Anorexia Nervosa in Adolescence: A Comprehensive Study of Multidimensional Factors Associated with Symptom Severity 1 Year Following the Diagnosis.

The overarching goal of this study was to examine the unique contribution of psychological, familial, and friendship factors in explaining anorexia nervosa (AN) symptom severity 1 year following diagnosis among a sample of adolescent girls. A second objective was to determine whether friendship factors mediated the association between psychological and/or familial factors and AN symptom severity. This study included 143 adolescent girls under the age of 18 diagnosed with AN (M = 14.84, SD = 1.31). Participants were recruited from specialized eating disorder treatment programs. At admission (T1), participants completed a set of self-report questionnaires measuring psychological, familial, and friendship factors. AN symptom severity was assessed 1 year later (T2). Results of hierarchical regression analysis revealed that greater general psychological maladjustment at T1 (b = .26; se = .03; p = .00) was associated with greater AN symptom severity at T2. Greater alienation from friends at T1 (b = 1.20, se = .53, p = .03) also predicted greater AN symptom severity at T2, above and beyond the influence of adolescent girls' general psychological maladjustment. Finally, the mediating role of alienation from friends in the association between general psychological maladjustment at T1 and AN symptom severity at T2 was also identified. AN is a multidimensional disorder with a prognosis that involves both psychological and social factors. The results stemming from the present study shed light on the role of peer as a mechanism through which general psychological maladjustment is linked to AN symptom severity 1 year following diagnosis.

Childhood behavioral inhibition and attachment: Links to generalized anxiety disorder in young adulthood.

Generalized anxiety disorder (GAD) is under-treated yet prevalent among young adults. Identifying early risk factors for GAD would contribute to its etiological model and identify potential targets for intervention. Insecure attachment patterns, specifically ambivalent and disorganized, have long been proposed as childhood risk factors for GAD. Similarly, childhood behavioral inhibition has been consistently associated with anxiety disorders in adulthood, including GAD. Intolerance of uncertainty (IU), the tendency to react negatively to uncertain situations, has also been shown to be a crucial component of GAD. Furthermore, maternal anxiety is an important feature of developmental models of anxiety including GAD. Yet, to date, no study has examined, within a comprehensive model, how attachment and behavioral inhibition in childhood, maternal anxiety in adolescence, and IU in emerging adulthood contribute to GAD in adulthood. The present study thus examines these links using a longitudinal design with 62 Canadian participants and their mothers. At age 6, participants' attachment and behavioral inhibition were assessed observationally. Maternal anxiety was measured when participants were 14 years of age. IU and GAD were assessed when participants were 21 and 23 years of age, respectively. Structural equation modeling showed that IU mediates the relationships between behavioral inhibition and GAD, while controlling for maternal anxiety. Ambivalent and disorganized-controlling attachment patterns are also indirectly associated with increased GAD symptoms via greater IU scores. Furthermore, a direct and positive effect of behaviorally disorganized attachment was found on GAD symptoms. This longitudinal study supports integrating attachment, behavioral inhibition, and IU in a model of GAD.

Maternal Functioning and Child's Externalizing Problems: Temperament and Sex-Based Driven Effects.

This study examines how maternal adverse parenting (hostility, neglect, low warmth) and psychological distress explain the associations between child temperament factors and externalizing problems. It also examines if these associations differ according to the child's biological sex. The sample consists of 339 school-age children receiving in-school services for conduct problems. Data were collected through questionnaires completed by mothers at 3 time points, at one-year intervals. Results from path analyses revealed that maternal psychological distress partly explained the associations between each child temperamental factors (negative affectivity, surgency/extraversion, effortful control) and levels of externalizing problems. Specifically, the indirect effect of psychological distress between child negative affectivity and externalizing problems was only significant for boys, not girls. Maternal hostility, on the other hand, mediated the association between child surgency/extraversion and externalizing problems in both boys and girls. Interestingly, neglectful parenting and maternal warmth did not explain the association between child temperamental factors and externalizing problems. The findings suggest small but significant temperament child-driven effects on maternal psychological distress and hostility, in turn, translating into higher levels of externalizing problems. These findings support the relevance of temperament-based interventions for children with conduct problems and of increased mental health support for their mothers. By aiding mothers in developing a larger repertoire of parenting strategies, mothers may be better equipped to respond appropriately to their child's various temperamental characteristics, hence, reducing their psychological distress and hostile behaviors and limiting the development of child externalizing problems.

