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Kozlowska K, Schollar-Root O, Savage B, Hawkes C, Chudleigh C, Raghunandan J, Scher S, Helgeland H. Illness-Promoting Psychological Processes in Children and Adolescents with Functional Neurological Disorder. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1724. [PMID: 38002815 PMCID: PMC10670544 DOI: 10.3390/children10111724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/03/2023] [Accepted: 10/06/2023] [Indexed: 11/26/2023]
Abstract
Previous studies suggest that subjective distress in children with functional neurological disorder (FND) is associated with stress-system dysregulation and modulates aberrant changes in neural networks. The current study documents illness-promoting psychological processes in 76 children with FND (60 girls and 16 boys, aged 10.00-17.08 years) admitted to the Mind-Body Program. The children completed a comprehensive family assessment and self-report measures, and they worked with the clinical team to identify psychological processes during their inpatient admission. A total of 47 healthy controls (35 girls and 12 boys, aged 8.58-17.92 years) also completed self-report measures, but were not assessed for illness-promoting psychological processes. Children with FND (vs. controls) reported higher levels of subjective distress (total DASS score, t(104.24) = 12.18; p ˂ 0.001) and more adverse childhood experiences across their lifespans (total ELSQ score, t(88.57) = 9.38; p ˂ 0.001). Illness-promoting psychological processes were identified in all children with FND. Most common were the following: chronic worries about schoolwork, friendships, or parental wellbeing (n = 64; 84.2%); attention to symptoms (n = 61; 80.3%); feeling sad (n = 58; 76.3%); experiencing a low sense of control (helplessness) in relation to symptoms (n = 44; 57.9%); pushing difficult thoughts out of mind (n = 44; 57.9%); self-critical rumination (n = 42; 55.3%); negative/catastrophic-symptom expectations (n = 40; 52.6%); avoidance of activities (n = 38; 50%); intrusive thoughts/feelings/memories associated with adverse events (n = 38, 50%); and pushing difficult feelings out of mind (n = 37; 48.7%). In children with FND-disabled enough to be admitted for inpatient treatment-illness-promoting psychological processes are part of the clinical presentation. They contribute to the child's ongoing sense of subjective distress, and if not addressed can maintain the illness process. A range of clinical interventions used to address illness-promoting psychological processes are discussed, along with illustrative vignettes.
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Affiliation(s)
- Kasia Kozlowska
- Department of Psychological Medicine, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia; (O.S.-R.); (B.S.); (C.H.); (J.R.)
- Child and Adolescent Heath and Specialty of Psychiatry, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Brain Dynamics Centre, Westmead Institute of Medical Research, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia
| | - Olivia Schollar-Root
- Department of Psychological Medicine, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia; (O.S.-R.); (B.S.); (C.H.); (J.R.)
| | - Blanche Savage
- Department of Psychological Medicine, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia; (O.S.-R.); (B.S.); (C.H.); (J.R.)
- Golden Wattle Clinical Psychology, 20 Jarrett St, Leichhardt, NSW 2040, Australia
| | - Clare Hawkes
- Department of Psychological Medicine, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia; (O.S.-R.); (B.S.); (C.H.); (J.R.)
| | - Catherine Chudleigh
- Department of Psychological Medicine, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia; (O.S.-R.); (B.S.); (C.H.); (J.R.)
- Golden Wattle Clinical Psychology, 20 Jarrett St, Leichhardt, NSW 2040, Australia
| | - Jyoti Raghunandan
- Department of Psychological Medicine, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia; (O.S.-R.); (B.S.); (C.H.); (J.R.)
