Executive function performance and trauma exposure in a community sample of children

ObjectiveThough children exposed to familial violence are reported to have difficulties with a range of emotional and behavioral problems (e.g., lower school achievement) that implicate executive function (EF) deficits, relatively little research has specifically examined EF as a function of trauma exposure in children.MethodsBased on parent report of children's exposure to potentially traumatic events, children (N = 110; Age_Mean = 10.39) from an ethnically diverse community sample were compared across three trauma-exposure groups: familial trauma, non-familial trauma, and no trauma. Children completed a battery of tests to assess working memory, behavioral inhibition, processing speed, auditory attention, and interference control.ResultsFamilial trauma (relative to non-familial and no trauma exposure) was associated with poorer performance on an EF composite (composed of working memory, inhibition, auditory attention, and processing speed tasks); the effect size was medium. Both trauma-exposure status and dissociation symptoms explained unique variance in EF performance after controlling for anxiety symptoms, socio-economic status, and potential traumatic brain injury. While IQ and EF performance were related, SES predicted unique variance in IQ (and not EF) scores, while familial-trauma exposure did not.ConclusionsThe contribution of trauma exposure to basic executive functioning held after taking into account symptoms (anxiety and dissociation), socio-economic status, and possible traumatic brain injury exposure. EF problems may provide one route via which maltreated children become at risk for peer, academic, and behavior problems relative to their peers.Practice implicationsEF problems may provide one route via which maltreated children become at risk for peer, academic, psychological, and behavior problems relative to their peers. Recently, intervention strategies have emerged in the anxiety and mood disorder treatment literatures that appear to effectively target EFs. As future research continues to specify the relationship between child trauma exposure and EF performance, these innovative treatments may have important practice implications for addressing EF deficits.     

Factors related to attrition from trauma-focused cognitive behavioral therapy

Attrition from child trauma-focused treatments such as Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is common; yet, the factors of children who prematurely terminate are unknown. The aim of the current study was to identify risk factors for attrition from TF-CBT. One hundred and twenty-two children (ages 3–18; M = 9.97, SD = 3.56; 67.2% females; 50.8% Caucasian) who received TF-CBT were included in the study. Demographic and family variables, characteristics of the trauma, and caregiver- and child-reported pretreatment symptoms levels were assessed in relation to two operational definitions of attrition: 1) clinician-rated dropout, and 2) whether the child received an adequate dose of treatment (i.e., 12 or more sessions). Several demographic factors, number of traumatic events, and children’s caregiver-rated pretreatment symptoms were related to clinician-rated dropout. Fewer factors were associated with the adequate dose definition. Child Protective Services involvement, complex trauma exposure, and child-reported pretreatment trauma symptoms were unrelated to either attrition definition. Demographics, trauma characteristics, and level of caregiver-reported symptoms may help to identify clients at risk for premature termination from TF-CBT. Clinical and research implications for different operational definitions and suggestions for future work will be presented.     

Adverse childhood experiences (ACE) and adult attachment interview (AAI) in a non-clinical population

Adverse childhood experiences (ACE) tend to be interrelated rather than independently occurring. There is a graded effect associated with ACE exposure and pathology, with an increase when ACE exposure is four or more. This study examined a sample of active individuals (n = 129) to determine distribution patterns and relationships between ACEs, attachment classification, unresolved mourning (U), and disclosure difficulty. The results of this study demonstrated a strong relationship between increased ACEs and greater unresolved mourning. Specifically, the group differences for individuals who experienced no ACE (n = 42, 33%), those with 1–3 ACEs (n = 48, 37.8%), and those with ≥4 ACEs (n = 37, 29.1%) revealed a pattern in which increased group ACE exposure was associated with greater lack of resolution for past trauma/loss experiences, more adult traumatic events, and more difficulty disclosing past trauma. Despite ≥4 ACEs, 51.4% of highly exposed individuals were classified as secure in the Adult Attachment Interview. Resilience in this group may be related to a combination of attachment security, college education, and engagement in meaningful activities. Likewise, adversity may actually encourage the cultivation of more social support, goal efficacy, and planning behaviors; factors that augment resilience to adversity.     

