# Attachment insecurity, adverse childhood experiences (ACEs), and suicidality in French residential-care adolescents: a gender-differentiated study

Bronsard, Guillaume, Dissaux, Nolwenn, Bruneau, Nathalie, Diallo, Issaga, Sanchez, Mélanie, Boyer, Laurent, Lavenne-Collot, Nathalie

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Bronsard, Guillaume, Dissaux, Nolwenn, Bruneau, Nathalie, Diallo, Issaga, Sanchez, Mélanie, et al. Attachment insecurity, adverse childhood experiences (ACEs), and suicidality in French residential-care adolescents: a gender-differentiated study. BMC Physiology, 2026, 10.6084/m9 figshare.c.8251807.v1. hal-05507212

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# Attachment insecurity, adverse childhood experiences (ACEs), and suicidality in French residential-care adolescents: a gender-differentiated study

Guillaume Bronsard<sup>1,2,3</sup>, Nolwenn Dissaux<sup>1,2</sup>, Nathalie Bruneau<sup>1</sup>, Issaga Diallo<sup>4</sup>, Mélanie Sanchez<sup>5</sup>, Laurent Boyer<sup>4,6</sup>
and Nathalie Lavenne-Collot<sup>1,2,7,8,9*</sup>

**Abstract**

**Background** Suicidality is alarmingly prevalent among adolescents placed in residential child welfare facilities, often as a consequence of early adverse childhood experiences (ACEs) and disrupted attachment relationships. Although these vulnerabilities are well established, the gender-specific mechanisms underlying suicidality in institutionalized youth remain poorly understood. Clarifying how trauma exposure and attachment insecurity interact with mental health symptoms is critical to inform targeted prevention.

**Methods** In a cross-sectional study, 98 adolescents aged 12–17 years (54 girls, 44 boys; M = 14.34, SD = 2.08) living in French residential care completed validated self-report instruments assessing ACEs, attachment security, depressive and anxiety symptoms, and suicidality. Descriptive statistics, gender comparisons, and multivariate logistic regressions were used to identify predictors of suicidality, with all predictors standardized prior to entry.

**Results** One-third of participants (33%) reported suicidal ideation or at least one suicide attempt. Emotional and physical abuse were the most frequent ACEs. Cumulative ACEs and attachment insecurity were independently associated with suicidality, and both correlated with heightened anxiety and depressive symptoms. Gender-stratified analyses showed that suicidality in girls was primarily linked to maternal alienation and emotional dysregulation, whereas in boys it was more strongly related to cumulative trauma exposure and depressive symptoms.

**Conclusions** Findings highlight suicidality as a major concern in residential care and identify two complementary risk pathways: adversity-related and attachment-related. Trauma-informed and attachment-based approaches—supported by systematic screening and the integration of mental health professionals within child welfare systems—may enhance early detection and individualized care. While contextualized in the French system, these mechanisms likely generalize across jurisdictions, underscoring the global need for gender-sensitive, relationally focused suicide prevention.

**Keywords** Residential treatment, Suicide, Attachment behavior, Child abuse, Adolescent, Sex factors

Full list of author information is available at the end of the article

<footnote>*Correspondence:
Nathalie Lavenne-Collot
nathalie.lavenne-collot@chu-brest.fr</footnote>
**Introduction**

Adolescents placed in child welfare systems experience markedly higher rates of psychiatric morbidity—estimated at three to five times those observed in the general adolescent population [1, 2]. This excess burden reflects the convergence of early adversity, unstable caregiving, and limited access to consistent psychological support. Suicidality—encompassing ideation, behaviors, and attempts—remains one of the most prevalent and lethal outcomes in this group [3, 4]. Yet, despite the magnitude of the problem, the mechanisms linking early vulnerability to suicide risk—particularly those involving attachment—are still poorly understood.

Unlike the extensive literature on foster care in anglophone countries, France relies predominantly on residential placements, where adolescents are cared for by rotating teams rather than individual foster parents. These institutional settings differ from foster-family models in unit size, staffing ratios, and medico-social governance—factors that may shape both mental-health risk and intervention opportunities. Such structural characteristics contribute to the under-representation of French cohorts in international research and justify the present focus on residential care.

Attachment theory provides a robust framework for understanding vulnerability to suicidality. Early caregiver interactions shape internal working models that guide emotion regulation and help-seeking across development [5, 6]. Inconsistent or disrupted caregiving—frequent in child-welfare populations—is associated with insecure or disorganized attachment [7, 8], which predicts anxiety, depression, and suicidal behavior [9]. Distinct attachment dimensions may confer specific risks: attachment anxiety, marked by emotional hyperactivation and fear of abandonment, has been linked to suicidal behavior, whereas attachment avoidance, characterized by emotional disengagement, more often accompanies suicidal ideation [10, 11].

Adverse childhood experiences (ACEs)—including abuse, neglect, and household dysfunction—are pervasive in residential care and exert well-documented effects on socio-emotional development. Beyond psychological sequelae, ACEs alter biological stress regulation and emotional reactivity [12–16], both of which heighten vulnerability to suicidality. Attachment insecurity may further mediate the link between early trauma and suicidal behavior [17, 18], highlighting the importance of relational pathways.

Despite this convergence of risk factors, few studies have examined their combined impact on suicidality in residential care, particularly in the French context. While attachment to multiple figures (mother, father, peers) can influence psychological outcomes, maternal attachment is most consistently associated with internalizing

symptoms [9, 19], justifying its focus in the present study. Moreover, although gender differences in suicidality are well established, their underlying mechanisms remain unclear. Existing evidence suggests that girls may be more vulnerable to attachment-related emotional dysregulation, whereas boys may be more affected by cumulative trauma and behavioral dysregulation [4, 20].

**Hypotheses**

We expected suicidality to be positively associated with both cumulative ACE exposure and attachment insecurity, and to exhibit gender-differentiated configurations: among girls, a stronger link between maternal alienation, anxiety, and ideation; among boys, a more pronounced association between cumulative trauma, depressive burden, and suicide attempts.

**Methods**

**Study design and setting**

We conducted a cross-sectional, multicenter observational study between November 2018 and November 2020 in ten residential care facilities in the Bouches-du-Rhône region (France). Facilities were purposively selected to capture a diversity of socio-geographical contexts (urban, peri-urban, rural) and psychosocial trajectories. This study was part of a broader research program on adolescent mental health in child protection systems and was approved by the Aix-Marseille University Ethics Committee (Approval No. 2016-09-11-1). All procedures adhered to national and international ethical standards for research involving minors, including the Declaration of Helsinki (2013). A cross-sectional design was selected to examine concurrent associations between adverse experiences, attachment patterns, and suicidality in a highly mobile population that is difficult to follow longitudinally, as retention is often compromised by placement instability and transitions. Given feasibility constraints in residential care, we targeted ~100 participants across 10 facilities, a sample size comparable to prior institutional studies and sufficient to estimate moderate-size odds ratios with acceptable precision (Cohen's d ≈ 0.50; α = 0.05; power ≈ 0.80).

**Participants and recruitment**

Eligible participants were adolescents aged 12–17 years residing in participating facilities during the study period. Inclusion criteria were: (1) sufficient proficiency in French to complete self-report instruments, (2) written informed assent from the adolescent, and (3) written consent from legal guardians or the child welfare judge when required.

Facility directors and care teams were informed about the study and received standardized training prior to data collection. Adolescents were approached individually by
trained research assistants unaffiliated with the institutions to minimize social desirability bias. Participation was voluntary and confidential. The final analytic sample comprised 98 adolescents with complete data on the main variables of interest.

