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This meta-analysis synthesized the distribution of attachment classifications as coded with the Cassidy-Marvin Preschool Attachment Coding System and the Main-Cassidy Six-Year-Old System. These systems have extended scholars' capacity to measure differences in the developing child-parent attachment relationship, and its sequelae, beyond the infancy period; however, the global distribution of the attachment categories in these systems, and the potential factors influencing this distribution, remain unknown. The meta-analysis included 97 samples (N = 8,186 children; 55% boys), mostly drawn from North American or European populations (89%; M = 76% White). Results indicated that the distribution of child-mother attachment was 53.5% secure, 14.0% avoidant, 11.0% ambivalent, and 21.5% disorganized/controlling. Moderator analyses showed that rates of security were lower, and rates of disorganization were higher, in samples of at-risk families, specifically when children were exposed to maltreatment. Variations in the procedure also moderated the distribution. The discussion calls for greater unity around methodological practices.

Aims: Based on interviews with leading researchers and researcher-clinicians in fields allied to attachment research, this paper describes participants’ perceptions of contemporary attachment research in the developmental tradition. Method: Semi-structured qualitative interviews were conducted with 13 research leaders in applied disciplines cognate to attachment research. Results: Participants perceived attachment research as having played a foundational role for developmental science, including highlighting the importance of a developmental perspective and attention to early caregiving experiences. They also identified important contemporary strengths in developmental attachment research, including the observational acuity and insightfulness of its measures, its attention to dyadic processes in contrast to much of biomedicine, the development of a number of attachment-based interventions with well-articulated mechanisms of action, and the capacity of developmental attachment concepts to resonate with clinical and popular audiences. However, participants suggested that the developmental tradition is also perceived as having a comparatively high ‘cost of entry’, and consequently they warned that it has become somewhat separated from wider developmental science, with its growing prominence of biological research, scalability of methods, and less reliance on theory. Conclusions: Participants perceived both strengths and weaknesses to contemporary developmental attachment research. However they felt that the classic concerns of developmental attachment research were placing the field potentially at odds with current trends in developmental science.

Peer reviewed: True, Acknowledgements: We would like to thank Roary Neat and all other members of the public involvement panel who contributed to this work., OBJECTIVE: In order to address the lack of data on the health and healthcare needs of trans and non-binary adults, NHS England includes questions asking about both gender and trans status in its surveys to support quality improvement programmes.We used self-reported data from the GP Patient Survey to answer the research question: what are the demographic characteristics, health conditions and healthcare experiences of trans and non-binary adults in England? DESIGN/SETTING: Nationally representative, population-based cross-sectional survey in England with survey data collection from January to March 2021. PARTICIPANTS: 840 691 survey respondents including 6333 trans and non-binary adults. OUTCOMES: We calculated weighted descriptive statistics, and using logistic regression explored 15 long-term physical and mental health conditions, and 18 patient experience items, covering overall experience, access, communication and continuity. RESULTS: Trans and non-binary adults were younger, more likely to be from Asian, black, mixed or other ethnic groups and more likely to live in more deprived parts of the country. Age-specific patterns of long-term conditions were broadly similar among trans and non-binary adults compared with all other survey respondents, with some variation by condition. Overall, inequalities in long-term health conditions were largest for autism: OR (95% CI), 5.8 (5.0 to 6.6), dementia: 3.1 (2.5 to 3.9), learning disabilities: 2.8 (2.4 to 3.2) and mental health: 2.0 (1.9 to 2.2), with variation by age. In healthcare experience, disparities are much greater for interpersonal communication (OR for reporting a positive experience, range 0.4 to 0.7 across items) than access (OR range 0.8 to 1.2). Additionally, trans and non-binary adults report much higher preference for continuity 1.7 (1.6 to 1.8), with no evidence of any differences in being able to see or speak to a preferred general practitioner. CONCLUSION: This research adds up to date evidence about population demographics, health and healthcare needs to support healthcare improvement for trans and non-binary adults.