Do abused young children feel less pain?

The objective of this study was to investigate whether acute pain in abused children was under recognized by doctors and nurses compared to children evaluated for accidental injuries. We hypothesize that an abused child’s reaction to physical pain could be an additional symptom of this challenging diagnosis. For the observational prospective case control study in an emergency department, children were eligible when: younger than six years old, the reported trauma occurred within the previous seven days, the trauma comprised a bone injury or burn, and the child was able to express his or her pain. The case group comprised children for whom the medical team reported their abuse suspicions and supporting information to a court, and whose cases of abuse were subsequently confirmed. The control group consisted of children with a plausible cause for their injury and no obvious signs of abuse. The children were matched according to their age and type of trauma. The pain was assessed by doctors and nurses before analgesic administration using a certified pain scale.Among the 78 included children, pain was significantly less recognized in the abused children vs. the controls (relative risk = 0.63; 95% CI: 0.402–0.986; p = 0.04). We observed a discrepancy between the nurses’ and doctors’ scores for the pain assessments (Kappa coefficient = 0.59, 95% CI: 0.40–0.77). Our results demonstrate that pain expression in abused children is under recognized by medical staff. They also suggest that abused children may have reduced pain expression after a traumatic event. Paying particular attention to the pain of abused children may also optimize the analgesic treatment.     

The association of child abuse and neglect with adult disability in schizophrenia and the prominent role of physical neglect

ObjectiveTo assess long-lasting effects of childhood trauma on the functional outcome of adult patients diagnosed with schizophrenia.MethodNinety-nine stable patients with schizophrenia followed in an outpatient program at a public university hospital in Porto Alegre, southern Brazil, were investigated for childhood traumatic experiences by the Childhood Trauma Questionnaire (CTQ) and for functional impairment by the World Health Organization Disability Assessment Schedule (WHO/DAS). The schizophrenia diagnosis was assessed by ICD-10 and DSM-IV criteria according to the Operational Criteria Checklist for Psychotic Illness (OPCRIT).ResultsChildhood trauma in general was associated with increased disability in adulthood, reflected by impaired Overall Behavior (p = .023) and Global Evaluation (p = .032). Analysis of specific traumatic domains revealed that increased childhood physical neglect was associated with functional impairment in Overall Behavior (p < .000), Social Role Performance (p = .037) and Global Evaluation (p = .014). Higher emotional abuse was associated with impaired Overall Behavior (p = .026), and higher emotional neglect with poor Global Evaluation (p = .047). Additionally, earlier onset of illness was associated with lower level of functioning evidenced by impairment in Overall Behavior (p = .042). Linear regression using WHO/DAS sections (Overall Behavior, Social Role Performance and Global Evaluation) as dependent variables and CTQ subscales indicated that only physical neglect had an effect on adult functionality.ConclusionsChildhood trauma was associated with functional and social impairment in adult patients with schizophrenia. Specific types of abuse and neglect, such as physical neglect and emotional abuse and neglect, influenced disability, and the most robust association was physical neglect. Studies involving more patients, with normal controls and additional measurements of biological liability, should be conducted to confirm this association and to increase the understanding of gene-environment relationship in schizophrenia and pathways to disability.Practice implicationsFurther investigation is warranted to clarify the association between childhood trauma and disability in schizophrenia, as well as to develop standardized instruments for the assessment of trauma and earlier detection of risk along with education of patients and families about adequate care, in an effort to reduce the incidence of disability in schizophrenia.     

