A systematic review of callous-unemotional traits and attachment in children and adolescents.

METHODS: The systematic review and meta-analysis included 17 research articles from 1994 to 2022. Results were summarized by developmental periods. RESULTS: Attachment insecurity was associated with CU traits across development (r = .17). This association was marginally stronger for high-risk samples (e.g., clinical, justice) and for continuous attachment measures versus coding schemes. From early to middle childhood, attachment disorganization was associated with CU traits (r = .17). IMPLICATIONS: Research on attachment and CU traits in childhood is still in its infancy. Changes in attachment measures from childhood to adolescence make developmental comparisons difficult. Results suggest attachment as a potential developmental mechanism for youth with CU traits, however, the area requires more research.

Parent-Youth Attachment Insecurity and Informant Discrepancies of Intrafamilial Aggression.

This study investigated how youth attachment anxiety and avoidance are associated with informant discrepancies of intrafamilial aggression within families where youth have clinically significant mental health challenges (N = 510 youth-parent dyads). Using polynomial regressions, we tested whether youth attachment avoidance and anxiety moderated the absolute magnitude of the association between youth- and parent-reports of aggression toward each other. Furthermore, difference scores were computed to test whether youth attachment was associated with the direction of youths' reports of the frequency of aggression relative to parents (i.e., did youth under- or over-report). Dyads' reports of youth-to-parent aggression were more strongly related at high than low levels of attachment anxiety. Results also revealed that youth attachment anxiety was associated with youth over-reporting of youth-to-parent and parent-to-youth aggression (relative to parents), whereas attachment avoidance was associated with youth over-reporting parent-to-youth aggression (relative to parents). These findings highlight the importance of understanding the source of informant discrepancies in social-emotional development and family functioning.

Psychometric Evaluation of the Affect Regulation Checklist: Clinical and Community Samples, Parent-Reports and Youth Self-Reports.

The Affect Regulation Checklist (ARC) was designed to capture affect dysregulation, suppression, and reflection. Importantly, affect dysregulation has been established as a transdiagnostic mechanism underpinning many forms of psychopathology. We tested the ARC psychometric properties across clinical and community samples and through both parent-report and youth self-report information. Clinical sample: Participants included parents (n = 814; Mage = 43.86) and their child (n = 608; Mage = 13.98). Community sample: Participants included independent samples of parents (n = 578; Mage = 45.12) and youth (n = 809; Mage = 15.67). Exploratory structural equation modeling supported a three-factor structure across samples and informants. Dysregulation was positively associated with all forms of psychopathology. In general, suppression was positively associated with many forms of psychopathology, and reflection was negatively associated with externalizing problems and positively associated with internalizing problems.

eConnect: implementation and preliminary evaluation of a virtually delivered attachment-based parenting intervention during COVID-19.

Connect, an attachment-based and trauma-informed parenting group intervention, has been demonstrated to improve adolescent mental health, parental wellbeing, and family functioning. We report on the online adaptation and delivery of Connect (eConnect) and pre-post treatment changes in parent, family and youth functioning in a clinical sample (N= 190) of parents of youth with serious mental health challenges. Consistent with research evaluating in-person Connect, parents reported significant reductions in youth internalizing and externalizing problems, attachment anxiety and avoidance, and aggression toward parents. Parents also reported significant reductions in caregiver strain and aggression toward their child. Unlike prior research, parent depressed mood did not decline, perhaps due to pandemic stressors. Program completion was remarkably high (84.7%), and parents reported high program satisfaction. Uptake by eConnect program facilitators and host agencies was extremely positive, suggesting good potential for sustainability and broadened program accessibility. Randomized clinical trials and implementation within diverse populations are needed.

Patterns and Predictors of Different Youth Responses to Attachment-Based Parent Intervention.