| | - Stephen Scher
- Department of Psychiatry, McLean Hospital, Harvard Medical School, Boston, MA 02115, USA;
- Specialty of Psychiatry, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
| | - Helene Helgeland
- Department of Child and Adolescent Mental Health in Hospitals, Oslo University Hospital, 0424 Oslo, Norway;
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O'Loghlen E, Galligan R, Grant S. The functions of binge eating scale (FBES): Development and preliminary psychometric validation. Appetite 2023; 183:106479. [PMID: 36736905 DOI: 10.1016/j.appet.2023.106479] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 01/19/2023] [Accepted: 01/27/2023] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Binge eating within binge-eating disorder (BED) is a behaviour widely understood as a response to dietary restraint and emotion dysregulation. However, qualitative literature suggests that a wider range of functions of binge eating exist, with associations between functions of binge eating and adverse childhood experiences highlighted across this research. The present study sought to develop a scale to measure a wide range of functions of binge eating within BED. A secondary aim was to examine the relationship between these functions and adverse childhood experiences (ACEs). METHOD The researchers developed an initial item pool for the Functions of Binge Eating Scale (FBES) and invited experts within the eating disorder (ED) field (n = 22) to review the items. The refined item pool was administered online to adults with self-reported binge eating symptoms (N = 882), along with related measures to establish scale validity. RESULTS Exploratory and confirmatory factor analyses produced an eight-factor structure (emotion regulation, hedonic hunger, compensatory eating, numbness/dissociation, emotion expression, self-punishment, control, self-protection). The scale demonstrated good internal reliability and adequate construct and predictive validity. Results also showed that functions theoretically related to childhood maltreatment were predicted by ACEs. DISCUSSION Findings extend our understanding of the range of functions of binge eating experienced in BED. Additionally, findings indicate that type of adverse childhood experience predicts functions of binge eating. Initial validation of the FBES suggests that functions of binge eating are wider than previously understood. Accordingly, clinicians are encouraged to explore and target more complex processes which might perpetuate binge-eating behaviour.
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Affiliation(s)
- Elyse O'Loghlen
- Department of Psychological Sciences, Swinburne University of Technology, Hawthorn, VIC, 3122, Australia.
| | - Roslyn Galligan
- Department of Psychological Sciences, Swinburne University of Technology, Hawthorn, VIC, 3122, Australia.
| | - Sharon Grant
- Department of Psychological Sciences, Swinburne University of Technology, Hawthorn, VIC, 3122, Australia.
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Evgin D, Sümen A. Childhood abuse, neglect, codependency, and affecting factors in nursing and child development students. Perspect Psychiatr Care 2022; 58:1357-1371. [PMID: 34448498 DOI: 10.1111/ppc.12938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 07/12/2021] [Accepted: 08/17/2021] [Indexed: 11/29/2022] Open
Abstract
PURPOSE This study was conducted to determine the relationship of neglect and abuse behaviors experienced by nursing and child development students during their childhood with codependency, and the factors affecting codependency. DESIGN AND METHODS This is a descriptive and correlational study. The study was conducted with 292 students who were studying at a Faculty of Health Sciences. FINDINGS A positive relationship was found between neglect and abuse behaviors that lead to trauma in childhood, and codependency. It was determined that there was a negative relationship between students' codependency and childhood traumatic experiences and their levels of self-esteem, depression and coping with stress. PRACTICE IMPLICATIONS In the educational processes, it is possible to focus on students' unresolved problems with their families, and the signs of codependency.
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Affiliation(s)
- Derya Evgin
- Department of Pediatric Nursing, Kumluca Faculty of Health Sciences, Akdeniz University, Antalya, Turkey
| | - Adem Sümen
- Department of Public Health Nursing, Kumluca Faculty of Health Sciences, Akdeniz University, Antalya, Turkey
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Cruz D, Lichten M, Berg K, George P. Developmental trauma: Conceptual framework, associated risks and comorbidities, and evaluation and treatment. Front Psychiatry 2022; 13:800687. [PMID: 35935425 PMCID: PMC9352895 DOI: 10.3389/fpsyt.2022.800687] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 06/27/2022] [Indexed: 11/17/2022] Open
Abstract
Children exposed to adverse childhood experiences (ACEs) and pervasive interpersonal traumas may go on to develop PTSD and, in most cases, will further undergo a significant shift in their developmental trajectory. This paper examines contemporary research on Developmental Trauma (DT), which is inextricably linked to disruptions in social cognition, physiological and behavioral regulation, and parent-child attachments. Developmental trauma associated with early experiences of abuse or neglect leads to multi-faceted and longstanding consequences and underscores critical periods of development, complex stress-mediated adaptations, and multilevel, trans-theoretical influences in the diagnostic formulation and treatment of traumatized children, adolescents, and adults. Psychological and medical correlates of Developmental Trauma Disorder are considered, and directions for future research are discussed.