Narrative fragmentation in child sexual abuse: The role of age and post-traumatic stress disorder

The present study aimed to assess the effects of age and PTSD on the narrative fragmentation in memories for child sexual abuse. Lexical complexity, cohesion and coherence were analyzed within a group of 86 allegations of children (M = 10 years; SD = 3.7; range: 4–17) who were victims of sexual abuse. Results illustrated that age played an important role in establishing narrative coherence and predicted the level of orientation, the sequence of events and the level of evaluation of the event. Instead, PTSD was related to narrative coherence and cohesion. Therefore, in children, the narrative fragmentation could be an effective diagnostic tool for understanding the effects of PTSD. Moreover in a legal setting the traumatic effects of PTSD on the narrative coherence and cohesion could be significant indices in the evaluation of child testimony.     

Effects of childhood trauma exposure and cortisol levels on cognitive functioning among breast cancer survivors

Cognitive functioning difficultiesin breast cancer patients receiving chemotherapy are common, but not all women experience these impairments. Exposure to childhood trauma may impair cognitive functioning following chemotherapy, and these impairments may be mediated by dysregulation of hypothalamic-pituitary-adrenal (HPA) axis function and cortisol slope. This study evaluated the association between childhood trauma exposure, cortisol, and cognition in a sample of breast cancer survivors. 56 women completed measures of trauma exposure (the Traumatic Events Survey), salivary cortisol, and self-reported cognitive functioning (the Functional Assessment of Cancer Therapy – Cognitive). We examined correlations between childhood trauma exposure and cognitive functioning, then used linear regression to control for factors associated with cognition (age, education, time since chemotherapy, depression, anxiety, and insomnia), and the MacArthur approach to test whether cortisol levels mediated the relationship between trauma and cognitive functioning. 57.1% of the sample had experienced at least one traumatic event in childhood, with 19.6% of the sample witnessing a serious injury, 17.9% experiencing physical abuse, and 14.3% experiencing sexual abuse. Childhood trauma exposure and cognitive functioning were moderately associated (r = −0.29). This association remained even when controlling for other factors associated with cognition; the final model explained 47% of the variance in cognitive functioning. The association between childhood trauma and cognitive functioning was mediated by steeper cortisol slope (partial r = 0.35, p = 0.02). Childhood trauma exposure is associated with self-reported cognitive functioning among breast cancer survivors and is mediated by cortisol dysregulation. Trauma should be considered, among other factors, in programs aiming to address cognition in this population.     

Increased risk for mental illness,injuries, and violence in children born to mothers with intellectual disability: A register study in Sweden during 1999–2012

Several studies have demonstrated that mothers with intellectual disability (ID) have a higher prevalence of mental health illness, lower socio-economic status, and a higher risk of alcohol and drug use compared to mothers without ID. The children of mothers with ID are over-represented in child protection and legal proceedings but are generally a less studied group than the mothers. The aim of this study was to investigate if children born to mothers with ID had an increased risk of being diagnosed with mental illness, injuries, and violence compared with children of mothers without ID. The study comprised a population-based cohort of children born in Sweden between 1999 and 2005. Data were collected from the Medical Birth Register and linked with two other national registers; ICD-10 codes were used for medical diagnoses, including ID. The children were followed from birth to seven years of age. In total, 478,577 children were included, of whom 2749 were born to mothers with ID. Children of mothers with ID were at a greater risk of having mental health problems (adjusted odds ratio (OR) = 2.02; 95% confidence interval (CI) = 1.74–2.35) and ID (OR = 4.14; CI = 2.95–5.82) in early childhood. They had an increased risk for injuries due to falls (OR = 1.15; Cl 1.04–1.27). The largest risk related to trauma was violence and child abuse (OR = 3.11; CI = 1.89–5.12). In conclusion, children of mothers with ID had an increased risk for injuries, violence, and child abuse. We therefore suggest that parents with ID should receive evidence based support so that their children receive the best care and protection.     

