapted intervention VIPP-V (Video-feedback Intervention to promote Positive Parenting in parents of children with Visual or visual-and-intellectual disabilities). Parent-child dyads will be randomized into two groups: 50 dyads will receive VIPP-V in combination with care-as-usual and 50 dyads will receive care-as-usual. Families with a child (1-5 years of age) with a visual or visual-and-intellectual disability will be recruited for participation in the study. Primary outcome measures are parental sensitivity and the quality of parent-child interaction. Secondary outcome measures are parental self-efficacy, and parenting stress. To assess feasibility of implementation of the intervention the experiences of early intervention workers with regard to using VIPP-V are assessed. Moderator variables are the child's developmental age, working alliance between parent and VIPP-V intervention worker and empathy of the VIPP-V intervention worker. Data will be collected approximately one week before the intervention starts (T1), one week (T2) and three months (T3) after the intervention. Parent-child dyads in the care-as-usual-only condition will be assessed at the same time points. Both intention-to-treat and completer analyses will be performed.

DISCUSSION

Descriptive findings in pilot cases suggest benefits from VIPP-V, and compatibility with existing services for parents of children with a visual or visual-and-intellectual disability. The current study will provide insight into the effectiveness of this intervention for parents of children with a visual or visual-and-intellectual disability, and, if the intervention is effective, prepare the field for broad-scale implementation.

TRIAL REGISTRATION

Nederlands Trial Register NTR4306 (registered 5 December 2013).

Mothers with intellectual disability, their experiences of maltreatment, and their children's attachment representations: a small-group matched comparison study

Maternal intellectual disability (ID) is regarded a risk factor in child development, but there is no scientific evidence on maternal ID in relation to children's attachment. Using a matched comparison design, a small group (n = 23) of mothers diagnosed with ID was studied to help fill this gap. Besides maternal ID, we examined the role of abuse/trauma/maltreatment (ATM) in the mothers' biographies, along with potential confounds. Comparison group mothers (n = 25) had normal variations in intelligence and matched mothers with ID on residential area, income, child age, and sex. History of maternal ATM was assessed using a semi-structured interview and was found to be significantly more likely in the ID group mothers' experience than the comparison group mothers. Children's (M age = 77 months) attachment representations were assessed with the Separation Anxiety Test. Among children of mothers with ID, a substantial minority (35%) had a secure and the vast majority (>80%) an organized attachment representation. Mothers with ID who had suffered elevated ATM were significantly more likely to have children who were scored high on disorganization and insecurity. We discuss possible implications of our findings for societal considerations regarding parenting and child attachment in the context of parental ID status.