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Affiliation(s)
- Daniel Cruz
- Hackensack Meridian Health Mountainside Medical Center, Montclair, NJ, United States
| | | | - Kevin Berg
- Hackensack Meridian Health Mountainside Medical Center, Montclair, NJ, United States
| | - Preethi George
- Hackensack Meridian Health Mountainside Medical Center, Montclair, NJ, United States
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Lee HS, Min D, Baik SY, Kwon A, Jin MJ, Lee SH. Association between Dissociative Symptoms and Morning Cortisol Levels in Patients with Post-traumatic Stress Disorder. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2022; 20:292-299. [PMID: 35466100 PMCID: PMC9048003 DOI: 10.9758/cpn.2022.20.2.292] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/04/2021] [Accepted: 03/06/2021] [Indexed: 11/26/2022]
Abstract
Objective Patients with post-traumatic stress disorder (PTSD) showed inconsistencies in their cortisol level, an index of the hypothalamic-pituitary-adrenal axis function. This study examined the relationship between dissociation, childhood trauma, and morning cortisol levels in PTSD patients. Methods This study included 69 (23 males and 46 females) patients and 82 (22 males and 60 females) healthy controls (HCs). Clinical assessments, including the Childhood Trauma Questionnaire (CTQ) and Peri-traumatic Dissociative Experiences Questionnaire scores, and morning cortisol levels were evaluated. The morning cortisol levels were compared between PTSD with high dissociation and low dissociation (PTSD-LD) groups. The effect of CTQ subtype on morning cortisol levels was analyzed. Results The PTSD with high dissociation group showed significantly lower cortisol levels than that of the PTSD-LD and HC groups. A significant inverse correlation was found between cortisol levels and dissociation. A significant positive correlation was found between dissociation and physical abuse and sexual abuse scores. Morning cortisol levels showed a significant positive correlation with emotional abuse, emotional neglect, and physical neglect, respectively. There was no moderating or mediating effect of CTQ on the relationship between cortisol level and dissociation. Conclusion These findings suggest that dissociation is a significant factor related to hypocortisolism in PTSD patients. Additionally, basal morning cortisol levels and dissociation scores were closely associated with childhood trauma.
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Affiliation(s)
- Hyun Seo Lee
- Clinical Emotion and Cognition Research Laboratory, Inje University, Goyang, Korea
| | - Dongil Min
- Clinical Emotion and Cognition Research Laboratory, Inje University, Goyang, Korea
| | - Seung Yeon Baik
- Department of Psychology, Penn State University, State College, PA, USA
| | - Aeran Kwon
- Department of Social Welfare and Counseling, Chodang University, Muan, Korea
| | - Min Jin Jin
- Institute of General Education, Kongju National University, Gongju, Korea
| | - Seung-Hwan Lee
- Clinical Emotion and Cognition Research Laboratory, Inje University, Goyang, Korea
- Department of Psychiatry, Inje University Ilsan Paik Hospital, Goyang, Korea
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Kozlowska K, Chudleigh C, McClure G, Maguire AM, Ambler GR. Attachment Patterns in Children and Adolescents With Gender Dysphoria. Front Psychol 2021; 11:582688. [PMID: 33510668 PMCID: PMC7835132 DOI: 10.3389/fpsyg.2020.582688] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 11/25/2020] [Indexed: 01/18/2023] Open
Abstract
The current study examines patterns of attachment/self-protective strategies and rates of unresolved loss/trauma in children and adolescents presenting to a multidisciplinary gender service. Fifty-seven children and adolescents (8.42–15.92 years; 24 birth-assigned males and 33 birth-assigned females) presenting with gender dysphoria participated in structured attachment interviews coded using dynamic-maturational model (DMM) discourse analysis. The children with gender dysphoria were compared to age- and sex-matched children from the community (non-clinical group) and a group of school-age children with mixed psychiatric disorders (mixed psychiatric group). Information about adverse childhood experiences (ACEs), mental health diagnoses, and global level of functioning was also collected. In contrast to children in the non-clinical group, who were classified primarily into the normative attachment patterns (A1-2, B1-5, and C1-2) and who had low rates of unresolved loss/trauma, children with gender dysphoria were mostly classified into the high-risk attachment patterns (A3-4, A5-6, C3-4, C5-6, and A/C) (χ2 = 52.66; p < 0.001) and had a high rate of unresolved loss/trauma (χ2 = 18.64; p < 0.001). Comorbid psychiatric diagnoses (n = 50; 87.7%) and a history of self-harm, suicidal ideation, or symptoms of distress were also common. Global level of functioning was impaired (range 25–95/100; mean = 54.88; SD = 15.40; median = 55.00). There were no differences between children with gender dysphoria and children with mixed psychiatric disorders on attachment patterns (χ2 = 2.43; p = 0.30) and rates of unresolved loss and trauma (χ2 = 0.70; p = 0.40). Post hoc analyses showed that lower SES, family constellation (a non-traditional family unit), ACEs—including maltreatment (physical abuse, sexual abuse, emotional abuse, neglect, and exposure to domestic violence)—increased the likelihood of the child being classified into a high risk attachment pattern. Akin to children with other forms of psychological distress, children with gender dysphoria present in the context of multiple interacting risk factors that include at-risk attachment, unresolved loss/trauma, family conflict and loss of family cohesion, and exposure to multiple ACEs.