Maltreatment in multiple-birth children

ObjectiveThe rate of multiple births has increased over the last two decades. In 1982, an increased frequency of injuries among this patient population was noted, but few studies have evaluated the increased incidence of maltreatment in twins. The study aim was to evaluate the features of all multiple-birth children with substantiated physical abuse and/or neglect over a four-year period at a major children's hospital.Study design and methodsA Retrospective chart review was conducted of multiple-gestation children in which at least one child in the multiple set experienced child maltreatment from January 2006 to December 2009. Data regarding the child, injuries, family, and perpetrators were abstracted. We evaluated whether family and child characteristics were associated with maltreatment, and whether types of injuries were similar within multiple sets. For comparison, data from the same time period for single-birth maltreated children also were abstracted, including child age, gestational age at birth, and injury type.ResultsThere were 19 sets of multiple births in which at least one child had abusive injuries and/or neglect. In 10 of 19 sets (53%), all multiples were found to have a form of maltreatment, and all children in these multiple sets shared at least one injury type. Parents lived together in 63% of cases. Fathers and mothers were the alleged perpetrator in 42% of the cases. Multiple-gestation-birth maltreated children were significantly more likely than single-birth maltreated children to have abdominal trauma (13% vs. 1%, respectively; p < .01), fractures (83% vs. 39%; p < .01), and to be injured at a younger mean age (12.8 months vs. 34.8 months; p < .01).ConclusionsSiblings of maltreated, multiple-gestation children often, but not always, were abused. In sets with two maltreated children, children usually shared the same modes of maltreatment. Multiples are significantly more likely than singletons to be younger and experience fractures and abdominal trauma. The findings support the current standard practice of evaluating all children in a multiple set when one is found to be abused or neglected.     

Trauma-related impairment in children—A survey in Sri Lankan provinces affected by armed conflict

ObjectivesThe present study examined traumatic experiences, PTSD, and co-morbid symptoms in relation to neuropsychological and school performance in school children affected by two decades of civil war and unrest.MethodThe epidemiological survey of children's mental health included a representative sample of 420 school children. Local teachers were trained to administer a translation of the UCLA-PTSD Index Form. The instrument and the epidemiological findings were validated by assessment through clinical expert interview, school grades, and neuropsychological testing in a subsample (N = 67).ResultsNinety-two percent of the children surveyed had experienced severely traumatizing events such as combat, bombing, shelling, or witnessing the death of a loved one. Twenty-five percent met the criteria for a diagnosis of PTSD. Traumatized children reported lasting interference of experiences with their daily life, which was corroborated by memory testing, scores in school performance and ratings of social withdrawal. Depressive symptoms and poor physical health were frequent in these children. The majority of trained teachers achieved valid results in the structured interviews.ConclusionPerformance and functioning in children are related to the total load of traumatic events experienced. An important component of psychosocial programs in post-conflict areas should include increasing community-based awareness of the consequences of traumatic stress, both as a preventative measure and as a way of decreasing stigmatization of affected individuals.     

Child maltreatment and trauma exposure among deaf and hard of hearing young adults

The purpose of the present study was to examine the prevalence of child maltreatment and lifetime exposure to other traumatic events in a sample of deaf and hard of hearing (DHH; n = 147) and matched hearing (H; n = 317) college students. Participants completed measures of child maltreatment (CM), adult victimization and trauma exposure, and current symptoms of posttraumatic stress disorder (PTSD). Overall, DHH participants reported significantly more instances of CM compared to H participants, with 76% of DHH reporting some type of childhood abuse or neglect. Additionally, DHH participants reported experiencing a higher number of different types of CM, and also reported increased incidents of lifetime trauma exposure and elevated PTSD symptoms. Severity of deafness increased the risk of maltreatment, with deaf participants reporting more instances of CM than hard of hearing participants, and hard of hearing participants reporting more instances of CM than H participants. Among DHH participants, having a deaf sibling was associated with reduced risk for victimization, and identification with the Deaf community was associated with fewer current symptoms of PTSD. A regression model including measures of childhood physical and sexual abuse significantly predicted adult re-victimization and accounted for 27% of the variance among DHH participants. DHH participants report significantly higher rates of CM, lifetime trauma, and PTSD symptoms compared to H participants. Severity of deafness appears to increase the risk of being victimized. Being part of the Deaf community and having access to others who are deaf appear to be important protective factors for psychological well-being among DHH individuals.     

