Cultural applicability and desirability of 'Broodles': The first serious game intervention for siblings of children with disabilities.

Objective: Serious games can serve as easily accessible interventions to support siblings of children with disabilities, who are at risk of developing mental health problems. The Dutch serious game 'Broodles' was developed for siblings aged 6-9 years. The current study aims to assess the cultural applicability, desirability, feasibility, and acceptability of 'Broodles' in Norway. Methods: Norwegian siblings (N = 16) aged 6-13 years and parents (N = 12) of children with intellectual disabilities assessed the game. Their feedback data from interviews and questionnaires were sorted using a model of engagement factors in serious games. Results: At pre-use, participants showed interest in the game, and after initial use the participants were overall positive about the format, content and objectives, including validation of emotions and recognition. The participants had suggestions for improved engagement and feasibility. Conclusion: The game was found to be culturally applicable, desirable and acceptable, although Norwegian translation is necessary for further evaluation. Recommendations to enhance engagement were provided, including suggestions to play the game with parents or in a group. Innovation: This initial assessment of the serious game Broodles in a non-Dutch setting shows promise for an innovative way of supporting siblings of children with disabilities.

Effectiveness of the mentalisation-based serious game 'You & I' for adults with mild to borderline intellectual disabilities: A randomised controlled trial.

BACKGROUND: Mentalising and stress regulation pose challenges for adults with mild to borderline intellectual disabilities (MBID), emphasising the importance of an intervention program. The study examined the effectiveness and social validity of the serious game 'You & I' in enhancing mentalising and stress regulation among adults with MBID. METHOD: A randomised controlled superiority trial with experimental and waitlist-control groups was conducted with 159 adults with MBID (Mage = 36) at baseline, post-test, and follow-up. Analyses investigated the effects on aspects of mentalising, stress regulation, and social validity. RESULTS: The experimental group showed decreased stress from negative interpersonal relations, while the control group experienced increased stress (d = 0.26). There were no significant effects on mentalising, but positive user expectations and experiences were reported. CONCLUSIONS: This initial study on 'You & I' provides limited evidence of its effectiveness for people with MBID, warranting further examination of the potential of serious games.

Lessons learned from the adaptation of the Reflective Functioning Questionnaire (RFQ) for Dutch people with mild to borderline intellectual disabilities.

BACKGROUND: People with mild to borderline intellectual disabilities (MBIDs) face challenges in social functioning, possibly as a result of limited mentalising abilities such as reflecting on the behaviour of themselves and others. Reflective functioning in people with MBIDs has not yet been investigated due to a lack of instruments. The Reflective Functioning Questionnaire (RFQ) is a seemingly easy adaptable, short self-report questionnaire. The aim of the present, explorative study was to adapt the RFQ for people with MBIDs and investigate the psychometric properties and correlations with other mentalising related constructs. The formulation of the items was adapted to the target group and items were added to broaden the scope towards reflection on both the self and other. METHOD: Participants were 159 adults with MBIDs who completed a Dutch-translated and easy-to-read RFQ with five supplemental items, a questionnaire for autistic traits, a self-report questionnaire assessing perspective taking and two performance-based measures assessing emotion recognition and Theory of Mind. RESULTS: Confirmatory factor analysis confirmed the factor structure of the RFQ and revealed a two-factor structure with a Self and Other subscale. Generally satisfactory internal consistency and test-retest reliability were found. Explorative results showed correlations of the RFQ-8 and RFQ subscales with autistic traits and between the RFQ Other and perspective taking. CONCLUSIONS: This explorative study is the first testing psychometric properties of the RFQ as a self-report questionnaire for assessing reflective functioning in adults with MBIDs. This step is relevant in gaining more scientific knowledge on assessing mentalising in people with MBIDs.

Effects of the Attune & Stimulate-checklist for caregivers of people with severe and profound intellectual disabilities: A randomised controlled trial.