Clinical practitioners are frequently encouraged, through literature, training, and policy, to learn, understand, refer to and use their knowledge of attachment theory and research when working to meet the needs of children and families. However, there has been very little empirical study of how practitioners understand and perceive the relevance of attachment concepts and methods. Q-methodology was used to examine the perceptions of attachment knowledge and its applications for practice among 30 UK clinicians working with children and an international group of 31 attachment researchers. Factor analysis revealed three perspectives, described as: i) pragmatic, developmental, and uncertain, ii) academic, and iii) autodidactic and therapeutic. Participants agreed on core tenants of theory, their aspirations for clinical practice and the inaccessibility of current assessment measures for practitioners. Yet they diverged on their understandings of attachment insecurity, disorganisation, and the implications of both for various aspects of child development., Wellcome; NIHR School of Primary Care Research

PURPOSE: We aimed to explore participants' experiences of mental health during an acceptance and commitment therapy (ACT)-based guided self-help intervention to support weight management in adults with overweight or obesity during the COVID-19 pandemic (SWiM-C: Supporting Weight Management during COVID-19). METHODS: We conducted semi-structured telephone interviews with twenty participants and used reflexive thematic analysis to identify patterns of meaning across the dataset relevant to mental health. RESULTS: Four themes were conceptualized: i) Mental health changes associated with SWiM-C, ii) External factors negatively impacted mental health and intervention engagement, iii) Use and impact of coping responses, and iv) Intervention preferences based on psychological needs. CONCLUSIONS: Findings suggest that participants were exposed to multiple factors, both related to and external to the intervention, that negatively impact their mental health, yet ACT-based aspects of the SWiM-C intervention appeared to support participants to adaptively manage the decline in their mental health. The findings can be used to inform the development of future weight management interventions, such as through intervention personalization and the inclusion of more strategies that target emotional regulation.Trial registration: ISRCTN 12107048, https://www.isrctn.com/ISRCTN12107048., This project is funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research Programme (Reference Number RP-PG-0216-20010). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. RR is supported the NIHR Programme Grants for Applied Research Programme (Reference Number RP-PG-0216-20010). RAJ, ALA, and SJG are supported by the Medical Research Council (MRC) (Grant MC_UU_00006/6). The University of Cambridge has received salary support in respect of SJG from the National Health Service in the East of England through the Clinical Academic Reserve.

ObjectivesPreventative coping is an underexplored aspect of coping behaviour. Specifically, coping is a key concern in stroke survivor accounts, but this has yet to be investigated with reference to secondary prevention.DesignSecondary analysis of a qualitative data set comprising semistructured interviews of 22 stroke survivors recruited from five general practices in the East of England. The topic guide included exploration of advice and support given by their doctor on medication and lifestyle. The interviews were coded using thematic analysis.ResultsThe accounts emphasised individual responsibility. Two key themes were identified, which foregrounded the role of self-concept for coping: (a) striving to be ‘good’, (b) appeal to ideas of ‘personality’. In the former, preventative behaviour was depicted in moralistic terms, with the doctor as an adjudicator. In the latter, participants attributed their coping behaviour to their personality, which might help or hinder these efforts.ConclusionsWe highlight that coping was characterised by survivors as something enacted by the individual self, and consider how constructions of self may impact preventative coping efforts.