<table><caption>**Table 1** Gender differences in Attachment, trauma Exposure, and psychological symptoms</caption><thead><tr><th>Variable</th><th>Male Mean (SD)</th><th>Female Mean (SD)</th><th>p-value</th><th>Effect Size (Cohen's d)</th></tr></thead><tbody><tr><td colspan="5"><strong>Adverse Childhood Experiences</strong></td></tr><tr><td>ACE Score</td><td>4.29 (2.51)</td><td>5.54 (1.92)</td><td>p=0.007</td><td>Medium</td></tr><tr><td colspan="5">Attachment – Mother</td></tr><tr><td>Total Score</td><td>78.29 (14.50)</td><td>74.40 (14.21)</td><td>p=0.196</td><td>Small</td></tr><tr><td>Trust</td><td><strong>34.59 (10.66)</strong></td><td><strong>29.42 (10.76)</strong></td><td>p=0.023</td><td>Small</td></tr><tr><td>Communication</td><td>29.51 (8.44)</td><td>26.79 (9.22)</td><td>p=0.145</td><td>Small</td></tr><tr><td>Alienation</td><td><strong>14.20 (7.26)</strong></td><td><strong>18.19 (7.78)</strong></td><td>p=0.013</td><td>Medium</td></tr><tr><td colspan="5">Attachment – Peers</td></tr><tr><td>Total Score</td><td><strong>82.26 (32.10)</strong></td><td><strong>57.98 (32.11)</strong></td><td>p=0.002</td><td>Large</td></tr><tr><td>Trust</td><td><strong>34.87 (13.36)</strong></td><td><strong>24.23 (13.86)</strong></td><td>p=0.002</td><td>Large</td></tr><tr><td>Communication</td><td><strong>27.19 (12.82)</strong></td><td><strong>20.18 (11.92)</strong></td><td>p=0.020</td><td>Small</td></tr><tr><td>Alienation</td><td><strong>20.19 (7.11)</strong></td><td><strong>13.92 (7.33)</strong></td><td>p=0.001</td><td>Large</td></tr><tr><td colspan="5">Attachment – Father</td></tr><tr><td>Total Score</td><td><strong>96.85 (20.52)</strong></td><td><strong>107.42 (16.11)</strong></td><td>p=0.007</td><td>Medium</td></tr><tr><td>Trust</td><td>43.08 (10.04)</td><td>47.00 (9.32)</td><td>p=0.056</td><td>Small</td></tr><tr><td>Communication</td><td><strong>30.75 (8.82)</strong></td><td><strong>35.83 (5.65)</strong></td><td>p=0.001</td><td>Medium</td></tr><tr><td>Alienation</td><td>23.03 (4.79)</td><td>24.60 (4.05)</td><td>p=0.092</td><td>Small</td></tr><tr><td colspan="5">Depression</td></tr><tr><td>CDI (Children's Depression Inventory)</td><td>26.00 (3.08)</td><td>26.08 (3.42)</td><td>p=0.918</td><td>Negligible</td></tr><tr><td>ADRS (Adolescent Depression Rating Scale)</td><td><strong>2.65 (2.33)</strong></td><td><strong>4.50 (2.98)</strong></td><td>p=0.001</td><td>Medium</td></tr><tr><td colspan="5">Anxiety</td></tr><tr><td>STAI-Trait</td><td><strong>43.24 (11.92)</strong></td><td><strong>52.13 (10.96)</strong></td><td>p&lt;0.001</td><td>Large</td></tr><tr><td>STAI-State</td><td><strong>36.07 (14.11)</strong></td><td><strong>42.89 (14.10)</strong></td><td>p=0.020</td><td>Medium</td></tr></tbody></table>

ACE Adverse Childhood Experiences, IPPA Inventory of Parent and Peer Attachment (Mother, Peers, Father subscales), CDI Children's Depression Inventory, ADRS Adolescent Depression Rating Scale, STAI State-Trait Anxiety Inventory (Form Y: Trait and State). Effect sizes are reported as Cohen's d: Small (0.20–0.49), Medium (0.50–0.79), Large (≥ 0.80), Negligible (&lt; 0.20). Bold values indicate statistically significant gender differences (p < 0.05)

## Measures

### Sociodemographic and contextual variables

A structured questionnaire, developed and validated by an interdisciplinary expert panel (child psychiatry, developmental psychology, social care), collected data on age, gender, schooling level, duration of current placement, number of prior placements, psychiatric history, and family contact. Socioeconomic status (SES) was estimated indirectly based on placement trajectories, educational disruptions, and parental indicators (e.g., unemployment, incomplete schooling), given the limited applicability of conventional SES indices in child welfare populations.

### Adverse childhood experiences (ACEs)

ACEs were measured using the validated French version of the Adverse Childhood Experiences Questionnaire [21]. The ten binary items assess emotional, physical, and sexual abuse; emotional and physical neglect; and five household dysfunctions (parental separation, mental illness, substance use, domestic violence, incarceration). A cumulative ACE score (range: 0–10) was computed, with higher scores indicating greater adversity. Internal consistency in this sample was satisfactory (Cronbach's α = 0.74). For descriptive purposes, ACEs were also grouped into abuse-related and household-related domains.

### Attachment patterns

Attachment security was assessed using the French adaptation of the Inventory of Parent and Peer Attachment (IPPA; α = 0.89) [22], which evaluates perceived attachment to mother, father, and peers across three dimensions (trust, communication, alienation). Each subscale yields a global score, with higher scores reflecting greater security. Although all IPPA subscales (mother, father, peers) were administered, only the maternal composite was retained for multivariate models to align with prior evidence—and our own findings—indicating that maternal attachment is most strongly linked to internalizing symptoms and suicidality. This choice also avoided redundancy among highly correlated sources and preserved events-per-variable in a sample with approximately 33% suicidality. Father and peer subscales are reported descriptively (Table 1) and discussed for clinical interpretation. The maternal subscale (25 items) was standardized (z-scores) for regression analyses, and tiles were used for descriptive comparisons.

### Psychiatric symptomatology

Depressive symptoms were assessed with two validated French instruments: the Children's Depression Inventory (CDI; α = 0.84) [24] and the Adolescent Depression Rating Scale (ADRS) [25]. The CDI served as the primary measure in regression models due to its established
clinical thresholds, widespread use, and comparability with prior suicidality research. The ADRS complemented gender comparisons to capture phenomenological variations without introducing collinearity in multivariate analyses.

Anxiety was assessed with the State-Trait Anxiety Inventory (STAI; Form Y; state α = 0.88; trait α = 0.86) [26], distinguishing state anxiety (20 items) from trait anxiety (20 items). All symptom scores were analyzed as continuous variables; validated French cut-offs (e.g., CDI ≥ 19; ADRS ≥ 12) were used in sensitivity analyses to examine clinical thresholds.

## Suicidality

Suicidal ideation and behaviors were assessed using the Columbia Suicide Severity Rating Scale (C-SSRS) [27], administered by trained interviewers. The C-SSRS distinguishes passive and active ideation, planning, and attempts. In line with Brent et al. [28], a binary outcome was constructed (“no suicidality” vs. “any suicidality”); a three-level ordinal outcome (no ideation, ideation only, attempt) was tested in sensitivity analyses.

## Data quality and missing data handling

All assessments were conducted individually in private settings to ensure confidentiality and optimize validity. Missing data were below 5% for all variables. Little's missing completely at random (MCAR) test indicated that data were missing completely at random. Multiple imputation using chained equations (MICE, 5 iterations) was applied in sensitivity analyses; results did not differ materially from complete-case analyses, which were retained for primary models.

## Statistical analyses

Analyses were conducted with SPSS v26 (Statistical Package for the Social Sciences) and R v4.3. Descriptive statistics (means, standard deviations, proportions) characterized the sample. Normality of continuous variables was tested using the Shapiro-Wilk test, guiding the use of parametric (t-tests) or non-parametric (Mann-Whitney U) tests; categorical variables were compared with χ² or Fisher's exact tests. Gender differences in depressive and anxiety symptoms were examined with independent-samples t-tests and effect sizes (Cohen's d).

Primary analyses used multivariate logistic regression to identify predictors of suicidality (binary outcome). Predictors included gender, age, cumulative ACE score, maternal attachment (IPPA), depressive symptoms (CDI), and trait anxiety (STAI-Trait). All continuous predictors were standardized (z-scores) to facilitate comparison of effect sizes. Model assumptions were checked: all variance inflation factors (VIFs) were <2, indicating

no multicollinearity. Model fit was evaluated using Nagelkerke's R² and the Hosmer-Lemeshow test.

Given prior evidence of gender-specific pathways to suicidality, stratified logistic regressions were conducted for boys and girls. Interaction terms (gender × attachment) were tested but not retained due to non-significance. Robustness checks included alternative outcome specifications (ordinal suicidality) and substitution of ADRS for CDI in the models; results remained consistent.

Variables such as placement duration, number of prior placements, and psychiatric history were recorded but not included in primary models to limit overfitting relative to the number of events. This analytic structure—combining standardized predictors, multivariate logistic regression, and gender-stratified models—was selected to directly test our hypotheses on cumulative adversity, attachment insecurity, and gender-differentiated pathways to suicidality. Potential residual confounding is addressed in the Limitations, and feasible longitudinal approaches are outlined as future directions.

## Results

### Sample characteristics

Ninety-eight adolescents (54 girls, 44 boys; M = 14.34 years, SD = 2.08) participated. All had been placed in residential care following severe family dysfunction and multiple adverse experiences.