BACKGROUND: Sensitive responsiveness is an important aspect in affect-regulation of people with severe to profound intellectual disabilities. AIM: This randomized controlled trial evaluated the Attune & Stimulate-checklist, a tool for detecting subtle and idiosyncratic communicative behaviours and responding adequately. METHODS: Effects on the sensitive responsiveness of professional caregivers and the arousal and valence of adults with severe to profound intellectual disabilities were investigated. Video recordings of 102 interactions were analysed with several observation instruments. RESULTS: Although no significant effect was found on the checklist-suggestions of responsive behaviours (d = 0.33, p = .052), the intervention increased caregivers' sensitive responsive and affective behaviour (d = 0.94 - 1.10, p < .001) and clients' optimal arousal (d = 0.48, p = .019) and interactive engagement (d = 0.40 - 0.48, p = .018 - .050). CONCLUSION: This low-intensity intervention had a medium to large immediate effect on the interaction. Future research should investigate medium- and long-term effects.

The effectiveness of the serious game "Broodles" for siblings of children with intellectual disabilities and/or visual impairment: study protocol for a randomized controlled trial.

BACKGROUND: Siblings of children with disabilities also need support. However, there are only a few evidence-based interventions for these siblings. The current study aims to assess the effectiveness of a newly developed serious game for young siblings of children with intellectual disability (ID) and/or visual impairment (VI). This serious game is hypothesized to improve sibling's quality of life, adjustment to their brother's or sister's disability, and multiple aspects of psychosocial well-being. METHODS: The intervention consists of a serious game called "Broodles" (in Dutch: "Broedels") that helps children to recognize and deal with thoughts, feelings, and difficult situations. The game consists of eight 20-minute levels that all have the same structure with eight game elements. Each level addresses a domain of sibling quality of life and combines animations, mini-documentaries, fun mini-games, and multiple-choice questions. In addition to the game, siblings make a worksheet after playing each level. In order to support the child, the parents or caregivers receive a short brochure with information and tips. The effectiveness of the intervention will be investigated among a sample of 154 children aged 6-9 years and their parents or caregivers, using a two-arm parallel RCT design. The experimental group will play the serious game "Broodles" over a period of 4 weeks, whereas the control group will be placed on a waiting list. Assessments will take place at three time points: pre-test (week 1), post-test (week 5), and follow-up (weeks 12-14). At each timepoint, children and parents will complete several questionnaires on quality of life and different aspects of psychosocial well-being. In addition, children will make drawings to assess the sibling relationship. Next to that, parents and children will answer closed and open-ended questions about the sibling adjustment to their brother or sister's disability. Finally, parents and children will evaluate the serious game through closed and open-ended questions. DISCUSSION: This study contributes to the knowledge about sibling interventions and serious games. Additionally, if the serious game is proven to be effective, it will be a readily available, easily accessible, and free of charge intervention for siblings. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05376007, registered prospectively on April 21, 2022.

Exploration of the effects of an innovative mentalization-based training on patient-centered communication skills of pharmacy staff: A video-observation study.

OBJECTIVE: To explore whether a mentalization-based communication training for pharmacy staff impacts their ability to elicit and recognize patients' implicit and explicit medication related needs and concerns. METHODS: A single-arm intervention pilot study was conducted, in which pre-post video-recordings of pharmacy counter-conversations on dispensed-medication (N = 50 and N = 34, respectively; pharmacy staff: N = 22) were coded. Outcome measures included: detecting needs and concerns, and implicitly and explicitly eliciting and recognizing them. Descriptive statistics and a multi-level logistic regression were conducted. Excerpts of videos with needs or concerns were analyzed thematically on mentalizing attitude aspects. RESULTS: Indications show that patients more often express their concerns in an explicit way post-measurement, just as pharmacy staffs' explicit recognition and elicitation of needs and concerns. This was not seen for patients' needs. No statistically significant differences were found for determinants for detecting needs or concerns (i.e., measurement-, professional-type, or interaction). Differences in mentalizing attitude were observed between pre-post-measurements, e.g., more attention for patients. CONCLUSION: This mentalizing training shows the potential of mentalizing to improve pharmacy staff members' explicit elicitation and recognition of patients' medication-related needs and concerns. PRACTICE IMPLICATIONS: The training seems promising for improving patient-oriented communication skills in pharmacy staff. Future studies should confirm this result.