INTRODUCTION: The cost-effectiveness and long-term health impact of behavioural weight management programmes depends on post-treatment weight-loss maintenance. Growing evidence suggests that interventions using acceptance and commitment therapy (ACT) could improve long-term weight management. We developed an ACT-based, guided self-help intervention to support adults who have recently completed a behavioural weight loss programme. This study will assess the feasibility and acceptability of this type of intervention and findings will inform the development of a full-scale trial. METHODS AND ANALYSIS: This is a pragmatic, randomised, single-blind, parallel group, two-arm, feasibility study with an embedded process evaluation. We will recruit and randomise 60 adults who have recently completed a behavioural weight loss programme to the ACT-based intervention or standard care, using a computer-generated sequence with 2:1 allocation stratified by diabetes status and sex. Baseline and 6-month measurements will be completed using online questionnaires. Qualitative interviews will be conducted with a subsample of participants and coaches about their experiences at 3 (mid-intervention) and 6 (postintervention) months. Feasibility and acceptability of the intervention, and a full-scale trial will be assessed using a number of outcomes, including adherence to, and engagement with the intervention, recruitment and retention rates, proportion of missing data for each outcome measure, participants' experiences of the intervention and study, and coaches' experiences of delivering intervention support. Quantitative and qualitative findings will be integrated and summarised to contribute to the interpretation of the main feasibility evaluation findings. Value of information methods will be used to estimate the decision uncertainty associated with the intervention's cost-effectiveness and determine the value of a definitive trial. ETHICS AND DISSEMINATION: Ethical approval was received from Cambridge South Research Ethics Committee on 15/03/2021 (21/EE/0024). This protocol (V.2) was approved on 19 April 2021. Findings will be published in peer-reviewed scientific journals and communicated to other stakeholders as appropriate. TRIAL REGISTRATION NUMBER: ISRCTN12685964., This study was funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research Programme (RP-PG-0216-20010). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Many healthcare systems are organised such that General Practitioners (GPs) often have a key role in identifying autism spectrum disorders (hereafter collectively referred to as autism) in children. In this review, we explored what GPs know about autism and the factors that influence their ability to identify and manage care for their patients with autism in practice. We conducted a systematic narrative review using eight electronic databases. These included Embase and MEDLINE via Ovid, Web of Knowledge, PsycINFO via Ebscohost, PubMed, Scopus, ProQuest Dissertations and Thesis, and Applied Social Sciences Index and Abstracts (ASSIA) via ProQuest. Our search yielded 2,743 citations. Primary research studies were included, and we did not impose any geographical, language or date restrictions. We identified 17 studies that met our inclusion criteria. Studies included in the review were conducted between 2003 and 2019. We thematically synthesised the material and identified the following themes: the prototypical image of a child with autism; experience, sources of information, and managing care; barriers to identification; strategies to aid in identification; and characteristics that facilitate expertise. Together, the findings from this review present a mixed picture of GP knowledge and experiences in identifying autism and managing care for children with the condition. At one end of the continuum, there were GPs who had not heard of autism or endorsed outmoded aetiological theories. Others, however, demonstrated a sound knowledge of the conditions but had limited confidence in their ability to identify the condition. Many GPs and researchers alike called for more training and this might be effective. However, framing the problem as one of a lack of training risks silences the array of organisational factors that impact on a GP's ability to provide care for these patients.

Introduction: On average, aspects of mental health improve following behavioural weight management programmes, yet this is not the case for all participants. It is important to identify those at risk of harm to provide more effective psychological support. We aimed to identify participant characteristics associated with changes in depression and anxiety in participants of a behavioural weight management programme. Methods: In the Weight loss Referrals for Adults in Primary care trial, 1,267 adults with body mass index ≥28 kg/m2 were randomized to brief intervention, or WW (formerly weight watchers) for 12-weeks or 52-weeks and followed for 5 years. We used linear and multinomial regression to explore the association between participant characteristics and changes in depression and anxiety (measured by the hospital anxiety and depression scale). Where possible, the impact of missing data was investigated using multiple imputation. Results: Higher baseline anxiety was associated with decreases in anxiety symptoms and increases in depression symptoms from baseline to follow-up. Higher baseline depression was associated with decreases in depression symptoms and increases in anxiety symptoms from baseline to follow-up. The magnitude of the associations was small. No further characteristics were consistently associated with changes in mental health. Discussion: Evidence suggests that baseline depression and anxiety may indicate how depression and anxiety symptoms change during and after attending WW. Measurement of depression and anxiety at the start of a behavioural weight management programme and subsequent monitoring may facilitate timely psychological support if a deterioration in mental health is identified. Further research in large and diverse participant samples is required to clarify the findings.

Attachment concepts are used in diverging ways, which has caused confusion in communication among researchers, among practitioners, and between researchers and practitioners, and hinders their potential for collaboration. In this essay we explore how attachment concepts may vary in meaning across six different domains: popular discourses, developmental science, social psychological science, psychiatric diagnosis, psychotherapy, and child welfare practice. We attempt to typify these forms of attachment discourse by highlighting points of convergence, divergence, and relay between the different domains. Our general conclusions are that diversity in the use of attachment concepts across different domains of application has been largely unrecognised, and that recognition of these differences would reduce confusion, help identify sites where infrastructure needs to be developed to support coordination, and strengthen opportunities for collaboration to mutual benefit. We suggest that academic attachment discourse would benefit from clarification of core terminology, including: “attachment”, “internal working model”, “trauma”, and “dysregulation”.