OBJECTIVE: Few studies have evaluated attachment-based parent interventions for pre-teens and teens, and in particular, differential adolescent trajectories of response. This study examined distinct patterns, and multi-level predictors, of intervention response among youth with serious behavioral and mental health problems whose parents participated in Connect, an attachment- and trauma-informed parent program. METHOD: Participants included 682 parents (Mage = 42.83, 86% mothers) and 487 youth (Mage = 13.95, 53% female, 28.1% ethnic minority) enrolled in a community-based evaluation of Connect. Parents and youth reported on youth externalizing and internalizing problems (EXT and INT) at six time points from baseline through 18-months post-intervention. Demographic and youth and family level predictors were assessed at baseline. RESULTS: Growth mixture modeling revealed three distinct trajectory classes in both the parent and youth models based on different patterns of co-occurring EXT and INT and degree of improvement over time. Youth with severe EXT showed the largest and fastest improvement, and, interestingly, were characterized by higher callous-unemotional traits and risk-taking at program entry. Youth with comorbid EXT/INT demonstrated a partial or moderate response to intervention in the parent and youth model, respectively, and were characterized by more attachment anxiety at baseline. Most youth showed relatively moderate/low levels of EXT/INT at baseline which gradually improved. Caregiver strain also predicted trajectory classes. CONCLUSIONS: These results have significance for tailoring and personalizing interventions for high-risk youth and provide new understanding regarding the profiles of subgroups of youth who show different responses to an attachment-based parent intervention.

Attachment goes to court: child protection and custody issues.

Attachment theory and research are drawn upon in many applied settings, including family courts, but misunderstandings are widespread and sometimes result in misapplications. The aim of this consensus statement is, therefore, to enhance understanding, counter misinformation, and steer family-court utilisation of attachment theory in a supportive, evidence-based direction, especially with regard to child protection and child custody decision-making. The article is divided into two parts. In the first, we address problems related to the use of attachment theory and research in family courts, and discuss reasons for these problems. To this end, we examine family court applications of attachment theory in the current context of the best-interest-of-the-child standard, discuss misunderstandings regarding attachment theory, and identify factors that have hindered accurate implementation. In the second part, we provide recommendations for the application of attachment theory and research. To this end, we set out three attachment principles: the child's need for familiar, non-abusive caregivers; the value of continuity of good-enough care; and the benefits of networks of attachment relationships. We also discuss the suitability of assessments of attachment quality and caregiving behaviour to inform family court decision-making. We conclude that assessments of caregiver behaviour should take center stage. Although there is dissensus among us regarding the use of assessments of attachment quality to inform child custody and child-protection decisions, such assessments are currently most suitable for targeting and directing supportive interventions. Finally, we provide directions to guide future interdisciplinary research collaboration.

Parent Emotion Regulation, Mindful Parenting, and Youth Attachment: Direct and Indirect Associations with Internalizing and Externalizing Problems.

The direct associations between two dimensions of parent emotion regulation within the parent-youth relationship (dysregulation; suppression), mindful parenting, and youth internalizing and externalizing problems were examined among 759 parents of youth with significant behavioural or emotional problems. The indirect associations of parent emotion regulation and mindful parenting with youth functioning through youth attachment anxiety and avoidance were also investigated. Parent dysregulation was associated with internalizing symptoms both directly and through attachment anxiety, and with externalizing symptoms directly and through attachment anxiety and avoidance. Parent suppression was associated with internalizing symptoms through attachment anxiety, and with externalizing symptoms through attachment anxiety and avoidance. Mindful parenting was associated with lower internalizing symptoms through attachment anxiety and with lower externalizing symptoms through attachment anxiety and avoidance. Emotion regulation within parent-child relationships and mindful parenting may be critical components of parenting programs aimed at promoting youth attachment security and mental health.

Effect of a parenting intervention on decreasing adolescents' behavioral problems via reduction in attachment insecurity: A longitudinal, multicenter, randomized controlled trial.