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Affiliation(s)
- Kasia Kozlowska
- Department of Psychological Medicine, The Children's Hospital at Westmead, Westmead, NSW, Australia.,Discipline of Child and Adolescent Health, University of Sydney Medical School, Darlington, NSW, Australia
| | - Catherine Chudleigh
- Department of Psychological Medicine, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Georgia McClure
- Department of Psychological Medicine, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Ann M Maguire
- Discipline of Child and Adolescent Health, University of Sydney Medical School, Darlington, NSW, Australia.,Department of Endocrinology, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Geoffrey R Ambler
- Discipline of Child and Adolescent Health, University of Sydney Medical School, Darlington, NSW, Australia.,Department of Endocrinology, The Children's Hospital at Westmead, Westmead, NSW, Australia
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Dallos R, Crittenden PM, Landini A, Spieker S, Vetere A. Family Functional Formulations as Guides to Psychological Treatment. CONTEMPORARY FAMILY THERAPY 2019. [DOI: 10.1007/s10591-019-09525-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
The dissociative disorders field and the hypnosis field currently reject the autohypnotic model of the dissociative disorders, largely because many correlational studies have shown hypnotizability and dissociation to be minimally related (r = .12). Curiously, it is also widely accepted that dissociative patients are highly hypnotizable. If dissociative patients are highly hypnotizable because only highly hypnotizable individuals can develop a dissociative disorder - as the author proposes - then the methodology of correlational studies of hypnotizability and dissociation in random clinical and community samples would necessarily be constitutively unable to detect, and statistically unable to reflect, that fact. That is, the autohypnotic, dissociative distancing of that small subset of highly hypnotizable individuals who repeatedly encountered intolerable circumstances is statistically lost among the data of (1) the highly hypnotizable subjects who do not dissociate and (2) subjects (of all levels of hypnotizability) who manifest other kinds of dissociation. The author proposes that, when highly hypnotizable individuals repeatedly engage in autohypnotic distancing from intolerable circumstances, they develop an overlearned, highly-motivated, automatized pattern of dissociative self-protection (i.e., a dissociative disorder). The author urges that theorists of hypnosis and the dissociative disorders explicitly include in their theories (a) the trait of high hypnotizability, (b) the phenomena of autohypnosis, and (c) the manifestations of systematized, autohypnotic pathology. Said differently, the author is suggesting that autohypnosis and autohypnotic pathology are unacknowledged nodes in the nomothetic networks of both hypnosis and dissociation.
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Affiliation(s)
- Paul F Dell
- a Churchland Psychological Center , Norfolk , VA , USA
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Pace AL, Bufford RK. Assessing adult attachment: Relation and validity of two dynamic-maturational model approaches. INTERPERSONA: AN INTERNATIONAL JOURNAL ON PERSONAL RELATIONSHIPS 2018. [DOI: 10.5964/ijpr.v12i2.318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Assessing attachment is essential yet challenging. The Adult Attachment Interview (AAI) provides the best appraisal of adult attachment but is time-intensive and costly. Likewise, concerns have been raised regarding the Berkeley-AAI coding and classification method. Meanwhile, self-report measures of adult attachment are time-efficient and low-cost, but their validity is questionable. The Dynamic-Maturational Model approach to the AAI (DMM-AAI) and a novel self-report measure – the Attachment Relationship Questionaire (ARQ) – may offer a solution. However, additional investigations regarding the validity of DMM-AAI are needed and the ARQ’s psychometric properties have not be tested. The validity of the DMM approach to the AAI and the predictive relationship between the ARQ and DMM-AAI classification were examined for 212 participants living the UK. Results indicated a strong positive relationship between high numbered attachment classification on the DMM-AAI and psychological treatment status, χ²(6) = 56.07, p < .001; Cramer’s V = .371, p < .001. Binomial logistic regressions between the ARQ and DMM-AAI found both single-statement and multi-statement predictive models were statistically significant. However, the ARQ accounted for only a small amount of the variance (R² ≤ 0.15). In conclusion, the DMM-AAI demonstrated strong construct validity, whereas the ARQ is not useful for assessment of adult attachment. Further investigation with a revised version of the ARQ that addresses psychometric concerns is suggested.
