Associations between attachment‐related symptoms and later psychological problems among international adoptees: Results from the FinAdo study

We examined the associations between attachment‐related symptoms (symptoms of reactive attachment disorder (RAD), symptoms of disinhibited social engagement disorder (DSED), and clinging) and later psychological problems among international adoptees. The study population comprised internationally adopted children (591 boys and 768 girls, 6–15 years) from the ongoing Finnish Adoption (FinAdo) study. Data were gathered with self‐administered questionnaires both from adoptive parents and from adoptees aged over 9 years. Attachment‐related symptoms were measured using of a short (8‐item) questionnaire and later behavioral/emotional problems were assessed using the Child Behavior Checklist (CBCL) and the Five to Fifteen (FTF) scale for attention‐deficit/hyperactivity disorder (ADHD) symptoms. RAD and DSED symptom subscales were associated with an increased risk of emotional and behavioral problems and ADHD. Especially the mixed type of attachment‐related symptoms was strongly associated with later emotional and behavioral problems.     

Prolonged touch screen device usage is associated with emotional and behavioral problems,but not language delay,in toddlers

BackgroundTouch screen devices are now ubiquitous, and their usage by young children is increasing. However, the effects of these devices on young children are still unknown. Therefore, this study aimed to address the associations of touch screen device exposure with symptomatic emotional and behavioral problems and language development in children between the ages of 18 and 36 months.MethodA total of 161 primary caregivers of children between the ages of 18 and 36 months were recruited from the pediatric ward and outpatient clinic at a medical center in southern Taiwan. All caregivers were asked to fill out the Child Behavior Checklist for Ages 1½–5 (CBCL 1½–5) and a questionnaire on basic personal information and touch screen device usage, and they were also interviewed with the Communication and Language Screening Test for Birth to Three Chinese-Speaking Infant-Toddlers (CLST). Independent t-test and one-way ANOVA were used to examine the differences among the categories in the demographic variables and to characterize the touch screen device usage behaviors. Pearson’s correlation was used to analyze the relationship between language delay and the extent of touch screen device exposure. After primary univariate analysis, we used multiple regression models to examine the relationships among the effects of touch screen device usage behaviors on children's emotional and behavioral problems and language development.ResultThe children’s mean age was 25.63 months (SD = 5.35). Children who spent more time on touch screen devices were more likely to have emotional problems (β = .219, p < .010, 95 % CI: .279–1.518), anxious/depressive symptoms (β = .206, p < .050, 95 % CI: .170–1.244), somatic complaints (β = .291, p < .001, 95% CI: .455–1.462), social withdrawal symptoms (β = .194, p < .050, 95 % CI: 0.133–1.150), attention problems (β = .300, p < .001, 95 % CI: .432–1.267), and aggressive behaviors (β = .247, p < .010, 95 % CI: .967–3.983). The effects were not noted on language development (β = −.136, p < .100, 95 % CI: −2.595–.147).ConclusionYoung children who spent more time on touch screen devices were more likely to have emotional problems, anxious/depressive symptoms, somatic complaints, social withdrawal symptoms, attention problems, and aggressive behaviors, but not language delay.     

Attachment Representations and Maternal Confidence: The Mediating Role of Postnatal Depressive Symptoms and Negative Thoughts

Attachment security can act as an inner resource to promote women’s adjustment to motherhood. However, the mechanisms explaining the relationship between attachment representations and maternal adaptation outcomes are not well understood. This study aimed to examine the direct and indirect effects of attachment representations on maternal confidence, through postpartum negative automatic thoughts and depressive symptoms. The sample consisted of 387 postpartum women who completed a cross-sectional online survey including measures of attachment representations, depressive symptoms, postpartum negative automatic thoughts and maternal confidence. Our results showed a significant relationship between more insecure attachment representations and higher depressive symptoms (p?<?.001), but also with more frequent postpartum negative automatic thoughts (p?<?.001); depressive symptoms and postpartum negative automatic thoughts were also inversely associated with women’s maternal confidence (p?<?.001). Moreover, indirect effects of attachment representations on maternal confidence were found, but only through postpartum negative thoughts [attachment-related anxiety: 95% CI?=??0.03/?0.01; attachment-related avoidance: 95% CI?=??0.05/?0.01]. The results of the present study emphasize the important role of the cognitive component of depressive symptomatology (postpartum negative automatic thoughts) in the relationship between attachment representations and maternal confidence, allowing to draw specific implications. We highlight the implications for clinical practice during the perinatal period to address both negative thoughts and women’s maternal confidence.     

