Attachment in school-age children with Autism Spectrum Disorder: moving to the level of representations to meet their needs
Creators: name: Giannotti, Michele
Publisher: name: Universit� degli studi di Trento
Year: 2020

description: Despite a large body of research has investigated child attachment during middle childhood, only a limited number of studies has focused on children with Autism Spectrum Disorder. Additionally. The few studies available on this topic have exclusively used self-reported measures to assess quality of attachment, overlooking the role of internal representations, which are considered to play a fundamental role since attachment is internalized. Therefore, no studies examined the way in which child attachment representations are associated with child diagnosis, parenting and caregiving environment in ASD. 
In the first study, we assessed attachment representations in children with ASD, Learning Disabilities (LD) and Typical development (TD). In particular, we investigated possible group differences on perceived attachment to parents, self-protective strategies and quality of attachment implicit representations using the Dynamic Maturational Model of Attachment and Adaptation (DMM). The Study 2 focused on the caregiving environment and its influence on child attachment implicit representations. To this aim, we assessed parenting stress and parental style in mothers and fathers of children with ASD and TD, examining whether parents of children with ASD differ from those of matched TD group. Secondly, we examined which caregiving environment dimensions contribute significantly in predicting at-risk attachment representations, assessing separately the contribution of maternal and paternal parenting stress and parental interactive social style. 
In the third study maternal and paternal attachment style were assessed to test the hypothesis of attachment continuity across generations. Firstly, we investigated whether parents of children of ASD reported higher level of attachment-related avoidance/anxiety compared to their TD counterpart. Next, the associations between attachment style of both mothers and fathers and quality of child attachment representations was tested, by examining the moderation effect of child ASD diagnosis. 
The Study 4 investigated the role of other potential child attachment predictors. Due higher co-occurrence of ASD and difficulties in identifying, describing and distinguishing one?s own feelings, the predictive effect of alexithymia on child explicit attachment representations was tested. Moreover, we also examined whether children with ASD reported higher level of alexithymia compared to controls. 
The Study 1 showed that children with ASD are able to develop secure and coherent attachment implicit representations, albeit with a lesser extent compared to typically developing children. They were able to engage the attachment interview, confirming the suitability of this method in this clinical sample. Importantly, children with ASD showed high-risk attachment implicit representations and greater presence of unresolved trauma and modifiers, despite no differences emerged on perceived attachment to parents. The lack of group difference on perceived attachment suggested that implicit and explicit attachment representations of children with ASD originate from different sources of information. It is plausible that low reflective functioning, impaired metacognition as well as altered psychobiological processes of children with ASD contributed to attachment maladaptive information processing. Secondly, we replicated the well-established finding of higher parenting distress in parents of children with ASD compared to controls also in fathers. Moreover, the Study 2 documented less didactic and limit/setting style in parents of children with ASD. In accordance to a bidirectional perspective, these parenting behaviors were interpreted as parental functional responses to adapt to child unusual social-communication. Interestingly, data revealed a significant effect of maternal parenting stress and social exchange style on child attachment implicit representations. Thus, the study supports the coexistence of both child-driven and parent-driven effects in the context of parent-child relationship in ASD. Similarly, the Study 3 documented that children with ASD who have an insecurely attached primary caregiver showed at-risk attachment implicit representations. In other words, the continuity of attachment security across generations revealed a clear effect in ASD, suggesting that these children may be more susceptible to this mechanism compared to controls. In addition, parents of children with ASD reported higher attachment-related avoidance in comparison to their TD counterpart. This difference could be associated to the significant couple adjustment associated to the impact of rear a child with ASD. In addition, the Study 4 showed that alexithymia, but not ASD predicts perceived attachment to parents highlighting the different nature of attachment explicit and implicit representation. Moreover, our results confirmed higher co-occurrence of alexithymia and ASD also in school-age, extending literature on adulthood. 
Our findings pointed out that children with ASD (without intellectual disability) showed higher rates of at-risk self-protective strategies (attachment pattern). These results may be related to several factors associated with ASD symptoms, such as the more frequent disruptions of interpersonal exchanges with the caregiver across development, the difficulties in social information processing and reflective functioning. The higher exposure to adverse childhood experience (e.g. bullying), may explained the higher occurrence of unresolved trauma in these children. Up to date, to the best of our knowledge, these are the first studies on group differences and parental predictors of attachment implicit representations in school-age children with ASD. Therefore, these studies brought initial data to ASD literature on attachment representations, suggesting that these children are at increased risk of developing maladaptive information processing. Limitations of the studies and clinical implications are discussed.