### Adverse childhood experiences (ACEs)

Exposure to ACEs was high, particularly emotional abuse (78%) and physical abuse (65%) (Table 1). Mean ACE scores were higher in girls than boys (M = 5.54 vs. 4.29; *p* = 0.007, d = 0.66). Girls were more likely to report emotional abuse (90.7% vs. 61.9%; *p* = 0.007, d = 0.66), physical abuse (85.2% vs. 61.9%; *p* = 0.021, d = 0.55), and sexual abuse (35.2% vs. 9.5%; *p* = 0.001, d = 0.76).

### Attachment patterns

As pre-specified, only the maternal IPPA subscale entered multivariate models; father and peer scales were examined descriptively (Table 1) to contextualize gender differences.

Attachment insecurity was frequent, with notable gender differences (Table 1). Girls scored higher on maternal alienation (*p* = 0.013, d = 0.53), whereas boys reported greater maternal trust (*p* = 0.023, d = 0.48). Although girls also showed some differences in peer and father attachment dimensions, these variables were not central to the present analyses.

Bivariate correlations indicated that ACE scores were negatively associated with maternal trust (boys: *r* = -0.52; girls: *r* = -0.58; all *p* < 0.001) and positively with
maternal alienation (boys: *r* = 0.48; girls: *r* = 0.62; all *p* ≤ 0.001) (Table S1).

## Mental health indicators

High rates of emotional distress were observed (Table 1). Trait anxiety was elevated in 45% of participants (scoring above the clinical cut-off), with girls reporting higher trait anxiety (M = 52.13 vs. 43.24; *p* < 0.001, *d* = 0.77) and higher state anxiety (*p* = 0.020, *d* = 0.48). While mean CDI scores did not differ by gender (*p* = 0.918), girls had higher ADRS scores (*p* = 0.001, *d* = 0.69). Across the whole sample, ACE scores correlated positively with depressive symptoms (*r* = 0.49, *p* < 0.001).

## Suicidal ideation and attempts

Overall, 33% of participants reported some form of suicidality (ideation and/or at least one attempt), with no significant gender difference (*p* = 1.00). Suicidality was strongly correlated with ACE scores (boys: *r* = 0.52; girls: *r* = 0.58; all *p* < 0.001) and maternal attachment insecurity (boys: *r* = 0.48; girls: *r* = 0.62; all *p* ≤ 0.001). Maternal alienation was the most salient correlate of suicidal ideation, whereas cumulative ACE exposure was the strongest predictor of suicide attempts.

## Multivariate analysis

Logistic regression models (Table 2) confirmed that cumulative ACE exposure and maternal alienation were the only significant independent predictors of suicidality. In the adjusted logistic regression (Table 2), higher ACE scores were the strongest predictors of suicidality, whereas maternal trust was not (*p* = 0.126). When outcomes were examined separately, suicidal ideation was most strongly predicted by maternal alienation

<table><caption>**Table 2** Multivariate logistic regression analysis of factors associated with suicidality</caption><thead><tr><th>Variable</th><th>Ad-justed OR</th><th>95% CI</th><th>p-value</th><th>Significance (adjusted model)</th></tr></thead><tbody><tr><td>ACE Score</td><td>2.45</td><td>[1.42–4.23]</td><td>p &lt; 0.001</td><td>Significant (Boys &amp; Girls)</td></tr><tr><td>Maternal Alienation</td><td>1.78</td><td>[1.12–2.82]</td><td>p = 0.009</td><td>Significant (Girls)</td></tr><tr><td>Maternal Trust</td><td>0.72</td><td>[0.51–1.08]</td><td>p = 0.126</td><td>Not significant</td></tr><tr><td>Anxiety (STAI-Trait)</td><td>1.33</td><td>[1.08–1.76]</td><td>p = 0.031</td><td>Significant (Girls)</td></tr><tr><td>Depression (CDI Score)</td><td>1.41</td><td>[1.11–1.92]</td><td>p = 0.017</td><td>Significant (Boys &amp; Girls)</td></tr></tbody></table>

OR Odds Ratio, CI Confidence Interval, ACE Adverse Childhood Experiences, IPPA Inventory of Parent and Peer Attachment (maternal subscale: Maternal Alienation, Maternal Trust), STAI-Trait State-Trait Anxiety Inventory, Trait form (Form Y-B), CDI Children's Depression Inventory. Odds ratios (ORs) are adjusted for age and sex. OR > 1 indicates increased likelihood of suicidality; OR < 1 indicates a potential protective factor. Bold values indicate statistically significant predictors (*p* < 0.05)

(OR = 2.21, 95% CI [1.38–3.55]; *p* = 0.004), while suicide attempts were best predicted by cumulative ACE exposure (OR = 2.89, 95% CI [1.64–5.12]; *p* < 0.001). In adjusted models, cumulative ACEs remained the most robust correlate of suicidality, whereas maternal alienation tracked most closely with ideation. Interpreted clinically, a one-SD increase in ACE load moves an adolescent from low to moderate-to-high risk on routine screening, supporting immediate safety planning and trauma-focused referral. Conversely, elevated maternal alienation flags youths—especially girls—whose presentations center on rumination, interpersonal mistrust, and help-seeking difficulties, for whom attachment-informed interventions (e.g., MBT/ABFT elements) are indicated in addition to standard risk management. This framing clarifies the clinical meaning of the odds ratios and translates statistical findings into actionable guidance for residential-care teams.

## Gender-specific risk profiles

Gender-stratified models suggest two service-relevant pathways: in girls, suicidality is anchored in attachment-based distress (maternal alienation) with high trait anxiety; in boys, it is more tightly coupled with cumulative trauma and depressive load, consistent with more disinhibited risk trajectories. For triage, girls with high alienation benefit from relationally focused care plans (validation, mentalization, family work), while boys with high ACEs and depressive symptoms require trauma-oriented and impulse-control strategies alongside standard safety procedures. These distinct configurations illustrate gender-specific mechanisms of vulnerability. Among girls, attachment-related emotional hyperactivation appears to drive rumination and ideation, whereas among boys, cumulative trauma and depressive burden promote more impulsive, attempt-prone trajectories. These patterns were confirmed in the stratified analyses (Table 2); ACE scores predicted suicidality in both boys (OR = 2.31, 95% CI [1.24–4.02]; *p* = 0.002) and girls (OR = 2.68, 95% CI [1.45–4.91]; *p* < 0.001). For girls, maternal alienation predicted ideation more strongly (OR = 2.01, 95% CI [1.19–3.24]; *p* = 0.005), whereas for boys the association did not reach significance (*p* = 0.081). For boys, suicidality—particularly suicide attempts—was primarily linked to cumulative trauma exposure (with depressive symptoms also contributing), whereas for girls both ACE exposure and maternal attachment insecurity were significant predictors.

Clinically, this differentiation underscores the need for gender-sensitive screening: attachment-based indicators (e.g., maternal alienation, high trait anxiety) should prompt relational interventions for girls, while cumulative ACE load and depressive symptoms should orient trauma-focused and impulse-regulation work for boys.
## Summary of gender differences

Girls' higher exposure to emotional, physical, and sexual abuse likely contributed to their elevated attachment insecurity and chronic anxiety. While depressive symptoms on the CDI were comparable across genders, ADRS scores revealed greater depressive expression among girls. ACE exposure emerged as the most robust predictor of suicidality across genders, but maternal alienation was particularly salient for girls, emphasizing the importance of gender-sensitive, trauma-informed interventions that address relational dimensions of distress.

These patterns highlight the need for gender-sensitive assessment within residential care, bridging relational and trauma-based approaches.

Girls' higher exposure to emotional, physical, and sexual abuse likely contributed to their elevated attachment insecurity and chronic anxiety. While depressive symptoms on the CDI were comparable across genders, ADRS scores revealed greater depressive expression among girls. ACE exposure emerged as the most robust predictor of suicidality across genders, but maternal alienation was particularly salient for girls, emphasizing the importance of gender-sensitive, trauma-informed interventions that address relational dimensions of distress.

These findings highlight complementary yet distinct pathways of risk, reinforcing the clinical value of integrating attachment-informed and trauma-focused frameworks in residential care.

## Discussion

### Attachment and suicidal behaviors

To our knowledge, this is the first study to link maternal alienation to suicidality within a French residential-care cohort, extending prior evidence from foster-care and community samples and underscoring the clinical utility of attachment-informed approaches in institutional settings. A robust literature across developmental psychopathology, attachment theory, and suicidology consistently shows an association between insecure attachment and suicidal behaviors [5, 9]. Secure attachment fosters emotion regulation, self-worth, and help-seeking, whereas attachment disruptions contribute to affective dysregulation, identity fragmentation, and increased vulnerability to suicidal ideation and attempts [7, 19].