Prior opportunities to identify abuse in children with abusive head trauma

Infants with minor abusive injuries are at risk for more serious abusive injury, including abusive head trauma (AHT). Our study objective was to determine if children with AHT had prior opportunities to detect abuse and to describe the opportunities. All AHT cases from 7/1/2009 to 12/31/2011 at four tertiary care children's hospitals were included. A prior opportunity was defined as prior evaluation by either a medical or child protective services (CPS) professional when the symptoms and/or referral could be consistent with abuse but the diagnosis was not made and/or an alternate explanation was given and accepted. Two-hundred-thirty-two children with AHT were identified; median age (IQR) was 5.40 (3.30, 14.60) months. Ten percent (22/232) died. Of the 232 patients diagnosed with AHT, 31% (n = 73) had a total of 120 prior opportunities. Fifty-nine children (25%) had at least one prior opportunity to identify abuse in a medical setting, representing 98 prior opportunities. An additional 14 (6%) children had 22 prior opportunities through previous CPS involvement. There were no differences between those with and without a prior opportunity based on age, gender, race, insurance, mortality, or institution. Children with prior opportunities in a medical setting were more likely to have chronic subdural hemorrhage (48 vs. 17%, p < 0.01) and healing fractures (31 vs. 19%, p = 0.05). The most common prior opportunities included vomiting 31.6% (38/120), prior CPS contact 20% (24/120), and bruising 11.7% (14/120). Improvements in earlier recognition of AHT and subsequent intervention might prevent additional injuries and reduce mortality.     

Is there a Complex Trauma Experience typology for Australians experiencing extreme social disadvantage and low housing stability?

Traumatic childhood experiences predict many adverse outcomes in adulthood including Complex-PTSD. Understanding complex trauma within socially disadvantaged populations has important implications for policy development and intervention implementation. This paper examined the nature of complex trauma experienced by disadvantaged individuals using a latent class analysis (LCA) approach. Data were collected through the large-scale Journeys Home Study (N = 1682), utilising a representative sample of individuals experiencing low housing stability. Data on adverse childhood experiences, adulthood interpersonal trauma and relevant covariates were collected through interviews at baseline (Wave 1). Latent class analysis (LCA) was conducted to identify distinct classes of childhood trauma history, which included physical assault, neglect, and sexual abuse. Multinomial logistic regression investigated childhood relevant factors associated with class membership such as biological relationship of primary carer at age 14 years and number of times in foster care. Of the total sample (N = 1682), 99% reported traumatic adverse childhood experiences. The most common included witnessing of violence, threat/experience of physical abuse, and sexual assault. LCA identified six distinct childhood trauma history classes including high violence and multiple traumas. Significant covariate differences between classes included: gender, biological relationship of primary carer at age 14 years, and time in foster care. Identification of six distinct childhood trauma history profiles suggests there might be unique treatment implications for individuals living in extreme social disadvantage. Further research is required to examine the relationship between these classes of experience, consequent impact on adulthood engagement, and future transitions though homelessness.     