Commercial Sexual Exploitation, Stigma, and Trauma: A Detrimental Trio for an Altered Sense of Self.

This study aimed to assess whether, and to what extent, the commercial sexual exploitation of female adolescents placed in residential care predicted different manifestations of an altered sense of self in emerging adulthood while considering the possible confounding effects of child maltreatment and perceived stigmatization. Data were gathered in a broader longitudinal study conducted among a sample of 124 female adolescents placed in residential youth care centers. Commercial sexual exploitation was self-reported during adolescence. Altered sense of self was self-reported in emerging adulthood with the following dependent variables: sense of failure, sense of defensiveness and shame, lack of self-awareness, and other-directedness. Findings suggest that, even after accounting for the significant effects of confounding variables, commercial sexual exploitation increases specific vulnerabilities pertaining to identity development. This creates unique intervention needs among young women. Our study adds to the literature by highlighting the unique influence of commercial sexual exploitation experiences among vulnerable female adolescents on their sense of self in young adulthood. Our results point to the relevance of considering the intersection of trauma and stigmatization when working with and providing services to adolescent females with a history of commercial sexual exploitation.

Identifying effective interventions for promoting parent engagement and family reunification for children in out-of-home care: A series of meta-analyses.

BACKGROUND: An important obstacle for family reunification following child placement in residential care and other temporary out-of-home care services is the lack of engagement among parents. OBJECTIVE: The aim of this meta-analysis is to identify the most effective interventions to promote parental engagement and family reunification. METHOD AND PARTICIPANTS: Eight studies, for a total of 2996 families, were used to conduct two series of meta-analyses. Each study examined the effectiveness of a goal-oriented parental engagement intervention, relative to a control group made up of parents who received standard services. Six moderators were analyzed: type of clinical modality, number of clinical strategies, sources of motivation for intervention, focus on the child care staff-parent relationship, child care staff training, and strategies to promote access to intervention. RESULTS: Results indicate that parents exposed to goal-oriented engagement interventions showed greater engagement (effect size d = 0.71, CI: 0.35-1.07, p < 0.001) and likelihood of reunification (effect size OR = 2.49, CI: 1.22-5.10, p < 0.05) than parents who received standard services. In particular, moderator analysis showed that parents who specifically participated in a family-focused intervention showed the highest engagement in comparison to parents involved in other types of interventions or who received standard services (effect size d = 1.08, CI: 0.58-1.59, p < 0.001). No moderators significantly explained heterogeneity of studies on family reunification. CONCLUSION: Overall, the results underline the effectiveness of family-focused interventions to promote parental engagement. Nevertheless, greater knowledge on the mechanisms by which interventions can increase parents' engagement and family reunification is still needed.

The dopamine D4 receptor gene, birth weight, maternal depression, maternal attention, and the prediction of disorganized attachment at 36 months of age: A prospective gene×environment analysis.