Our findings corroborate this evidence, showing a strong link between maternal alienation and suicidality—most notably among girls. The maternal alienation subscale, which captures perceived emotional distance, unavailability, and impaired affective communication, emerged as a significant predictor of suicidal ideation. This aligns with research indicating that insecure or disorganized attachment undermines emotional containment and promotes internalizing symptomatology [23, 29]. In our sample, girls reported higher exposure to

emotional abuse and greater maternal alienation, suggesting a convergence of trauma exposure and relational insecurity in shaping their suicidal risk.

This gender-specific pattern mirrors large-scale findings that adolescent girls are more prone to internalizing distress following attachment disruption, while boys more often externalize distress or adopt affective disengagement strategies [30, 31]. In our stratified regression models, suicidal ideation in girls was significantly associated with maternal alienation, whereas in boys, cumulative ACE scores and depressive symptoms were more salient predictors. These divergent pathways underscore the need for gender-sensitive risk formulations.

In the French residential care context, these results are particularly concerning. Although awareness of trauma-related vulnerabilities is increasing, attachment insecurity is rarely assessed explicitly, and interventions often prioritize behavioral stabilization over relational repair [1, 32]. Fragmentation between social, medical, and judicial sectors further impedes integrated, attachment-focused care. Placement instability, a frequent reality for adolescents in care, disrupts continuity of caregiving relationships, fosters mistrust, and reinforces relational disengagement. In such contexts, expressions of alienation are at risk of being misinterpreted as oppositional behavior or mood swings rather than as adaptive responses to repeated relational disruptions.

Emerging clinical and neuroscientific models suggest that attachment-related suicidality may operate through interacting mechanisms, including emotional dysregulation, altered self-representation, and maladaptive interpersonal schemas [33]. One salient pathway involves hypermentalization—the overinterpretation of others' intentions—observed in trauma-exposed youth with disrupted attachment. Evidence indicates that trauma can impair mentalizing, with dissociation mediating the link between trauma and hypermentalization [34]. In institutional contexts lacking stable adult mirroring, such distortions in self-other understanding may consolidate into mistrust, negative attributional bias, and affective overcontrol, thereby amplifying suicidal vulnerability. Consistent with this, recent evidence in children admitted to emergency departments for suicidal behaviors demonstrated that emotional dysregulation mediates the association between anxious attachment and suicidality, underscoring the central role of regulatory processes in attachment-related risk pathways [35].

Therapeutic approaches such as Attachment-Based Family Therapy (ABFT) and Mentalization-Based Therapy (MBT) offer promising avenues for restoring relational security and enhancing affective modulation. ABFT, while not consistently superior to alternative interventions [36], remains relevant when relational trauma is central to the clinical picture. MBT,
by targeting distortions in self–other representation and
strengthening mentalizing capacity, may be particularly
suited to adolescents in residential care with cumulative
adversity and attachment fragmentation [37, 38].

Given the chronicity and complexity of these vulner-
abilities, attachment-informed assessment and care plan-
ning should be standard practice in institutional child
psychiatry. Instruments such as the Child Attachment
Interview [39] or trauma-specific attachment screeners
could help identify adolescents at elevated relational risk.
Staff training in trauma-sensitive relational care is also
essential, particularly when embedded within teams to
ensure continuity and emotional availability—elements
too often absent in large-scale residential environments.

***Translating profiles into assessment moves***

In residential care, we recommend (i) flagging maternal alienation scores in the upper tertile of the IPPA or persistent active suicidal ideation on the C-SSRS as triggers for relationally focused interventions (e.g., MBT-A components, validation training for staff, structured family sessions when feasible); and (ii) flagging ACE scores ≥6 and/or clinically significant depressive symptoms as indicators for trauma-oriented care (e.g., TF-CBT elements, affect regulation skills, and close monitoring of impulsivity). Embedding these relational and trauma indicators in admission assessments and weekly clinical reviews can help residential teams move from generic “high-risk” labels toward gender-sensitive, targeted care pathways.

Neurobiological insights

A substantial body of evidence indicates that early
trauma and attachment disruption exert profound neuro-
biological effects during adolescence, particularly among
institutionalized youth. Exposure to ACEs is associated
with HPA-axis dysregulation (e.g., flattened diurnal cor-
tisol), a canonical form of biological embedding [40, 41]
linked to affective lability and suicidality [42, 43].

At the neural level, trauma-related alterations include
amygdala hyperactivation, hippocampal volume reduc-
tion, and prefrontal hypoactivation, reflecting impaired
regulation of threat detection, emotional arousal, and
impulse control [12, 44]. Attachment insecurity may fur-
ther amplify these vulnerabilities by depriving the child
of co-regulatory experiences needed to modulate limbic-
prefrontal interactions.

Recent functional-connectivity studies identify dys-
regulation within the default mode network (DMN)—
notably the medial prefrontal and posterior cingulate
cortices—as a neural correlate of intrusive rumination,
negative self-appraisal, and hopelessness, all strong pre-
dictors of suicidality [45–47]. These network alterations
may help explain persistent self-referential distress and
hopelessness in adolescents in care.

Our findings are consistent with this framework: ado-
lescents with high maternal alienation also showed
elevated depressive and anxiety symptoms, particularly
among girls, suggesting an interaction between attach-
ment disruption, stress-axis dysregulation, and impaired
emotion regulation. While we did not assess cortisol or
brain function directly, evidence from related work on
borderline traits shows that attachment avoidance and
rejection sensitivity predict both cortisol blunting and
limbic overactivation [48], supporting the plausibility of
similar mechanisms in this sample.

Sex-specific neurodevelopmental trajectories likely
modulate these responses. As shown by Roeske et al.
(2025), amygdala–prefrontal maturation follows dif-
ferent timelines, with earlier development in females
[49]. This may increase girls’ susceptibility to emotion-
focused rumination and internalizing distress, while
slower prefrontal maturation in boys may foster impul-
sivity and externalizing behaviors. These developmental
asymmetries, converging with our behavioral findings,
underline the need to integrate neurobiological and
gender-informed perspectives in suicide-prevention
frameworks.

Despite these convergences, neurobiologically
informed approaches remain rare in French residen-
tial care. Ethical and logistical barriers, limited funding,
and fragmented services hinder integration of biological
knowledge into practice [50]. Somatic and mental-health
teams often work in isolation, and caregivers receive little
training on the physiological embedding of trauma. This
limits implementation of body-based or neuroregulatory
interventions—such as trauma-sensitive yoga, neuro-
feedback, EMDR, or vagal-nerve stimulation—that have
demonstrated efficacy in modulating stress physiology
and affective regulation [51–53].

Bridging this divide requires a developmental-trauma
framework integrating neurobiology, attachment, and
environment, with practical steps such as incorporat-
ing simple physiological indicators, staff education, and
intersectoral protocols toward biologically informed sui-
cide-prevention strategies.

Gender-specific risk trajectories

Our findings, derived from one of the first French resi-
dential-care cohorts examined through a gender-dif-
ferentiated lens, indicate two distinct, developmentally
grounded pathways linking attachment insecurity and
early adversity to suicidality in adolescents placed in resi-
dential care. Girls reported significantly higher maternal
alienation and perceived relational unavailability, pat-
terns strongly associated with internalizing distress. This
aligns with evidence that female adolescents are more
sensitive to interpersonal stressors, possibly through oxy-
tocin-mediated social-salience mechanisms that amplify
<figure><img src="image_4.png" /><figcaption>**Fig. 1** Conceptual model of gender-specific pathways linking adverse childhood experiences (ACEs) to suicide risk in adolescents in residential care. In girls, emotional and sexual abuse were associated with suicidal ideation directly and through attachment insecurity, anxiety, rumination/internalization, and emotional dysregulation. In boys, cumulative exposure to physical abuse and neglect was linked to depressive symptoms and externalizing tendencies, with hypothesized contributions from reduced inhibitory control and increased stress reactivity leading to impulsive suicidal behaviors. Dashed boxes represent hypothesized mechanisms not directly assessed in this study. Arrows indicate proposed direct or indirect relationships, and the order of boxes reflects the suggested sequence of influence</figcaption></figure>

the emotional impact of relational rupture and evaluation by others [54]. Interpersonal adversity—such as emotional invalidation, bullying, or rejection—predicts internalizing symptoms and suicidal ideation more strongly in girls, consistent with the relational—affective profile observed in our data [55, 56].