INTRODUCTION: Secure attachment in adolescence, related to caregiving quality, is a robust predictor of positive behavioral adjustment in early adulthood and beyond. Nevertheless, few attempts have been made to develop treatments to promote parent-adolescent attachment security. METHODS: Using a longitudinal, multicenter, randomized controlled trial design, two questionnaire-based studies were run in Italy (Study 1: n = 100 mothers of adolescents, 60% boys, Mage = 14.89, SD = 1.58; Study 2: n = 40 mothers and 40 adolescents, 60% boys, Mage = 14.90, SD = 1.91) to test the effectiveness of an attachment-based parenting intervention (i.e., Connect) in reducing adolescents' behavioral problems and attachment insecurity 2 weeks post-intervention (t2) and at a 4-month follow-up (t3). It was further investigated whether a decrease in avoidant and anxious attachment at t2 would account for changes in externalizing and internalizing problems, respectively, at t3. All adolescents belonged to two-parent intact families. RESULTS: Mothers who completed Connect reported significantly fewer adolescent behavioral problems and lower adolescent attachment insecurity, compared to mothers in the waitlist group, at both t2 and t3 (Study 1). These findings were confirmed in a second subsample (Study 2), considering both mothers' and adolescents' reports. Controlling for pre-intervention behavioral problems, reductions in internalizing and externalizing problems were observed in both studies at t3 via a decrease in anxious and avoidant attachment, respectively, at t2. CONCLUSIONS: The findings point to the malleability of attachment security in adolescence and highlight the importance of targeting parenting quality to promote adolescent behavioral adjustment.

The Mediational Effect of Affect Dysregulation on the Association Between Attachment to Parents and Oppositional Defiant Disorder Symptoms in Adolescents.

Oppositional defiant disorder (ODD) is a childhood disorder, commonly occurring in early school aged children with some symptoms becoming normative in adolescence (e.g., irritability, disagreeing). Affect dysregulation is a risk factor in the development of ODD. Affect regulation is nurtured within parent-child relationships, thus disruptions to attachment may derail children's capacity to develop adaptive affect regulation, increasing the risk for ODD. Using a high-risk sample of adolescents, we investigated the association between attachment anxiety and attachment avoidance with ODD through affect dysregulation. Attachment anxiety, but not avoidance, was associated with affect dysregulation and ODD. Affect dysregulation was found to fully mediate the relationship between attachment anxiety and ODD concurrently and prospectively. Similar findings have been demonstrated among children; results show that attachment anxiety, and its effects on affect dysregulation, are associated with ODD symptoms well into adolescence.

Profiles of primary and secondary callous-unemotional features in youth: The role of emotion regulation.

There is increasing evidence for multiple pathways in the development of callous-unemotional (CU) features, including primary and secondary profiles. Understanding affect regulation strategies among variants may provide further insight to the development and treatment of CU features. This study evaluated whether profiles of CU features could be identified within a clinical sample of youth using measures of affect dysregulation, affect suppression, anxiety, and maltreatment. We also examined whether these profiles were consistent across gender. Participants (N = 418; 56.7% female) ranged in age from 12 to 19 years (M = 15.04, SD = 1.85) and were drawn from a clinical sample. Latent profile analysis (LPA) was conducted using five indicators, including affect regulation, suppression, anxiety, CU features, and maltreatment. The best fitting model, a four-profile solution, included a low (low CU/dysregulation), anxious (low CU/high dysregulation), primary CU (high CU/low dysregulation), and secondary CU profile (high CU/dysregulation/maltreatment). LPAs found the same four-profile model when conducted separately for males and females. This is the first study to examine gender and include affect regulation strategies in the examination of primary and secondary profiles of CU.

An attachment-based intervention for parents of adolescents at risk: mechanisms of change.

Mechanisms that account for treatment effects are poorly understood. The current study examined processes that may underlie treatment outcomes of an attachment-based intervention (Connect) for parents of pre-teens and teens with serious behavior problems. Parents (N = 540) in a non-randomized trial reported on their teen's functioning prior to and following treatment. Results confirmed significant decreases in parents' reports of teens' externalizing and internalizing symptoms, replicating prior evaluations of this program. Reductions in parents' reports of teen attachment avoidance were associated with decreases in externalizing symptoms, while reductions in parents' reports of teen attachment anxiety were associated with decreases in internalizing symptoms. Parents' reports of improved teen affect regulation were also associated with decreases in both internalizing and externalizing symptoms. Results were comparable across gender and for parents of teens with pre-treatment externalizing symptoms in the clinical versus sub-clinical range. A model of therapeutic change in attachment-based parenting programs is discussed.