Factors associated with re-entry to out-of-home care among children in England

Exiting and re-entering out-of-home care (OHC) is considered a disruption to permanence which may have long-lasting, negative consequences for children due to a lack of stability and continuity. Each year approximately one-third of children in OHC in England exit, but information is lacking on rates of re-entries and associated factors. Using national administrative data, we calculated rates of re-entry among children exiting OHC from 2007 to 2012, identified key child and care factors associated with re-entry using Cox proportional hazards modelling, and developed a simple probability calculator to estimate which groups of children are most likely to re-enter OHC within three months. Between 2007 and 2012 re-entries to OHC in England decreased (from 23.3% to 14.4% within one year of exit, p < 0.001), possibly due to concurrent changes in the way children exited OHC. Overall, more than one-third of children exiting OHC in 2008 re-entered within five years (35.3%, N = 4076), but rates of re-entry varied by child and care characteristics including age, ethnicity, mode of exit, and placement stability. Based on these associated factors, we developed a calculator that can estimate the likelihood of rapid re-entry to OHC for a group of children and could be used by social care practitioners or service planners. Our findings provide insight into which groups of children are most likely to re-enter OHC, who may benefit from additional support or ongoing monitoring.     

Organic vs. functional neurological disorders: The role of childhood psychological trauma

Although the relationship between psychological trauma and medically unexplained symptoms (MUS) is well established, this relationship is less well understood in people with medically unexplained neurological symptoms. In the present study, we set out to compare people with functional neurological disorders, and organic neurological disorders, in terms of childhood and adulthood traumatic events, traumatic stress, emotional dysregulation and symptoms of depression and anxiety. We have hypothesised that those with functional neurological disorders would be more likely to report childhood and adulthood traumatic life events, traumatic symptomatology, emotional dysregulation and symptoms of anxiety and depression, compared to those with organic neurological disorders. Sample consisted of a consecutive series of people with functional neurological disorders and with organic neurological disorders (n = 82) recruited from a hospital in Scotland. Participants completed measures of life events, traumatic stress, emotional regulation, anxiety and depression. The two groups were found to significantly differ in relation to all measures, with the MUS group being more likely to report childhood and adulthood life events, more severe emotional dysregulation, traumatic stress and symptoms of anxiety and stress. Logistic regression analysis revealed that exposure to childhood traumatic life events, specifically childhood sexual abuse, and childhood physical neglect, were the only factors which were significantly associated with membership of the medically unexplained neurological symptoms group. Although further research is required to confirm our findings, our results suggest that identifying and addressing the impact of childhood trauma, may alleviate distress and aid recovery from functional neurological disorders.     

Relational trauma in the context of intimate partner violence

The relational model of trauma (Scheeringa & Zeanah, 2001) proposes that infants’ trauma symptoms may be influenced by their mothers' trauma symptoms and disruptions in caregiving behavior, although the mechanisms by which this occurs are less well understood. In this research, we examined the direct and indirect effects of a traumatic event (maternal intimate partner violence [IPV]), maternal trauma symptoms, and impaired (harsh and neglectful) parenting on infant trauma symptoms in a sample of mother–infant dyads (N = 182) using structural equation modeling. Mothers completed questionnaires on IPV experienced during pregnancy and the child's first year of life, their past-month trauma symptoms, their child's past-month trauma symptoms, and their parenting behaviors. Results indicated that the effects of prenatal IPV on infant trauma symptoms were partially mediated by maternal trauma symptoms, and the relationship between maternal and infant trauma symptoms was fully mediated by neglectful parenting. Postnatal IPV did not affect maternal or infant trauma symptoms. Findings support the application of the relational model to IPV-exposed mother–infant dyads, with regard to IPV experienced during pregnancy, and help identify potential foci of intervention for professionals working with mothers and children.     

Language skills,mathematical thinking,and achievement motivation in children with ADHD,disruptive behavior disorders,and normal controls

Recent models of attention deficit/hyperactivity disorder (ADHD) suggest that the association between achievement motivation and school performance may be stronger in children with ADHD than in typically developing children. Therefore, the present study investigated associations between achievement motivation and performance on language skills and mathematical thinking in children with ADHD (n = 23; M = 9.4 years, SD = 1.1 years; 78% boys) and two matched control groups, i.e., a clinical control group (children with related disruptive behavior disorders; DBD), and a non-clinical control group (NC). Results confirmed stronger associations between achievement motivation and performance on receptive language and mathematical thinking in children with ADHD than in NC. Specifically, performance of children with ADHD was equal to NC for highly motivated ADHD children. These results underscore the importance of achievement motivation as a more essential key factor in the performance of children with ADHD as compared to typically developing children.     