For boys, suicidality was more tightly linked to cumulative trauma exposure—particularly physical abuse and neglect—and to externalizing traits such as impulsivity and irritability. Although inhibitory control was not directly assessed, prior studies suggest that trauma-exposed boys exhibit heightened emotional reactivity and reduced executive control, fostering disinhibited, less premeditated suicidal behaviors [57, 58]. This divergence supports neurodevelopmental stress models in which girls tend to internalize affective distress whereas boys manifest it through behavioral dysregulation and impulsive action [46, 59].

Taken together, these trajectories—characterized by ruminative internalization in girls and dysregulated behavioral control in boys—may constitute distinct mediational routes between ACEs and suicidality. Longitudinal evidence confirms that insecure attachment predicts suicidality via internalizing symptoms in girls and behavioral dysregulation in boys, highlighting gender-specific regulatory vulnerabilities [35].

Figure 1 synthesizes these parallel mechanisms, integrating our empirical data with developmental and neurobiological evidence. It illustrates how specific ACE profiles (e.g., relational trauma in girls, cumulative neglect or abuse in boys) interact with attachment insecurity and regulatory vulnerabilities to produce differentiated risk configurations.

From a clinical standpoint, these divergences justify gender-tailored intervention strategies. For girls, approaches that address relational schemas, foster emotional validation, and modulate internal dialogue—such as attachment-informed Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), or Mentalization-Based Therapy (MBT)—may be particularly beneficial. Boys, in contrast, often require trauma-focused interventions targeting behavioral regulation and impulse control—such as Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), neurofeedback, or somatic-based therapies. Embedding such interventions within institutional care protocols, coupled with staff training to recognize and respond to gendered modes of suffering is essential to improving suicide-prevention outcomes in residential care.
## The worsening mental health of adolescent girls

Our findings are consistent with growing international concern over the disproportionate rise in suicidality and internalizing symptoms among adolescent girls. In the United States, data from the Youth Risk Behavior Surveillance System indicate that the proportion of high school girls seriously considering suicide increased from 19% in 2011 to 30% in 2021—nearly double the rate observed in boys (14.3%) [60]. Similarly, emergency department visits for suspected suicide attempts rose by 51% among females aged 12–17 during early 2021 compared with the same period in 2019 [61].

These trends predate the COVID-19 pandemic. A recent systematic review confirms that adolescent suicide is a multifactorial phenomenon shaped by mental health conditions, family and school environments, and broader social stressors [62]. In the United Kingdom, epidemiological monitoring shows a significant rise in eating disorder rates among adolescents—rising from 0.8% in 2017 to 12.5% in 2023 among 17- to 19-year-olds [63]. This surge in eating disorder prevalence further illustrates the growing psychosocial vulnerability of adolescent girls, which is closely linked to heightened risks of suicidality.

This deterioration appears to result from the convergence of factors in three domains: (1) developmental and neurobiological vulnerabilities—pubertal hormonal changes, particularly within corticolimbic circuits, heighten stress responsivity and emotional volatility, especially in contexts marked by early trauma or chronic stress [49, 59]; (2) relational factors—higher rates of maternal alienation and anxious–depressive profiles among girls point to the role of insecure attachment and interpersonal invalidation in the development of internalizing distress [10, 19]; and (3) sociocultural pressures—appearance-based validation, perfectionistic self-expectations, and upward social comparison, often intensified by digital media, are strongly associated with depressive symptoms, disordered eating, and low self-worth [64–66].

Within residential care settings, discontinuities in caregiving, frequent staff turnover, and limited emotional containment may exacerbate these vulnerabilities. In the French context, repeated placement changes and fragmented support structures can compound the impact of pre-existing emotional vulnerability, leaving adolescent girls with reduced access to stable, validating relationships.

Addressing this crisis requires early, gender-sensitive strategies. Attachment-informed, trauma-focused, and emotion regulation-oriented programs—such as CBT, Acceptance and Commitment Therapy (ACT), and MBT—have shown efficacy in reducing suicidal ideation and depressive symptoms in adolescent girls [67, 68]. Structural measures—including digital literacy

education, resilience-building within institutional contexts, and targeted reduction of school-related stressors—are also essential.

In sum, the adolescent girls’ mental health crisis reflects an interplay of neurobiological, relational, and sociocultural forces. These findings directly inform the policy and clinical priorities outlined in Sect. 4.5, under-scoring the urgency of developing tailored, context-sensitive approaches within residential care systems.

## Implications for policy and practice

Our findings underscore critical gaps in the mental-health care continuum for adolescents in residential care—particularly in the systematic assessment and treatment of suicidality, attachment disturbances, and trauma-related disorders. In our sample, over one-third of youth reported suicidal ideation or behavior, and attachment insecurity and early adversity were highly prevalent. Despite this burden, existing protocols remain fragmented and inconsistently implemented, rarely tailored to adolescents’ developmental and relational needs [1, 69]. Addressing these shortcomings requires integrated, trauma- and attachment-informed strategies embedded within residential structures.

Action priorities can be organized by feasibility and timeframe:

### Immediate priorities (next 6 months): strengthening suicide-prevention protocols

Routine risk screening with validated tools such as the C-SSRS should be implemented across all residential units, accompanied by standardized referral pathways and staff training in emergency response [27, 28]. Screening must be gender-responsive: girls with high attachment insecurity should receive relationally focused interventions emphasizing emotional validation and interpersonal safety, whereas boys may benefit from modules targeting impulse control and emotion recognition [57, 59].

### Medium-term goals (6–24 months): embedding trauma- and attachment-informed care

The convergence of early adversity and insecure attachment calls for interventions that rebuild trust while enhancing regulation capacities. Attachment-informed models such as MBT, DBT, or the Attachment, Regulation and Competency (ARC) framework have shown efficacy in reducing suicidality and improving relational security [38, 70, 71]. Trauma-Informed Care (TIC) principles—viewing dysregulated behaviors as adaptive responses to adversity—should guide daily practice. Key structural levers include staff continuity, emotional containment, and non-punitive caregiving climates.
**Longer-term reforms (beyond 24 months): integrating
mental-health professionals and ensuring systemic
coordination**

Embedding psychiatrists, psychologists, and trauma-
trained therapists within residential teams enables indi-
vidualized case formulation, rapid crisis response, and
longitudinal planning [1, 72]. Ongoing supervision and
specialized training in attachment-aware, mentalizing,
and affect-regulation approaches can reduce coercive
practices and improve relational climates [73, 74]. At the
policy level, national frameworks should mandate routine
suicide-risk screening, enforce trauma- and attachment-
informed standards, and guarantee access to embedded
professionals in all placements.

*Critical transition periods (before and after placement exits): ensuring structured aftercare*

Transitions out of care remain high-risk windows often
marked by abrupt loss of support. Coordinated after-
care programs—combining peer mentorship, mobile
outreach, and sustained psychological follow-up—are
essential to reduce relapse risk and foster long-term
adjustment [70].

By translating these four evidence-based priorities into
graduated institutional and policy actions, child-welfare
systems can better meet adolescents' developmental and
psychiatric needs, ultimately reducing suicide risk, and
promoting healthier trajectories. The cost of inaction—
measured in preventable loss of life and intergenerational
trauma—underscores the urgency of systemic reform.

**Limitations and future directions**

This study advances understanding of the interplay
between trauma exposure, attachment insecurity, and
suicidality among adolescents in residential care. While
the findings offer clinically and theoretically relevant
insights, several methodological and structural limita-
tions must be considered. Addressing these constraints
is essential for both interpreting our results and guiding
future research aimed at clarifying risk and resilience
mechanisms in this high-need population.

**Sample size and representativeness**

Although sufficient for exploratory analysis, the relatively
small sample size limits the generalizability of our find-
ings. Residential care institutions vary in organizational
structure, staffing models, therapeutic frameworks, and
institutional climate—factors likely to influence ado-
lescents' developmental and clinical trajectories. While
these contextual variables are specific to the French
system (e.g., judicial oversight, staff-to-youth ratios,
placement instability), the core associations observed—
between cumulative adversity, attachment insecurity, and
suicidality, particularly the salience of maternal alienation

for girls' ideation—are consistent with cross-jurisdic-
tional evidence, suggesting that our findings likely extend
beyond the French context. Multicenter designs spanning
diverse placement types, regions, and demographic pro-
files are needed to capture this heterogeneity.

Data collection occurred partly in the aftermath of the
COVID-19 pandemic, which may have shaped referral
patterns and participation rates. Adolescents with the
most severe psychiatric symptoms or systemic exclusion
may have been underrepresented, potentially leading to
an underestimation of suicidality prevalence [75]. Future
research should therefore employ inclusive, trauma-
informed recruitment strategies in post-pandemic youth
mental health studies.