"It opened a new door for me": A qualitative study of forcibly displaced parents' experiences of an attachment-based parenting program.

The aim of the study was to explore forcibly displaced parents' experiences of how an online attachment-based parenting program (eConnect) impacted their relationships with their teens. Data was collected from four focus group discussions with 28 parents who participated in the eConnect program. Data was analyzed using network thematic analysis. A global theme emerged from the analysis: Strengthened Parent-Teen Relationships. Four underpinning organizing themes described the process through which the parent-teen relationship was strengthened: Knowledge Served as the Foundation for Change, Increased Parental Self-Efficacy, Improved Emotional Attunement Facilitates Dyadic Affect Regulation, and Shifted Power Dynamics and Emerging Mutual Parent-Teen Partnership. Findings suggest that eConnect is promising intervention for strengthening parent-teen relationships and supporting forcibly displaced families.

Network Structure of Callous-Unemotional Traits and Conduct Disorder Symptoms Among At-Risk Youth: Multi-Informant Reports and Gender Differences.

Network analytic techniques examine how items used to measure underlying constructs are related to one another and identify core characteristics. While many studies have examined the covariance of callous-unemotional (CU) traits or features and conduct disorder (CD) symptoms, the inter-item relations of these constructs and the core characteristics of the CU construct are unclear. The present study aimed to examine the network connectivity of, and between, CU features and CD symptoms. We also examined both parent-reports and youth self-reports and gender differences. CU features and CD symptoms were rated by parents (n = 814; 74% mothers; age 23-73, M age = 43.86, SD = 8.13) and their child (n = 608; 57% female; age 7-19, M age = 13.98, SD = 2.36). Network plots depicted greater connectivity (i.e., density and weights) for CU features relative to CD symptoms across both informants. However, youth-reported CU features and CD symptoms were less densely connected than parent-reports. Items commonly comprising the callousness subscale were more central and linked the two constructs together, relative to uncaring items, across informant and gender. Gender related effects indicated lower centrality for male versus female youth, and this finding was particularly evident in youth-reports. Our findings highlight relations between CU features and CD symptoms, and point to the importance of callousness items in conceptualizations of CU features among high-risk youth from both the perspective of the parent and child. We also inform understanding of gender differences in CU features for which the literature is currently limited.

Transforming Connections: A Trauma-Informed and Attachment-Based Program to Promote Sensitive Parenting of Trans and Gender Non-conforming Youth.

Gender non-conforming and trans youth experience high rates of bullying and victimization, placing them at risk for serious mental health challenges. Parent support is one of the most significant protective factors in this population, and yet few programs are specifically developed to promote parenting sensitivity, understanding, and acceptance. Connect, a trauma-informed and attachment-based group program for caregivers of at-risk adolescents, has been shown to reduce parent stress and depressed mood, increase parents' sense of efficacy and satisfaction, and reduce parent-teen conflict. Teens benefit from increased attachment security and improved mental health and well-being. Treatment effects have been documented to continue for up to 2 years post-treatment. This paper describes the adaptation of the Connect program to create a new program, Transforming Connections, for caregivers of transgender and gender non-conforming youth. Participants in the first three groups were 20 parents of 16 gender non-conforming youth (ages 12-18). Common themes in group discussions related to gender included: coming out, connecting with peers, affirming pronouns/names, medical transition, parental reactions (e.g., confusion, isolation, grief, acceptance), and concerns about safety and mental health. All parents completed the full program, attending on average 9 of 10 sessions. Caregivers reported feeling respected, safe, and welcomed in the program and indicated that learning about attachment enhanced their understanding of their teen and their gender journey as well as themselves as a parent. Additionally, all parents reported applying the ideas discussed in the group frequently (60%) or somewhat frequently (40%). The majority indicated that their relationship with their teen had improved somewhat (65%) or a great deal (20%). Findings provide positive preliminary evidence of the fit and value of Transforming Connections for these families.