BACKGROUND: Efforts to understand the developmental pathways for disorganized attachment reflect the importance of disorganized attachment on the prediction of future psychopathology. The inconsistent findings on the prediction of disorganized attachment from the dopamine D4 receptor (DRD4) gene, birth weight, and maternal depression as well as the evidence supporting the contribution of early maternal care, suggest the importance of exploring a gene by environment model. METHODS: Our sample is from the Maternal Adversity, Vulnerability, and Neurodevelopment project; consisting of 655 mother-child dyads. Birth weight was cross-referenced with normative data to calculate birth weight percentile. Infant DRD4 genotype was obtained with buccal swabs and categorized according to the presence of the 7-repeat allele. Maternal depression was assessed with the Center for Epidemiologic Studies Depression Scale at the prenatal, 6-, 12-, and 24-month assessments. Maternal attention was measured at 6-months using a videotaped session of a 20-min non-feeding interaction. Attachment was assessed at 36-months using the Strange Situation Procedure. RESULTS: The presence of the DRD4 7-repeat allele was associated with less disorganized attachment, ß=-1.11, OR=0.33, p=0.0008. Maternal looking away frequency showed significant interactions with maternal depression at the prenatal assessment, ß=0.003, OR=1.003, p=0.023, and at 24 months, ß=0.004, OR=1.004, p=0.021, as at both time points, women suffering from depression and with frequent looking away behavior had an increased probability of disorganized attachment in their child, while those with less looking away behavior had a decreased probability of disorganized attachment in their child at 36 months. CONCLUSIONS: Our models support the contribution of biological and multiple environmental factors in the complex prediction of disorganized attachment at 36 months.

The interplay of birth weight, dopamine receptor D4 gene (DRD4), and early maternal care in the prediction of disorganized attachment at 36 months of age.

Disorganized attachment is an important early risk factor for socioemotional problems throughout childhood and into adulthood. Prevailing models of the etiology of disorganized attachment emphasize the role of highly dysfunctional parenting, to the exclusion of complex models examining the interplay of child and parental factors. Decades of research have established that extreme child birth weight may have long-term effects on developmental processes. These effects are typically negative, but this is not always the case. Recent studies have also identified the dopamine D4 receptor (DRD4) as a moderator of childrearing effects on the development of disorganized attachment. However, there are inconsistent findings concerning which variant of the polymorphism (seven-repeat long-form allele or non-seven-repeat short-form allele) is most likely to interact with caregiving in predicting disorganized versus organized attachment. In this study, we examined possible two- and three-way interactions and child DRD4 polymorphisms and birth weight and maternal caregiving at age 6 months in longitudinally predicting attachment disorganization at 36 months. Our sample is from the Maternal Adversity, Vulnerability and Neurodevelopment project, a sample of 650 mother-child dyads. Birth weight was cross-referenced with normative data to calculate birth weight percentile. Infant DRD4 was obtained with buccal swabs and categorized according to the presence of the putative allele seven repeat. Macroanalytic and microanalytic measures of maternal behavior were extracted from a videotaped session of 20 min of nonfeeding interaction followed by a 10-min divided attention maternal task at 6 months. Attachment was assessed at 36 months using the Strange Situation procedure, and categorized into disorganized attachment and others. The results indicated that a main effect for DRD4 and a two-way interaction of birth weight and 6-month maternal attention (frequency of maternal looking away behavior) and sensitivity predicted disorganized attachment in robust logistic regression models adjusted for social demographic covariates. Specifically, children in the midrange of birth weight were more likely to develop a disorganized attachment when exposed to less attentive maternal care. However, the association reversed with extreme birth weight (low and high). The DRD4 seven-repeat allele was associated with less disorganized attachment (protective), while non-seven-repeat children were more likely to be classified as disorganized attachment. The implications for understanding inconsistencies in the literature about which DRD4 genotype is the risk direction are also considered. Suggestions for intervention with families with infants at different levels of biological risk and caregiving risk are also discussed.

Refining the assessment of internal working models: the Attachment Multiple Model Interview.

The Attachment Multiple Model Interview (AMMI) was developed to assess internal working models (IWMs) of specific relationships in adulthood (e.g., with mother, father, and romantic partner). In an initial effort to validate the AMMI, the interview was administered to participants who were followed from age 4 to 23. ANOVA and contrast tests confirmed the AMMI's capacity to discriminate between mother, father, and partner IWMs. AMMI security with each parent was correlated with coherence according to the Adult Attachment Interview, and AMMI disorganization with mother with unresolved trauma (N = 53). AMMI dimensions of security, deactivation, and hyperactivation with the mother were associated with cumulative lifetime scores of security (N = 23), avoidance, and resistance (N = 34), respectively. Intercorrelations between these AMMI scales were also theory-consistent. Associations with the AAI and between AMMI security scores of different relationships are consistent with previous findings suggesting a contribution from both parents in the development of a state of mind, but a more important role of the mother for representations of the partner.