**Cross-sectional design constraints**

The cross-sectional design precludes causal inference.
While we observed strong associations between attach-
ment insecurity, early adversity, and suicidal behaviors,
the temporal direction of these relationships remains
unclear. Insecure attachment may precede suicidality,
yet suicidal ideation can also emerge as a consequence of
cumulative distress and relational fragmentation.

Longitudinal studies are needed to track attachment
representations, emotion regulation capacities, and men-
tal health outcomes over time, while considering the
moderating effects of placement characteristics—such as
caregiver consistency, emotional attunement, and insti-
tutional transitions—on these developmental pathways.
In practice, such follow-ups are feasible even in mobile
populations through mixed-mode strategies (e.g., tele-
phone or online interviews during placement transitions,
data linkage across child-protection and health services).
Incorporating these pragmatic methods would move the
field beyond cross-sectional inference toward develop-
mentally sensitive, longitudinal understanding.

**Measurement limitations and self-report biases**

Our reliance on adolescent self-report instruments was
necessary to capture subjective experiences, yet such
measures are susceptible to recall bias, mood-congruent
reporting, and social desirability effects—particularly in
sensitive domains like suicidality and maltreatment. Ret-
rospective evaluations of attachment or trauma may be
influenced by current emotional distress, complicating
causal interpretation.

Future research should incorporate multimodal assess-
ments, combining clinical interviews, behavioral tasks
assessing distress tolerance or emotional reactivity, and
biological markers of stress regulation (e.g., salivary cor-
tisol, heart rate variability). This approach would enhance
validity and provide finer-grained insight into self-regu-
lation processes and trauma sequelae in institutionalized
youth [74, 76].
## Resilience processes and intervention research

Our focus on risk factors leaves resilience processes underexplored. Not all adolescents exposed to adversity follow maladaptive trajectories; protective factors such as supportive adult relationships, reflective functioning, and adaptive emotion regulation skills can buffer the psychological impact of trauma and lower suicide risk.

Future studies should systematically investigate these resilience-promoting factors and their developmental plasticity within residential contexts marked by relational discontinuity. Pragmatic trials and implementation studies are also needed to assess the feasibility, effectiveness, and sustainability of evidence-based interventions such as MBT, DBT, and the ARC model in real-world residential settings [38, 70, 71]. Training residential staff in co-regulation and trauma-responsive caregiving should be evaluated for its impact on both youth outcomes and institutional climate.

## Long-term outcomes and structural continuity

Research on residential care remains largely confined to the placement period, yet the transition out of care is a particularly vulnerable juncture. Service discontinuities, emotional instability, and social marginalization during this phase significantly increase the risk of psychiatric relapse and suicidality [69].

Long-term follow-up studies are essential to determine the enduring effects of early adversity, placement histories, and intervention exposure on adult mental health and psychosocial adjustment. Applying implementation science frameworks could help identify sustainable strategies for embedding mental health services within child welfare systems, ensuring continuity of care beyond placement.

In sum, advancing the field will require longitudinal, multi-method, and interdisciplinary approaches that integrate risk and resilience perspectives. Such work is vital for developing context-sensitive, empirically grounded interventions capable of addressing the complex mental health needs of adolescents in care—and for preventing suicide among the most vulnerable youth.

## Conclusion

This study demonstrated that adolescents in residential care face a disproportionate burden of mental health difficulties, with suicidality strongly linked to attachment insecurity and histories of ACEs. Approximately one-third of participants reported suicidal ideation or behavior, confirming suicidality as a major public health issue in institutional settings. The high prevalence of maternal alienation and the marked vulnerability of girls to relational trauma, emotional dysregulation, and self-injurious behaviors underscore the need for targeted, gender-sensitive interventions. Our findings identify two

distinct yet complementary risk pathways: cumulative adversity and depressive burden predict suicidality across genders, whereas maternal alienation specifically amplifies ideation among girls.

Integrated relational and trauma-informed frameworks should serve as the foundation of institutional mental health provision. Embedding qualified mental-health professionals within residential teams—alongside systematic staff training in trauma-responsive and attachment-sensitive caregiving—could improve early detection, enhance relational continuity, and foster emotional regulation skills. Routine screening for suicide risk and attachment-related symptomatology across all child welfare placements should become standard practice. In the short term, systematic C-SSRS screening and structured referral protocols are feasible steps; in the medium term, embedding mental-health professionals and implementing trauma-informed training programs should be prioritized.

Beyond immediate implementation, sustainable change will require therapeutic environments that ensure psychological safety, relational stability, and developmental attunement. Future longitudinal research should clarify causal trajectories between ACE exposure, attachment insecurity, and suicidality, while identifying resilience-promoting processes such as mentoring relationships, peer connectedness, and adaptive emotion regulation. Long-term follow-up studies are particularly needed to evaluate the durability of these integrated interventions beyond the placement period.

Integrating gender-sensitive, developmentally attuned suicide prevention strategies into both policy and practice can move child welfare systems toward more equitable and relationally grounded care—offering a pragmatic path to prevent suicide among the most vulnerable youth.

## Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s13034-025-01010-3.

Supplementary Material 1. Supplementary material is available online, including Table S1 presenting the bivariate correlations among the main study variables (ACE, attachment dimensions, depressive symptoms, suicidality).

## Acknowledgements

We gratefully acknowledge the Conseil Départemental des Bouches-du-Rhône and the Direction des Maisons de l'Enfance et de la Famille (DiMEF) for their institutional support, commitment, and trust. We also thank the professionals in the participating residential care facilities for their engagement throughout the study, and the adolescents who agreed to participate and share their experiences.

## Author contributions

GB conceptualized the study design, and contributed to data analysis. LB supervised the methodological aspects and statistical analyses. NL conducted data analysis and drafted the manuscript. NB and ID coordinated and carried out data collection. MS contributed to the implementation of the study
protocol. ND critically revised the manuscript for important intellectual
content. All authors contributed to the interpretation of findings, reviewed the
manuscript, and approved the final version.

Funding

This research was supported by the Direction des Maisons de l'Enfance et de
la Famille (DiMEF), through the Conseil Départemental des Bouches-du-Rhône
(CD13).

Data availability

The anonymized dataset underlying this article is available from the
corresponding author upon reasonable request and subject to institutional
data protection policies.

Declarations

Ethics approval and consent to participate

This study was approved by the Aix-Marseille University Ethics Committee (Approval No. 2016-09-11-1). Written informed assent was obtained from adolescents, and written consent from their legal guardians or the child welfare judge when required. All procedures adhered to national and international ethical standards for research involving minors, including the Declaration of Helsinki (2013).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Author details

¹Department of Child and Adolescent Psychiatry, Brest University Hospital, Bohars, France

²University of Western Brittany, Brest, France

³EA 7479, SPURBO, University of Western Brittany, Brest, France

⁴EA 3279, CERESS, Aix-Marseille University, Marseille, France

⁵Public Mental Health Institution (EPSM), Guadeloupe, France

⁶Department of Medical Information, Assistance Publique, Hôpitaux de
Marseille (AP-HM), Marseille, France

⁷INSERM UMR 1018, CESP, PsyDev NDTA Team, Paris-Saclay University, UVSQ, Villejuif, France

⁸Necker-Enfants Malades University Hospital, Paris, France

⁹INSERM UMR 1101, LaTIM, Brest, France

Received: 7 September 2025 / Accepted: 3 December 2025

Published online: 15 December 2025

References

1. Bronsard G, Alessandrini M, Fond G, Loundou A, Auquier P, Tordjman S, et al. The prevalence of mental disorders among children and adolescents in the child welfare system: A systematic review and Meta-Analysis. Med (Baltimore) févr. 2016;95(7):e2622.

2. De Montaigne L, Bernard O, Da Fonseca D, Gaudart J, Richardson A, Soffer M, et al. Étude des notifications à La Maison départementale des personnes handicapées Chez les enfants placés à l'aide sociale à l'enfance Dans les Bouches-du-Rhône [Reports to the departmental house for disabled persons concerning children in child welfare placements in Bouches-du-Rhône]. Arch Pediatr. 2015;22(9):932-42. https://doi.org/10.1016/j.arcped.2015.06.018.

3. Evans R, White J, Turley R, Slater T, Morgan H, Strange H, et al. Comparison of suicidal ideation, suicide attempt and suicide in children and young people in care and non-care populations: systematic review and meta-analysis of prevalence. Child Youth Serv Rev. 2017;82:122-9.