Pilot randomized controlled trial of an attachment- and trauma-focused intervention for kinship caregivers.

BACKGROUND: Kinship care placements are increasing in many Western countries, however families in kinship care are underserved partly due to the lack of evidence-based interventions addressing their unique needs. OBJECTIVE: We conducted a pilot randomized controlled trial (RCT) to examine research feasibility and the acceptability, fidelity, and preliminary outcomes of an attachment- and trauma-focused intervention for kinship caregivers in Australia. PARTICIPANTS AND SETTING: Participants included 26 kinship caregivers (Mage = 55.00 years; 54% grandparents) with youth (Mage = 10.58 years; 38% female), and 19 practitioners from child protection, out-of-home care and other services. METHOD: Kinship caregivers were randomized to Connect for Kinship Parents (Connect-KP) or care-as-usual (CAU), and completed assessments at baseline, post-intervention, and 6-month follow-up. Placement changes were evaluated at 6-month follow-up. A subset of practitioners received both training and supervision in implementing Connect-KP, and their videorecorded sessions were coded for fidelity. RESULTS: Practitioners rated the training highly and demonstrated excellent fidelity to program content and process. Results supported the research feasibility and all kinship caregivers reported high levels of program satisfaction and had very high attendance and completion rates. Direction of effects favored Connect-KP vs. CAU for all nine caregiver and youth outcomes, with the largest effects observed for significant reductions in caregiver strain, caregiver psychological aggression, and youth affect suppression following intervention. At 6-month follow-up, more youth from CAU (15%) vs. Connect-KP (0%) experienced an unplanned placement change. CONCLUSIONS: Our findings show promise of Connect-KP as a potentially effective intervention that can be successfully implemented in child welfare services, and provide impetus for a larger-scale RCT.

Gender differences in risk factors for violence: an examination of the predictive validity of the Structured Assessment of Violence Risk in Youth.

The research literature on predicting violence is particularly lacking in specifying risk factors for violence in adolescent girls. The recently developed Structured Assessment of Violence Risk in Youth [SAVRY; Borum et al., 2006] shows promise as it is empirically derived and incorporates dynamic factors in its assessment of risk. To date, there exists little information attesting to the reliability and validity of the SAVRY, and few investigations of the SAVRY's utility across gender. This study investigated the SAVRY in a sample of 144 high-risk adolescents (80 males and 64 females), focusing on gender discrepancies in the predictive utility of the measure. Results indicate that the SAVRY moderately predicts violent and non-violent reoffending in the entire sample, and also suggest that the SAVRY operates comparably across gender. Although not precluding the existence of gender-specific domains of risk, current results suggest that validated risk factors in boys hold relevance for the prediction of violence and delinquency in girls.

Short-term stability of psychopathic traits in adolescent offenders.

There is considerable debate about the assessment of psychopathic traits in adolescence due in part to questions regarding the stability of traits. We investigated the 6-month stability of psychopathic traits in a sample of 83 male adolescent offenders using an augmented protocol for the Psychopathy Checklist: Youth Version and the self-report Antisocial Process Screening Device. Findings suggested moderate to high stability of psychopathic traits, as indexed by total scores, and low to moderate stability of psychopathic traits at the factor level. The interpersonal and behavioral traits demonstrated greater stability relative to the affective traits, and stability varied by developmental stage, with lower stability in early adolescence. Implications for understanding the developmental expression of psychopathic traits in adolescence, as well as for clinical-forensic practice, are discussed.

Effectiveness of an attachment-focused manualized intervention for parents of teens at risk for aggressive behaviour: The Connect Program.