Preschool children without 7-repeat DRD4 gene more likely to develop disorganized attachment style.

BACKGROUND: The current paper aimed to explore the effects of birth weight and the 7-repeat allele in Exon III of the dopamine D4 receptor (DRD4) gene on the development of disorganized attachment, a potential endophenotype of depression. Infants born with low birth weight have been shown to be at higher risk for later neurological impairments, psychological disorders or behavioural problems. The DRD4 gene is critical for the cognitive and emotional processes that are sub-served by neural circuits in the prefrontal cortex. This paper examined the main effect of birth weight and DRD4 on the development of disorganized attachment. METHODS: Data was used from the Maternal Adversity, Vulnerability and Neurodevelopment (MAVAN) project. The sample consisted of 251 mother-child dyads with complete data. Attachment style was assessed using the modified separation-reunion procedure. RESULTS: There was no main effect for birth weight on disorganized attachment, (b = -0.001, p = 0.998). There was, however, a main effect for the DRD4 7-repeat polymorphism on disorganized attachment (b = -1.120, p = 0.004). LIMITATIONS: Compared to studies of similar design, the sample size in this study was relatively small. Additionally, a significant number of subjects did not have complete data. CONCLUSIONS: Children without the DRD4 7-repeat allele were more likely to have disorganized attachment than children with the DRD4 7-repeat allele. This indicates that the 7-repeate allele of the DRD4 gene may actually serve as a protective factor against disorganized attachment.

Video-feedback intervention with maltreating parents and their children: program implementation and case study.

This article describes a video-feedback intervention program with maltreating parents and their children aged 1 to 5 years using a case-study approach. The 8-week program is of interest to researchers and clinicians because it is the first short-term attachment-based intervention program to demonstrate efficacy in enhancing parental sensitivity, improving child attachment security, and reducing disorganized attachment for children and parents who have been reported for child abuse and/or neglect. We have previously described the theoretical and empirical basis of the intervention program and evidence for its efficacy. Details of program implementation and a case study are currently presented.

Preschool attachment, self-esteem and the development of preadolescent anxiety and depressive symptoms.

This study examined the longitudinal association between preschool attachment patterns, the development of anxiety and depression at preadolescence and the mediational role of self-esteem. Child-mother attachment classifications of 68 children (33 girls) were assessed between 3-4 years of age (M = 3.7 years, SD = 4.4 months) using the Separation-Reunion Procedure. At age 11-12 (M = 11.7 years, SD = 4.3 months), anxiety and depressive symptoms (Dominic Interactive Questionnaire), and self-esteem (Self-Perception Profile for Children) were also evaluated. Preadolescents who had shown disorganized attachment at preschool age scored higher on both anxiety and depression and lower on self-esteem than those who had shown secure and insecure-organized attachment strategies. Self-esteem was a partial mediator of the association between preschool disorganization and symptoms of preadolescent depression, but the model was not supported for anxiety. These findings support the idea that early attachment and self-esteem should be central themes in prevention programs with young children.

Behavior problems in middle childhood: the predictive role of maternal distress, child attachment, and mother-child interactions.