4. Katz CC, Busby DR, Wall EV. Suicidal behaviors in youth with foster care experience. Handbook of youth suicide prevention: integrating research into practice. Cham, Switzerland: Springer Nature Switzerland AG; 2021. pp. 241-60.

5. Bowlby J. A secure base: Parent-child attachment and healthy human development. New York, NY, US: Basic Books; 1988. xii, 205 p. (A secure base: Parent-child attachment and healthy human development).

6. Mikulincer M, Shaver PR. An attachment perspective on psychopathology. World Psychiatry Off J World Psychiatr Assoc WPA févr. 2012;11(1):11-5.

7. Lyons-Ruth K, Jacobvitz D. Attachment disorganization: genetic factors, parenting contexts, and developmental transformation from infancy to adulthood. Handbook of attachment: Theory, research, and clinical applications. 2nd ed. New York, NY, US: The Guilford Press; 2008. pp. 666-97.

8. van IJzendoorn MH, Schuengel C, Bakermans-Kranenburg MJ. Disorganized attachment in early childhood: meta-analysis of precursors, concomitants, and sequelae. Dev Psychopathol. 1999;11(2):225-49.

9. Venta A, Sharp C. Attachment organization in suicide prevention research: preliminary findings and future directions in a sample of inpatient adolescents. Crisis. 2014;35(1):60-6.

10. Falgares G, Marchetti D, De Santis S, Carrozzino D, Kopala-Sibley DC, Fulcheri M et al. Attachment styles and Suicide-Related behaviors in adolescence: the mediating role of Self-Criticism and Dependency. Front psychiatry [Internet]. 10 Mar 2017 [cité 5 févr 2025];8. Disponible sur: https://www.frontiersin.org/journals/psychiatry/articles/https://doi.org/10.3389/fpsyt.2017.00036/full

11. Macneil S, Roderbourg L, Orri M, Geoffroy MC, Mcgrath JJ, Renaud J, et al. Attachment styles and suicidal thoughts and behaviors: a meta-analysis. J Soc Clin Psychol août. 2023;42(4):323-64.

12. Teicher MH, Samson JA, Anderson CM, Ohashi K. The effects of childhood maltreatment on brain structure, function and connectivity. Nat Rev Neurosci 19 Sept. 2016;17(10):652-66.

13. van Bodegom M, Homberg JR, Henckens MJAG. Modulation of the hypothetical-pituitary-adrenal axis by early life stress exposure. Front Cell Neurosci. 2017;11. https://doi.org/10.3389/fncel.2017.00087/full

14. Chen Y, Aitken Z, Hammond D, Thompson A, Marwaha S, Davey C, et al. Adverse childhood experiences and their differential relationships with transdiagnostic mental health outcomes in young adults. Psychol Med 22 Mai. 2025;55:e147.

15. Herzog JI, Schmahl C. Adverse childhood experiences and the consequences on Neurobiological, Psychosocial, and somatic conditions across the lifespan. Front Psychiatry. 2018;9:420.

16. Vyas N, Wimberly CE, Beaman MM, Kaplan SJ, Rasmussen LJH, Wertz J, et al. Systematic review and meta-analysis of the effect of adverse childhood experiences (ACEs) on brain-derived neurotrophic factor (BDNF) levels. Psychoneuroendocrinology Mai. 2023;151:106071.

17. Kobrinsky V, Siedlecki KL. Mediators of the relationship between adverse childhood experiences (ACEs) and symptoms of Anxiety, Depression, and suicidality among adults. J Child Adolesc Trauma Jun. 2023;16(2):233-46.

18. Kong SS, Kang DR, Oh MJ, Kim NH. Attachment insecurity as a mediator of the relationship between childhood trauma and adult dissociation. J Trauma Dissociation Off J Int Soc Study Dissociation ISSD. 2018;19(2):214-31.

19. Leben Novak L, Gomboc V, Poštuvan V, De Leo D, Rosenberg Z, Drobnič Radobuljac M. The influence of insecure attachment to parents on adolescents' suicidality. Int J Environ Res Public Health 5 févr. 2023;20(4):2827.

20. Hawton K, Bale L, Brand F, Townsend E, Ness J, Waters K, et al. Mortality in children and adolescents following presentation to hospital after non-fatal self-harm in the multicentre study of Self-harm: a prospective observational cohort study. Lancet Child Adolesc Health févr. 2020;4(2):111-20.

21. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The adverse childhood experiences (ACE) study. Am J Prev Med Mai. 1998;14(4):245-58.

22. Armsden GC, Greenberg MT. The inventory of parent and peer attachment: individual differences and their relationship to psychological well-being in adolescence. J Youth Adolesc. 1987;16(5):427-54.

23. Venta A, Harmon J, Abate A, Marshall K, Mouton-Odum S. Pilot data supporting an attachment-based theory of adolescent social media use. Child Adolesc Ment Health Sept. 2019;24(3):274-82.

24. Kovacs M. The children's Depression, inventory (CDI). Psychopharmacol Bull. 1985;21(4):995-8.

25. Revah-Levy A, Birmaher B, Gasquet I, Falissard B. The adolescent depression rating scale (ADRS): a validation study. BMC Psychiatry 12 Janv. 2007;7:2.

26. Spielberger CD. State-Trait Anxiety Inventory for Adults [Internet]. 2012. https://doi.apa.org/doi/. Accessed 5 févr 2025.

27. Posner K, Brown GK, Stanley B, Brent DA, Yershova KV, Oquendo MA, et al. The Columbia-Suicide severity rating scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry déc. 2011;168(12):1266-77.

28. Brent DA, Horowitz LM, Grupp-Phelan J, Bridge JA, Gibbons R, Chernick LS, et al. Prediction of suicide attempts and suicide-related events among
adolescents seen in emergency departments. JAMA Netw Open 1 févr. 2023;6(2):e2255986.

29. Cyr C, Euser EM, Bakermans-Kranenburg MJ, Van IJzendoorn MH. Attachment security and disorganization in maltreating and high-risk families: a series of meta-analyses. Dev Psychopathol. 2010;22(1):87-108.

30. Leadbeater BJ, Kuperminc GP, Blatt SJ, Hertzog C. A multivariate model of gender differences in adolescents' internalizing and externalizing problems. Dev Psychol Sept. 1999;35(5):1268-82.

31. Zahn-Waxler C, Klimes-Dougan B, Slattery MJ. Internalizing problems of childhood and adolescence: prospects, pitfalls, and progress in Under-standing the development of anxiety and depression. Dev Psychopathol. 2000;12(3):443-66.

32. Observatoire national de la protection de l'enfance. Les chiffres clés de la protection de l'enfance au 31 décembre 2021 [Key figures in child protection as of December 31, 2021; Statistical report]. France Enfance Protégée; 2023. https://onpe.gouv.fr/system/files/publication/note_chiffres_cles_pe_2021.xlsx.pdf

33. Sharp C, Venta A, Vanwoerden S, Schramm A, Ha C, Newlin E, et al. First empirical evaluation of the link between attachment, social cognition and borderline features in adolescents. Compr Psychiatry Janv. 2016;64:4-11.

34. Katzman W, Papouchis N. Effects of childhood trauma on mentalization capacities and dissociative experiences. J Trauma Dissociation Off J Int Soc Study Dissociation ISSD. 2023;24(2):284-95.

35. Cohen-Bausi O, Shahovsky O, Haruvi-Catalan L, Benaroya-Milshtein N, Fennig S, Barzilay S. The mediating role of emotional dysregulation in the relationship between anxious attachment and suicidal behavior in children admitted to an emergency department. Child Psychiatry Hum Dev [Internet] 9 mai 2025 [cité 10 août 2025]; Disponible sur: https://doi.org/10.1007/s10578-025-01844-0

36. Schulte-Frankenfeld PM, Breedveld JF, Brouwer ME, van der Spek N, Bosmans G, Bockting CL. Effectiveness of Attachment-Based family therapy for suicidal adolescents and young adults: a systematic review and Meta-Analysis. Clin Psychol Eur déc. 2024;6(4):e13177.

37. Midgley N, O'Keeffe S, French L, Kennedy E. Psychodynamic psychotherapy for children and adolescents: an updated narrative review of the evidence base. J Child Psychother. 2017;43(3):307-29.

38. Rossouw TI, Fonagy P. Mentalization-based treatment for self-harm in adolescents: a randomized controlled trial. J Am Acad Child Adolesc Psychiatry déc. 2012;51(12):1304-e13133.

39. Target M, Fonagy P, Shmueli-Goetz Y. Attachment representations in school-age children: the development of the child attachment interview (CAI). J Child Psychother Janv. 2003;29(2):171-86.