More than a Physical Problem: The Effects of Physical and Sensory Impairments on the Emotional Development of Adults with Intellectual Disabilities.

With the introduction of the ICD-11 and DSM-5, indicators of adaptive behavior, including social-emotional skills, are in focus for a more comprehensive understanding of neurodevelopmental disorders. Emotional skills can be assessed with the Scale of Emotional Development-Short (SED-S). To date, little is known about the effects of physical disorders and sensory impairments on a person's developmental trajectory. The SED-S was applied in 724 adults with intellectual disabilities, of whom 246 persons had an additional physical and/or sensory impairment. Ordinal regression analyses revealed an association of movement disorders with more severe intellectual disability and lower levels of emotional development (ED) on the overall and domain levels (Others, Body, Material, and Communication). Visual impairments predicted lower levels of ED in the SED-S domains Material and Body, but not the overall level of ED. Hearing impairments were not associated with intellectual disability or ED. Epilepsy correlated only with the severity of intellectual disability. Multiple impairments predicted more severe intellectual disabilities and lower levels of overall ED. In conclusion, physical and sensory impairments may not only affect physical development but may also compromise intellectual and emotional development, which should be addressed in early interventions.

COVID-19 Vaccination Intentions amongst Healthcare Workers: A Scoping Review.

A worldwide vaccination programme is the chosen strategy against the COVID-19 pandemic. Vaccine hesitancy, however, forms a threat to achieving a high degree of vaccination. Healthcare workers (HCWs) are exposed to greater risks, in addition to HCWs who care for people with intellectual disabilities (ID). However, little is still known about these groups' vaccine hesitancy. This review aims to provide insight into the intentions and attitudes of HCWs on COVID-19 vaccination, including those who care for people with ID. The search included both types and was conducted in nine databases. A total of 26 papers were identified concerning the vaccine intentions of 43,199 HCWs worldwide. The data were gathered both quantitively and qualitatively. The papers were analysed for all of the themes regarding vaccine intentions, which were: (1) percentages of vaccine willingness; (2) predictors of willingness; (3) attitudes of willingness and hesitancy; (4) sources of vaccination information; (5) contextual factors and changes in COVID-19 vaccine acceptance over time; and (6) future strategies for interventions. Concerns about vaccine safety, efficacy and short- and long-term side effects were the most prominent in HCWs and, therefore, should be addressed in future intervention strategies. Furthermore, interactive interventions are recommended to facilitate exchange, and accurate information should be accessible to target groups on social media platforms.

Towards Understanding Behaviour and Emotions of Children with CLN3 Disease (Batten Disease): Patterns, Problems and Support for Child and Family.

The juvenile variant of Neuronal Ceroid Lipofuscinosis (CLN3 disease/Batten disease) is a rare progressive brain disease in children and young adults, characterized by vision loss, decline in cognitive and motor capacities and epilepsy. Children with CLN3 disease often show disturbed behaviour and emotions. The aim of this study is to gain a better understanding of the behaviour and emotions of children with CLN3 disease and to examine the support that the children and their parents are receiving. A combination of qualitative and quantitative analysis was used to analyse patient files and parent interviews. Using a framework analysis approach a codebook was developed, the sources were coded and the data were analysed. The analysis resulted in overviews of (1) typical behaviour and emotions of children as a consequence of CLN3 disease, (2) the support children with CLN3 disease receive, (3) the support parents of these children receive, and (4) the problems these parents face. For a few children their visual, physical or cognitive deterioration was found to lead to specific emotions and behaviour. The quantitative analysis showed that anxiety was reported for all children. The presented overviews on support contain tacit knowledge of health care professionals that has been made explicit by this study. The overviews may provide a lead to adaptable support-modules for children with CLN3 disease and their parents.

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.

Implications of COVID-19 Regulations for People With Visual and Intellectual Disabilities: Lessons to Learn From Visiting Restrictions.