The role of callous/unemotional traits in mediating the association between animal abuse exposure and behavior problems among children exposed to intimate partner violence

Children exposed to intimate partner violence are at increased risk for concomitant exposure to maltreatment of companion animals. There is emerging evidence that childhood exposure to maltreatment of companion animals is associated with psychopathology in childhood and adulthood. However, few studies have explored developmental factors that might help to explain pathways from animal maltreatment exposure to children’s maladjustment. The present study addresses this gap in the literature by examining relations between children’s exposure to animal maltreatment, callous/unemotional traits (i.e., callousness, uncaring traits, and unemotional traits), and externalizing and internalizing behavior problems. A sample of 291 ethnically diverse children (55% Latino or Hispanic) between the ages of 7 and 12 was recruited from community-based domestic violence services. A meditational path model indicated that child exposure to animal maltreatment was associated with callousness (β = 0.14), which in turn was associated with greater internalizing (β = 0.32) and externalizing problems (β = 0.47). The effect of animal maltreatment exposure on externalizing problems was mediated through callousness. Results suggest that callous/unemotional traits are a potential mechanism through which childhood exposure to animal maltreatment influences subsequent behavior problems. Future research is needed to evaluate the extent to which exposure to animal maltreatment affects children’s adjustment over time in the context of other co-occurring adverse childhood experiences.     

Child welfare outcomes for youth in care as a result of parental death or parental incarceration

Every day, in the United States, children are removed from their homes and placed into state supervised out-of-home care because of concerns around their safety. These children enter care as a result of child abuse, child neglect, abandonment or some other reasons. Lost in most discussions of out-of-home care is the role that parental incarceration and parental death have on the trajectory of children through the child welfare system. In order to address this gap in the literature, the present study aims to compare youth in foster care as a result of parental death or youth in foster care as a result of parental incarceration with youth in care because of child maltreatment in terms of the length of time to achieve permanency. Holding all other variables constant, entering care as a result of parental death more than doubled the average time to exit (HR = 2.32, SE = 0.22), and these youth were significantly less likely to exit to permanency when compared to children entering care for other maltreatment reasons (OR = 0.35, SE = 0.24). Entering care as a result of parental incarceration led to a 24% longer time to exit (HR = 1.24, SE = 0.09) compared to children entering care for other maltreatment reasons. Findings suggest that a one-size-fits-all approach to policy and practice may not be useful to identifying permanent placements for children entering care as a result of parental death or incarceration.     

Attachment in institutionalized children: A review and meta-analysis

In this article we review the literature on attachment patterns in institutionalized children and then perform a meta-analysis on data from 10 attachment studies involving 399 children in institutional settings. We computed the overall attachment distribution of secure, insecure, and disorganized rates and explored the effect of a set of moderating variables (i.e., country of institutionalization, attachment assessment procedure, age at entry, and age at assessment). To overcome bias related to the small number of studies, we conducted both classical and Bayesian meta-analysis and obtained comparable results. Distribution of children's attachment patterns was: 18% secure, 28% insecure, and 54% disorganized/cannot classify. Compared to their family-reared peers, children living in an institution were found to be at greater risk for insecure and disorganized attachment, with a similar medium effect size for both distributions (d = 0.77 and d = 0.76, respectively). The following moderating variables were associated with insecure attachment: representational assessment procedures (d = 0.63) and Eastern European countries of origin (d = 1.13). Moderators for disorganized attachment were: Eastern European countries of origin (d = 1.12), age at institution entry before the first birthday (d = 0.93), and age at assessment under three years of age (d = 0.91). Implications for child development and policies are discussed.