40. Berens AE, Jensen SKG, Nelson CA. Biological embedding of childhood adversity: from physiological mechanisms to clinical implications. BMC Med 20 Juill. 2017;15(1):135.

41. Koss KJ, Gunnar MR. Annual research review: early adversity, the hypothetical-pituitary-adrenocortical axis, and child psychopathology. J Child Psychol Psychiatry Avr. 2018;59(4):327-46.

42. Bernard K, Frost A, Bennett CB, Lindhiem O. Maltreatment and diurnal cortisol regulation: a meta-analysis. Psychoneuroendocrinology Avr. 2017;78:57-67.

43. Leroux PA, Dissaux N, Le Reste JY, Bronsard G, Lavenne-Collot N. Association between Hpa axis functioning and mental health in maltreated children and adolescents: a systematic literature review. Child Basel Switz 3 août. 2023;10(8):1344.

44. McCrory EJ, Gerin MI, Viding E. Annual research review: childhood maltreatment, latent vulnerability and the shift to preventative psychiatry - the contribution of functional brain imaging. J Child Psychol Psychiatry Avr. 2017;58(4):338-57.

45. Cheng X, Chen J, Zhang X, Wang T, sun J, Zhou Y, et al. Characterizing the Temporal dynamics of intrinsic brain activities in depressed adolescents with prior suicide attempts. Eur Child Adolesc Psychiatry. 2024;33(4):1179-91.

46. Ho TC, Walker JC, Teresi GI, Kulla A, Kirshenbaum JS, Gifuni AJ et al. Default mode and salience network alterations in suicidal and non-suicidal self-injurious thoughts and behaviors in adolescents with depression. Transl Psychiatry. 12 janv. 2021;11(1):38.

47. Zhou HX, Chen X, Shen YQ, Li L, Chen NX, Zhu ZC, et al. Rumination and the default mode network: meta-analysis of brain imaging studies and implications for depression. Neurolmage 2020;206:116287.

48. Ehrenthal JC, Levy KN, Scott LN, Granger DA. Attachment-related regulatory processes moderate the impact of adverse childhood experiences on stress reaction in borderline personality disorder. J Personal Disord Janv. 2018;32(Suppl):93-114.

49. Roeske J, Long X, Perdue MV, Long M, Geeraert B, Ghasoub M, et al. Sex differences in maturational timing of amygdala and prefrontal cortex volumes and white matter tract microstructure. Dev Cogn Neurosci 1 août. 2025;74:101568.

50. Racine N, Greer K, Dimitropoulos G, Collin-Vézina D, Henderson JL, Madigan S. Youth engagement in child maltreatment research: Gaps, barriers, and approaches. Child Abuse Negl Mai. 2023;139:106127.

51. Burbach L, Brémault-Phillips S, Nijdam MJ, McFarlane A, Vermetten E. Treatment of posttraumatic stress disorder: a state-of-the-art review. Curr Neuropharmacol. 2024;22(4):557-635.

52. Schweizer S, Gotlib IH, Blakemore SJ. The role of affective control in emotion regulation during adolescence. Emot Wash DC févr. 2020;20(1):80-6.

53. van der Kolk BA. The body keeps the score: Brain, mind, and body in the healing of trauma. New York, NY, US: Viking; 2014. xvi, 443 p. (The body keeps the score: Brain, mind, and body in the healing of trauma).

54. Taylor SE, Klein LC, Lewis BP, Gruenewald TL, Gurung RA, Updegraff JA. Biobehavioral responses to stress in females: tend-and-befriend, not fight-or-flight. Psychol Rev Juill. 2000;107(3):411-29.

55. Barzilay S, Brunstein Komek A, Apter A, Carli V, Wasserman C, Hadlaczky G, et al. Bullying victimization and suicide ideation and behavior among adolescents in Europe: a 10-Country study. J Adolesc Health Off Publ Soc Adolesc Med août. 2017;61(2):179-86.

56. Morken IS, Viddal KR, von Soest T, Wichström L. Explaining the female preference in adolescent Depression-A Four-Wave cohort study. Res Child Adolesc Psychopathol Juill. 2023;51(6):859-69.

57. Stadtler H, Neigh GN. Sex differences in the neurobiology of stress. Psychiatr Clin North Am Sept. 2023;46(3):427-46.

58. Tintori A, Pompili M, Ciancimino G, Corsetti G, Cerbara L. The developmental process of suicidal ideation among adolescents: social and psychological impact from a nation-wide survey. Sci Rep 28 Nov. 2023;13(1):20984.

59. Goltser-Dubner T, Benarroch F, Lavon M, Amer R, Canetti L, Giesser R et al. Childhood trauma cortisol and immune cell glucocorticoid transcript levels are associated with increased risk for suicidality in adolescence. Mol Psychiatry. 2025.

60. Centers for Disease Control and Prevention. Youth risk behavior survey data summary & trends report: 2011-2021. U.S. Department of Health and Human Services; 2023.

61. Canady VA. CDC data finds Sharp rise in suicide attempts among teen girls amid COVID-19. Ment Health Wkly 21 Juill. 2021;31(24):1-3.

62. Farbstein D, Lukito S, Yorke I, Wilson E, Crudgington H, El-Aalem O, et al. Risk and protective factors for self-harm and suicide in children and adolescents: a systematic review and meta-analysis protocol. BMJ Open 25 Nov. 2022;12(11):e058297.

63. NHS Digital. (2023). Mental health of children and young people in England, 2023: Wave 4 follow-up to the 2017 survey. https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2023-wave-4-follow-up

64. Danielsen HE, Finserås TR, Andersen AIO, Hjetland GJ, Woodfin V, Skogen JC. Mirror, mirror on my screen: focus on self-presentation on social media is associated with perfectionism and disordered eating among adolescents. Results from the LifeOnSoMe-study. BMC Public Health 10 Sept. 2022;24(1):2466.

65. Nesi J, Burke TA, Bettis AH, Kudinova AY, Thompson EC, MacPherson HA, et al. Social media use and self-injurious thoughts and behaviors: A systematic review and meta-analysis. Clin Psychol Rev 1 Juill. 2021;87:102038.

66. Orben A, Tomova L, Blakemore SJ. The effects of social deprivation on adolescent development and mental health. Lancet Child Adolesc Health août. 2020;4(6):634-40.

67. Calear AL, Christensen H, Freeman A, Fenton K, Busby Grant J, van Spijker B, et al. A systematic review of psychosocial suicide prevention interventions for youth. Eur Child Adolesc Psychiatry Mai. 2016;25(5):467-82.

68. Linehan MM, Comtois KA, Murray AM, Brown MZ, Gallop RJ, Heard HL, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry Juill. 2006;63(7):757-66.

69. Häggman-Laitila A, Salokekkilä P, Karki S. Young people's preparedness for adult life and coping after foster care: a systematic review of perceptions and experiences in the transition period. Child Youth Care Forum 1 Oct. 2019;48(5):633-61.

70. Bateman A, Fonagy P. Mentalization-Based treatment. Psychoanal Inq 1 Nov. 2013;33(6):595-613.
71. Hodgdon HB, Kinniburgh K, Gabowitz D, Blaustein ME, Spinazzola J. Development and implementation of Trauma-Informed programming in youth residential treatment centers using the ARC framework. J Fam Violence 1 Oct. 2013;28(7):679-92.

72. Janssens A, Deboutte D. Screening for psychopathology in child welfare: the strengths and difficulties questionnaire (SDQ) compared with the Achenbach system of empirically based assessment (ASEBA). Eur Child Adolesc Psychiatry Nov. 2009;18(11):691-700.

73. Domon-Archambault V, Terradas MM, Drieu D, De Fleurian A, Achim J, Poulain S, et al. Mentalization-Based training program for child care workers in residential settings. J Child Adolesc Trauma 21 Junin. 2019;13(2):239-48.

74. Dorado JS, Martinez M, McArthur LE, Leibovitz T. Healthy environments and response to trauma in schools (HEARTS): A whole-school, multi-level, prevention and intervention program for creating trauma-informed, safe and supportive schools. Sch Ment Health Multidiscip Res Pract J. 2016;8(1):163-76.

75. Guessoum SB, Lachal J, Radjack R, Carretier E, Minassian S, Benoit L, et al. Adolescent psychiatric disorders during the COVID-19 pandemic and lockdown. Psychiatry Res Sept. 2020;291:113264.

76. Bloom SL, Farragher B. Restoring sanctuary: A new operating system for trauma-informed systems of care. New York, NY, US: Oxford University Press; 2013. xviii, 314 p. (Restoring sanctuary: A new operating system for trauma-informed systems of care).

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