Background: Due to the COVID-19 pandemic, governments of many countries announced regulations to prevent the virus from spreading. For people with a disability living in a sheltered care facility in the Netherlands, this meant that they were not able to receive any visitors for almost 3 months. Aim: This study examines how people with an intellectual and visual disability and their families experienced the period in which it was mandated not to have any physical contact. The aim is to examine the experiences of this target group and gain insight in the way measures were taken in order to be able to advise care organizations about adequate care with respect to possible restrictive measures in the future. Methods: In-depth interviews were conducted with two groups of people: (1) fourteen people with an intellectual and visual disability, living in sheltered care facilities and (2) twelve people being relatives of residents of these same sheltered care facilities. In the interviews, the participants were questioned about their experiences with respect to the adjusted visiting regulations and with respect to the relation with their family during this period. A thematic analysis was performed first separately and then combined. Results and Discussion: A number of themes resulted from the analysis that were related to (1) the instructed regulations of the sheltered care facilities and the government; (2) the relation with family and friends; and (3) the consequences of COVID-19 and the regulations. Both relatives and residents were understanding of the difficult situation, but also expressed criticism about the chosen regulations, the communication thereof, and the practical implementation. Both groups have experienced the interruption of close contact as emotional and difficult. However, also positive consequences of the restrictions due to COVID-19 were mentioned. The results provide a list of recommendations for sheltered care facilities.

An Exploratory Study among Intellectual Disability Physicians on the Care and Coercion Act and the Use of Psychotropic Drugs for Challenging Behaviour.

The new Dutch Care and Coercion Act aims to better regulate the use of psychotropic drugs for challenging behaviour in people with an intellectual disability. This study explores experiences of intellectual disability physicians (IDPs) in prescribing psychotropic drugs and investigates how the Act and the new multidisciplinary guideline on challenging behaviour affects their practice. A qualitative study was conducted, consisting of nine semi-structured in-depth interviews with IDPs, followed by a thematic analysis. It was found that IDPs experienced the new Act and guideline as supportive of their work as guardians of the appropriate use of psychotropic drugs. The multidisciplinary character of the guideline was experienced positively. However, IDPs are faced with organisational barriers and time constraints, as such, they question the feasibility of implementing the Act. Based on these findings, it can be concluded that the Care and Coercion Act may support the existing shift towards the appropriate use of psychotropic drugs if required conditions can be met.

Identifying when children with visual impairment share attention: A novel protocol and the impact of visual acuity.

BACKGROUND: In Coordinated Joint Engagement (CJE), children acknowledge that they and their social partners are paying attention to the same object. The achievement of CJE, critical for healthy development, is at risk in infants with visual impairment (VI). Research on CJE in these children is limited because investigators use a child's gaze switch between social partner and object to index CJE. Research is needed that identifies CJE in children with VI using behaviors that do not require normal vision and that explores the relationship between CJE and visual function. This study aimed to (a) develop a protocol for identifying CJE in children with VI, and (b) explore the relationship between CJE and infants' visual acuity (VA) and contrast sensitivity (CS), measured with Preferential Looking (PL) techniques and Visual Evoked Potential (VEP). METHODS: A protocol that included 9 indices of CJE that did not require normal vision was developed to code videos of 20 infants with VI (mean age =1 year, 6 months, 27 days) and their caregivers. The percentage of CJE episodes in which each index was observed was calculated. Inter-coder reliability was measured using Cohen's Kappa. Linear regression analysis was used to examine the relationship between the infants' visual function and CJE. RESULTS: Inter-rater reliability between a first coder and each of two second coders were 0.98 and 0.90 for determining whether the child participated in CJE. The following indices were observed the most (in 43-62 % of CJE): child's body orientation to caregiver, gaze switch between caregiver and object, and vocalization to caregiver. The only significant model included VA (measured with PL) as a single predictor and explained 26.8 % of the variance in CJE. CONCLUSIONS: The novel protocol can be used to identify CJE in children with VI with good inter-coder reliability. The data suggest that children with lower VA exhibited less CJE.

Robot-mediated therapy to reduce worrying in persons with visual and intellectual disabilities.