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Spieker SJ, Crittenden PM. CAN ATTACHMENT INFORM DECISION-MAKING IN CHILD PROTECTION AND FORENSIC SETTINGS? Infant Ment Health J 2018; 39:625-641. [DOI: 10.1002/imhj.21746] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Van Ijzendoorn MH, Bakermans JJ, Steele M, Granqvist P. DIAGNOSTIC USE OF CRITTENDEN'S ATTACHMENT MEASURES IN FAMILY COURT IS NOT BEYOND A REASONABLE DOUBT. Infant Ment Health J 2018; 39:642-646. [DOI: 10.1002/imhj.21747] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Baldoni F, Minghetti M, Craparo G, Facondini E, Cena L, Schimmenti A. Comparing Main, Goldwyn, and Hesse (Berkeley) and Crittenden (DMM) coding systems for classifying Adult Attachment Interview transcripts: an empirical report. Attach Hum Dev 2018; 20:423-438. [PMID: 29308700 DOI: 10.1080/14616734.2017.1421979] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Few studies have compared different systems in classifying Adult Attachment Interview (AAI) transcripts. In this study, the AAI was administered to 90 Italian parents (45 couples), and the AAI transcripts were independently classified according to Main, Goldwyn, and Hesse's (Berkeley) and Crittenden's (Dynamic-Maturational Model [DMM]) criteria. The two classification systems were not significantly associated, with some limited convergent results only when the interviews resulted in organized (Berkeley) and normative (DMM) attachment classifications. Otherwise, the Berkeley system identified more secure individuals than the DMM system, and many texts judged secure on the Berkeley system were identified as insecure on the DMM system. Since the Berkeley and the DMM systems rest on remarkably different conceptualizations of the nature and functioning of the attachment behavioral system (e.g. fear is conceived as organizing in the DMM and as potentially disorganizing in the Berkeley), the attachment classifications resulting from their applications should not be considered measurements of the same phenomena.
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Affiliation(s)
- Franco Baldoni
- a Attachment Assessment Lab, Department of Psychology , University of Bologna , Bologna , Italy
| | - Mattia Minghetti
- a Attachment Assessment Lab, Department of Psychology , University of Bologna , Bologna , Italy
| | - Giuseppe Craparo
- b Faculty of Human and Social Sciences , UKE - Kore University of Enna , Enna , Italy
| | - Elisa Facondini
- c Obstetrics and Gynecology Unit and Neonatal Intensive Care Unit , Infermi Hospital , Rimini , Italy
| | - Loredana Cena
- d Department of Clinical and Experimental Sciences , University of Brescia , Brescia , Italy
| | - Adriano Schimmenti
- b Faculty of Human and Social Sciences , UKE - Kore University of Enna , Enna , Italy
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Crittenden PM, Robson K, Tooby A, Fleming C. Are mothers' protective attachment strategies related to their children's strategies? Clin Child Psychol Psychiatry 2017; 22:358-377. [PMID: 28429614 DOI: 10.1177/1359104517704027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIMS We explored the relation between mothers' protective attachment strategies and those of their school-age children. METHODS In total, 49 child-mother dyads participated in a short longitudinal study when the children were 5.5 and 6.0 years old. Their strategies were first assessed with the Preschool Assessment of Attachment (PAA) and then with the School-age Assessment of Attachment (SAA). Mothers were assessed with the Adult Attachment Interview (AAI). The Dynamic-Maturational Model of Attachment and Adaptation (DMM) was used to classify the assessments. RESULTS The validity and precision of the DMM-AAI were supported: Mothers' AAI classifications were related to their referral group (normative or clinical) and measures of stress and distress. The DMM categories were more associated with risk than the Ainsworth categories. Types A, C and A/C were differentiated by trauma, triangulation and depression. Mothers' and children's protective attachment strategies were related, with B mothers having B children and A or C mothers having children using the same or opposite strategy. Children whose classification changed from the PAA to the SAA had mothers with complex traumas. CONCLUSION When psychosocial treatment is needed, knowing whether mother and child use the same or different strategies and whether mothers have complex trauma can affect treatment success.
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