The term ‘toxic trio’ was coined to describe the risk of child abuse and neglect stemming from a combination of domestic violence, parental mental health issues and/or learning disability, and parental alcohol and/or drug misuse (Brandon, 2009). Although concerns about the language have been raised in some quarters, it has become a dominant reference point in children’s social care in England and, to an extent, internationally over the past two decades. It has become embedded in the family justice system, child protection assessment processes and national data collection. There is evidence that each factor in isolation can lead to worse child outcomes, although this is of mixed quality and far from comprehensive. This article reports the results of a systematic review of evidence relevant to the relationship between the ‘toxic trio’ factors in combination and child maltreatment, identifying 20 papers. Despite the term’s currency, we found little quality evidence of the incidence of the ‘trio’ factors in child maltreatment, little consideration of intersectionality and almost no theoretical examination of the supposed relationships. Such studies as have been conducted have too rarely taken into account, or controlled for, contextual factors, such as the socioeconomic circumstances or the ethnicity of the families, or children’s ages. The discrepancy between the priority given to the ‘toxic trio’ and the paucity of the evidence-base makes a case for a shift away from over-simplified attributions of parental risk in policy and practice, and towards greater attention being given to other significant factors for child protection.

It is well-known that people with an intellectual disability often face a host of health inequalities and co-morbidities. These include childhood obesity, mental health problems, and challenging behaviour. People with an intellectual disability also have reduced life expectancy. GPs are uniquely placed to advocate for and signpost these patients, ensuring they have access to appropriate support. However, it is often unclear what resources are, in reality, both available and beneficial. Here we aim to summarise some of the common inequalities and complexities when working with patients with an intellectual disability and provide an overview of some potentially helpful services.

Anatomy education by cadaveric dissection teaches medical students not only the formal curriculum in human anatomy, but also a ‘hidden curriculum’ whereby they learn the attitudes, identities and behaviours expected of doctors. While dissection has been investigated as a challenge to and training in emotional regulation, little attention has been paid hitherto to the forms of medical knowledge and identity which students encounter and develop in the dissection room. This study analyses a corpus of 119 tributes written by three consecutive cohorts of first-year medical students at a university to their cadaveric donors. We employ a Foucauldian discourse analysis methodology, seeking to elucidate the features of the subject position, the narrative ‘I’ or ‘we’ of the tributes, and the modes of knowledge which operate between that subject position and its object, the donor. We observe that students find themselves in a transitional state between personal and scientific modes of knowledge of the human, which correspond to different models of the subject position occupied by the student. While in many tributes these modes exist in an uneasy disjunction, others employ creative reflection to suggest new modes of knowledge and identity which may inform ethical practice.

Background: Millions of children worldwide are brought up in institutional care settings rather than families. These institutions vary greatly both in terms of their organizational principles and structure and in the quality of care they provide. Although universally recognized as providing sub-optimal caregiving environments there is less consensus on how to interpret the evidence relating to the size, range and persistence of their impact on children’s development and well-being. This has led to disagreement as to whether policy should focus on eliminating, transforming or improving institutions. Methods: We reviewed the literature on child institutionalisation and deinstitutionalisation from a global perspective. This included a survey of historical and cultural trends and current levels of institutional care, a systematic review and meta-analysis of developmental sequelae, and a largely qualitative review of factors found to predict individual variations in such outcomes. Findings: The numbers of children in institutional care have varied enormously over the years and from region-to-region - driven by a range of political, cultural and socio-economic factors. Currently, although precise and up-to-date figures are not available, millions of children across the globe are known to be housed in institutions. We found strong negative associations between institutional care and children’s development, especially in relation to developmental levels of physical growth, cognition and attention. Significant but smaller associations were found for socio-emotional development and mental health. Leaving institutions for foster/family care is associated with significant recovery for some (e.g., growth and cognition) outcomes but not for others (e.g., attention). The length of time in institutions was associated with increased risk of adverse sequelae and diminished chance of recovery. However, it was not possible to disentangle the association between developmental outcomes and the duration of institutional care as opposed to its timing, as would be required to establish the precise boundaries of sensitive periods. Interpretation: Every effort should be made to minimise children’s exposure to institutional care. There is an urgent need to reduce the numbers of children entering and to increase the numbers leaving institutions. Where institutional care is considered absolutely necessary, length of stays should be as short as possible, even if care is adequate. To this end, preventive approaches should be promoted, keeping children in birth families when possible. When not possible, family-based care alternatives should be supported, including extended kinship networks, adoption and stable high quality fostering. Policy recommendations to support the implementation of these care reform goals at the global, regional and local levels, will be set out in a separate policy document following on from this paper.