BACKGROUND: The study explored the use of a robot-mediated therapeutic intervention in persons with visual and intellectual disabilities. METHOD: Three robot-mediated intervention sessions were developed to teach three coping skills for worrying. Effectiveness was examined using a multiple-baseline case study design (N = 7). Baseline, pre-intervention and post-intervention assessments included social validity, severity of worrying (PSWQ-C-NL), and observations by caregivers (SDQ). Short checklists on worrying were repeated throughout baseline and intervention stages. Transcripts of the sessions were analysed for participants' emotional openness. RESULTS: Social validity was equally high before and after the intervention. The intervention did not impact the severity of worrying, although mentor caregivers reported a lower impact of personal difficulties for participants. We found no change in self-disclosure towards the robot over sessions. CONCLUSIONS: The participants' positive responses warrant further exploration of using robot-mediated therapy for persons with visual and intellectual disabilities. Recommendations for additional adaptations are discussed.

Effectiveness of the serious game 'You & I' in changing mentalizing abilities of adults with mild to borderline intellectual disabilities: a parallel superiority randomized controlled trial.

BACKGROUND: Persons with mild to borderline intellectual disabilities generally show dysfunctions in mentalization and stress regulation, resulting in problematic social relationships and personal distress. Intervention programs may improve mentalizing abilities. The aim of this study is to examine the effectiveness of the serious game 'You & I' in changing mentalizing abilities and stress regulation in adults with mild to borderline intellectual disabilities. METHODS: A two-arm, parallel, superiority randomized controlled trial will be used with 172 adults with mild to borderline intellectual disabilities. Participants will be randomly assigned to either the experimental group to play the serious game 'You & I' or a waitlist control group. Participants will be assessed at baseline, post intervention (5 weeks after baseline), and follow-up (6-8 weeks after post intervention). They also will fill in questionnaires for personal factors, personal development, personal well-being, social validity, autism spectrum quotient (demographic variables), mentalizing abilities (primary outcome measure), and stress regulation (secondary outcome measure). DISCUSSION: The serious game 'You & I' aims to improve mentalizing abilities in adults with mild to borderline intellectual disabilities, which is expected to lead to improved regulation of stress in social relationships. The study's unique feature is the use of a serious game to improve mentalizing abilities. If the intervention is effective, the serious game can be implemented on a broad scale in Dutch care organizations for people with intellectual disabilities as an effective preventive tool to improve mentalizing abilities. TRIAL REGISTRATION: Netherlands Trial Register, NTR7418 . Registered on 2 August 2018.

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.

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.

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).

Attachment, intellectual disabilities and mental health: research, assessment and intervention.

BACKGROUND: Attachment theory is highly influential in child and adult mental health research and practice. Research and practice have started now to explore the potential value of an attachment perspective for understanding and alleviating the challenges that persons with intellectual disabilities face in mental health and social participation. MATERIALS AND METHODS: Research on attachment and intellectual disabilities is reviewed on its importance for knowledge, assessment and intervention. RESULTS: Progress was found in understanding and distinguishing attachment behaviours, attachment relationships, attachment representations, attachment styles and attachment disorders and their respective implications for assessment and intervention. CONCLUSIONS: Of the various attachment-related concepts, insights into attachment behaviours and relationships showed the most promise for practical applications in the field of intellectual disabilities. Findings on representations, styles and disorders were inconclusive or preliminary. Attachment-informed research and practice can be part of emerging developmental understanding of functioning with intellectual disabilities.

Children with disrupted attachment histories: interventions and psychophysiological indices of effects.

Diagnosis and treatment of children affected by disruptions of attachment (out of home placement, multiple changes of primary caregiver) is an area of considerable controversy. The possible contribution of psychobiological theories is discussed in three parts. The first part relates the attachment theoretical perspective to major psychobiological theories on the developmental associations of parent-child relationships and emotional response. The second part reviews studies of autonomic reactivity and HPA-axis activity with foster children, showing that foster children show more reactivity within physiological systems facilitating fight or flight behaviours rather than social engagement, especially foster children with atypical attachment behaviour. The third part is focused on treatment of children suffering from the consequences of disrupted attachment, based on a psychotherapy study with psychophysiological outcome measures. Implications are discussed for theory, diagnosis, and intervention.