The objective of the study was to examine the longitudinal relation between early school-age measures of maternal psychosocial distress, quality of mother-child interactions, and child attachment behavior, and behavior problem profiles in middle childhood using a multi-informant design. Participants were 243 French-speaking mother-child dyads (122 girls) who were part of an ongoing longitudinal project. Maternal psychosocial distress was assessed when children were between 4 and 6 years of age. Mother-child interactive quality and attachment patterns were observed at age 6 during a laboratory visit. At age 8.5, externalizing and internalizing problems were assessed using mother and child reports. Results show that maternal psychosocial distress predicted later social adaptation reported by the child through the mediation of mother-child interactions. Analyses also revealed that higher maternal psychosocial distress and controlling attachment patterns, either of the punitive or caregiving type, significantly predicted membership in both child internalizing and externalizing clinical problem groups. Lower mother-child interactive quality, male gender, and child ambivalent attachment were also predictors of externalizing clinical problems.

Longitudinal association between adolescent attachment, adult romantic attachment, and emotion regulation strategies.

Attachment security towards parents and peers in adolescence, and romantic attachment styles and emotion regulation strategies in young adulthood, were evaluated using an eight-year longitudinal design. Fifty-six young adults completed the Inventory of Parent and Peer Attachment (IPPA) at age 14, and then, at age 22, the Experience in Close Relationships (ECR) and the Coping Inventory for Stressful Situations (CISS), an emotion regulation questionnaire concerning coping strategies, including task-oriented versus emotion-oriented foci. Results indicated that greater insecurity to parents and peers in adolescence predicted a more anxious romantic attachment style and greater use of emotion-oriented strategies in adulthood. Concurrently, anxious adult attachment style was related to more emotion-oriented strategies, whereas an avoidant attachment style was related to less support-seeking. Analyses also identified emotion-oriented coping strategies as a partial mediator of the link between adolescent attachment insecurity to parents and adult anxious attachment, and a complete mediator of the association between adolescent attachment insecurity to peers and adult anxious attachment. These findings support the core assumption of continuity in attachment theory, where relationships to parents influence close romantic relationships in adulthood.

Early maladaptive schemas and child and adult attachment: a 15-year longitudinal study.

OBJECTIVES: To examine the relation between early maladaptive schemas (EMS), as defined in schema therapy, and both child and adult attachment. DESIGN: A 15-year longitudinal design in which child attachment groups (secure, avoidant, ambivalent, and disorganized) were compared in early adulthood on their profile of scores across EMS domains. A similar strategy was used to examine EMS profiles as a function of adult attachment groups (secure, preoccupied, and fearful). METHODS: Sixty participants, recruited from Montreal day-care centres, were assessed at 6 (Time 1) and 21 years of age (Time 2). Time 1 attachment was assessed using a separation-reunion procedure and Time 2 attachment, using the Experiences in Close Relationships questionnaire. EMS were evaluated with the Young Schema Questionnaire (Time 2). RESULTS: There were more signs of EMS among young adults with either an insecure ambivalent child attachment, or an insecure preoccupied adult attachment style, compared to their secure peers. These differences were not specific to one domain of EMS; they were reported for various EMS. CONCLUSIONS: The results suggest that specific elements of representational models are more likely to be related to the development of EMS: high anxiety over abandonment, negative self-view, and explicit manifestations of personal distress. Unmet childhood needs for secure attachment may lead to a large variety of EMS as defined in schema therapy.

Attachment-based intervention for maltreating families.

This article presents attachment theory-based intervention strategies as a means of addressing the core parent-child interaction deficits that characterize homes in which children are exposed to maltreatment. The article outlines the socioemotional and cognitive outcomes of maltreatment and proposes that although many prevention programs target different parental and family characteristics, few address the core relationship issues that are at stake. Recent research on attachment-based intervention strategies, aimed at improving the sensitivity and responsiveness of the parenting behaviors that children are exposed to, are presented as providing a means of addressing this domain. Attachment theory and research are briefly summarized, and the relational and interactional patterns observed in maltreating families, and their link to infant and child developmental outcome, are described. Research on attachment-based intervention is addressed, with a focus on studies conducted in the context of maltreating or high-risk families. This work is synthesized to present the basic components viewed as critical to effective attachment intervention with maltreating families. Finally, the authors end with recommendations aimed at the effective implementation of attachment-based intervention.