For Vicedo, ‘putting attachment in its place’ seems to entail two aspects. The first is working to understand the rise of attachment theory and its place within the history of knowledge practices. The second is to criticize the validity of attachment theory. In this reply, we appraise three criti- cisms made by Vicedo of attachment theory, chosen as points for 15 sustaining a dialogue. Our main point in this reply is that, in excluding the work of attachment researchers after Ainsworth from consideration, Vicedo’s work is not yet able to properly ‘put attachment in its place’, in either sense of the phrase. At most, she puts Bowlby in the 1950s–1960s in his place, but without speaking effectively to subsequent attachment 20 research. In our view, not just the validity, but the very meaning of attachment as a scientific research programme cannot be understood outside of its temporal context, and the relationship this entails between theory and research, past and future.

This study examined how fathers' adult attachment representations, assessed before the birth of their first child, predict feeding practices with their 8-month-old infants. Fathers have been underrepresented in child feeding research, particularly in longitudinal and observational studies. Feeding is a key parenting task of infancy and a growing number of studies have begun to explore the connection between attachment and parental feeding practices and behavior, revealing a clear link between mothers' adult attachment and how they feed their children. This is the first longitudinal examination of attachment as a prenatal predictor of fathers' infant feeding behavior. Participants were 118 first-time fathers and their infants. Adult Attachment Interviews were conducted in the third trimester of pregnancy, and father-infant feeding interactions were observed at home when the infant was 8-months-old. Videotaped feedings were coded using Chatoor's Feeding Scale (1997). Compared to other fathers, (1) those with secure attachment representations were more attuned to their infants during feeding, (2) those with dismissing representations were less attuned, and (3) those with unresolved trauma displayed more controlling behaviors. Fathers were more controlling with their sons than their daughters across all attachment representations. Study results suggest that father's infant feeding behaviors may influence by their own attachment representations. The links to fathers' controlling feeding practices are noteworthy because of the negative implications controlling parental feeding practices can have on child outcomes. The prediction of paternal feeding behaviors from assessments conducted prenatally has important intervention implications.

Distinguishing autism spectrum behaviours from behaviours relating to disorganised attachment can be challenging. There is, for instance, a notable overlap between both conditions in terms of behaviours deemed stereotypical. In addition, there are also similarities regarding some atypical social overtures. Responding to this overlap has been the subject for much debate in the literature. Disorganised attachment was first introduced and conceptualised by the attachment researcher, Mary Main. Main is considered the leading authority on coding this phenomenon. During the course of archival research, we obtained Main’s notes on coding attachment in a group of fifteen children with autism spectrum conditions (hereafter ASC). Drawing on these texts, this paper explores Main’s reasoning when making distinctions between ASC and attachment at the behavioural level. Our approach is informed by Chang’s (2017) argument for the potential of “history as complementary science. Analysis indicate that, for Main, frequency and timing was an important differential factor when attributing a behaviour to either ASC or the child’s attachment pattern., The authors wish to thank the Wellcome Trust [Grant WT103343MA] and the NIHR School of Primary Care Research [RG94577]

ArgumentThis article explores historical sociology as a complementary source of knowledge for scientific research, considering barriers and facilitators to this work through reflections on one project. This project began as a study of the emergence and reception of the infant disorganized attachment classification, introduced in the 1980s by Ainsworth’s student Mary Main, working with Judith Solomon. Elsewhere I have reported on the findings of collaborative work with attachment researchers, without giving full details of how this came about. Here, I will offer personal reflections arising from the process, and my work in what Hasok Chang has called history as “complementary science.”

What might clinicians make of Bowlby’s first patient if he were seen by services today? How might thinking with Bowlby help us critically consider children whose presentations span a number of diagnoses, and children who do not readily fit any existing diagnostic category? We will consider these questions through exploration of Bowlby’s writings, as well as review of the literature on diagnosis, trauma, and caregiving environments. We identify tensions between the three key legacies of Bowlby’s work: the focus on family systems; attachment theory as a theory of individual development; and psychiatric classification of attachment. In doing so, we will use conversation with Bowlby’s ideas as the basis for a consideration of the purpose and function of diagnosis, Wellcome Trust

‘Patient experience’ has become a significant concept in contemporary healthcare administration and policy, and the object of a good deal of caring and useful concern. Yet it is also a concept somehow rather set adrift. This article traces six different factors that have contributed to concern with patient experience, but that now lead to tensions between the multiple, potentially contradictory investments in the concept. Disentangling the different investments in the idea of patient experience offers greater clarity in evaluating criticisms that have been made of the solicitation and reporting of patient (and carer) experience data and affords an opportunity to examine what is at stake in both conceptual and policy discussions.