Aggressive, violent and antisocial behaviour in children and adolescents is a growing concern across the globe. Targeting parent-teen relationships is critical in reducing problem behaviour. 'Connect' is a manualized ten-week program for parents or alternative caregivers of at-risk teens that focuses on the building blocks of secure attachment: parental sensitivity, cooperation, reflective capacity, and effective dyadic affect regulation. Through didactic and experiential activities, parents develop the competence necessary to identify, understand and respond to the needs of their teen in a manner that provides structure and safety while safeguarding the quality of the parent-teen relationship. In Study 1, twenty parents reported significant increases in perceived parenting satisfaction and efficacy and reductions in adolescents' aggression, antisocial behaviour and other mental health problems following completion of Connect as compared to a waitlist control period. These effects were sustained and additional small effects were noted in decreases in conduct problems, depression and anxiety at a 12-month follow-up. The program was then transported to 17 communities serving 309 parents through standardized training and supervision of group leaders. Study 2 summarizes significant pre- to post-treatment reductions in teen externalizing and internalizing problems; enhanced social functioning; and improvements in affect regulation. Parents also reported significant increases in parenting satisfaction and perceived efficacy and reductions in caregiver burden.

Maltreatment, attachment, and substance use in adolescence: Direct and indirect pathways.

Past research indicates that maltreatment increases risk for adolescent substance use; however, research is limited on how attachment between adolescents and their parents influences this relationship. The present study examined psychological and physical maltreatment, attachment avoidance and attachment anxiety, and substance use (i.e., cigarettes, alcohol, marijuana, and 'other drugs') among adolescents between the ages of 12 and 18 (N = 737; 59.3% female; Mage = 14.69, SD = 1.46). Psychological maltreatment was significantly related to cigarettes, alcohol, and marijuana use, and physical maltreatment was related to cigarette and marijuana use. Exposure to both forms of maltreatment was also associated with increased attachment avoidance and attachment anxiety, but only attachment avoidance predicted substance use. Indirect paths indicated that attachment avoidance mediated the relationship between psychological maltreatment and cigarette (B = 0.14, CI [0.001, 0.314]) and alcohol use (B = 0.09, CI [0.011, 0.188]). Attachment avoidance also mediated the relationship between physical maltreatment and cigarette (B = 0.15, CI [0.031, 0.311]) and alcohol use (B = 0.09, CI [0.027, 0.185]). No significant mediated effects for attachment anxiety emerged. Attachment avoidance may increase risk for substance use because youth have a lower rate of disclosing their activities to their parents, and do not seek or accept their guidance. Instead, they may turn to peers who also engage in substance use as a source of support. Interventions designed to increase parent-teen attachment security and decrease attachment avoidance may be particularly useful in reducing risk for substance use.

Attachment insecurity accounts for the relationship between maternal and paternal maltreatment and adolescent health.

OBJECTIVES: Maltreatment is linked with poor health outcomes. Attachment and affect regulation may mitigate the long-term impact of these adverse experiences on health outcomes. Little is known about the relative impact of maternal versus paternal maltreatment and interparental violence (IPV) on general health status of female and male youth. METHOD: The present study examined the impact of exposure to maternal and paternal emotional and physical maltreatment, neglect, IPV, and cumulative maltreatment exposure in adolescence on general physical health problems reported five years later. High-risk youth (N = 179; Mage = 15.34, SD = 1.53; 46.4% female) self-reported maltreatment experiences, attachment insecurity, and affect dysregulation at Time 1; and affect dysregulation and physical health five years later at Time 2. RESULTS: Attachment insecurity accounted for the effect of maternal and paternal emotional maltreatment, and maternal and paternal cumulative maltreatment exposure, on physical health. Additionally, attachment insecurity accounted for the effect of paternal neglect on physical health. Further sex differences were found with regard to maltreatment type and are discussed. CONCLUSION: Both maternal and paternal maltreatment in adolescence predicted poor general health five years later via attachment insecurity. Youth who lack a secure attachment with their parents are most vulnerable to these impacts.