Maternal Depression in Families of Children with ADHD: A Meta-Analysis

Although research has demonstrated a relationship between maternal depression and child attention deficit/hyperactivity disorder (ADHD); the strength of the relationship is currently unclear. The results of some studies have found a strong association between maternal depression and child ADHD, while other studies have found little or no association. A meta-analysis was conducted to clarify the strength of the association between maternal depression and child ADHD. The current study included 51 published and unpublished studies that included a quantitative comparison between maternal depression and child ADHD. Mothers of children with ADHD had significantly higher levels of depressive symptoms than mothers of children without ADHD (d?=?0.58; 95% CI [0.43, 0.74]; p?<?.001; k?=?18). The relationship between maternal depressive symptoms and child ADHD symptoms was moderate (r?=?.22; 95% CI [.17, .28]; p?<?.001; k?=?21). 17.11% of mothers of children with ADHD currently met criteria for a depressive disorder (95% CI [11.95, 23.89], p?<?.001, k?=?19). The DSM version used to evaluate child ADHD status was the only moderator that was statistically significant (p?=?.021, k?=?15). Specifically, studies that used the DSM-III or DSM-III-R were associated with larger effect sizes than studies that used the DSM-IV or DSM-IV-TR. The results suggest that clinicians should screen for the possible co-occurrence of maternal depression when working with families of children with ADHD.     

Mothers’ Mental Health Treatment Associated with Greater Adolescent Mental Health Service Use for Depression

Despite concerns surrounding depression in adolescence and the existence of effective treatments, adolescent depression often goes untreated. In 2014, only 41.2% of adolescents experiencing a major depressive episode (MDE) received mental health treatment. Parents play a key role in adolescents’ treatment utilization. We examined whether among mothers with any mental illness, mothers’ utilization of mental health treatment was associated with greater likelihood of their adolescent children who experienced an MDE receiving mental health treatment. Using nationally representative data from the National Survey on Drug Use and Health (2008–2014), we performed logistic regression analysis to model the odds of adolescents (aged 12 to 17 years) with a past year MDE receiving any mental health treatment in the past year as a function of their mothers’ mental health treatment utilization in the past year, adjusting for control variables. The rate of adolescent treatment utilization was 66% when mothers had utilized treatment, as compared to 45% when mothers did not utilize treatment (p?<?0.001). The odds of an adolescent with an MDE receiving mental health treatment were two times greater when the mother received mental health treatment as compared to adolescents whose mothers did not receive any mental health treatment (OR?=?2.09, 95% CI [1.04, 4.17]). There was no effect of adolescent gender (OR?=?1.15, 95% CI [0.40, 3.28]) or interaction between gender and mothers’ treatment (OR?=?0.95, 95% CI [0.26, 3.46]). Barriers to adolescent mental health treatment may be lower when mothers receive mental health treatment.     

Impact of psychiatric illness upon asthma patients’ health care utilization and illness control. Are all psychiatric comorbidities created equal?

The impact of psychiatric illnesses upon asthma patients' functioning is not well understood. This study examined the impact of psychiatric comorbidity upon illness management in asthma patients using empirically-derived psychiatric comorbidity groups. Participants were a clinic sample of Greek-speaking asthma patients (N = 212) assessed using the Patient Health Questionnaire (PHQ) Somatoform, Depression, Panic Disorder (PD), Other Anxiety Disorder, Eating Disorder (ED) and Alcohol sub-scales. The associations between sub-scales were examined using multiway frequency analysis. The following groups were derived: Somatoform disorder and/or Any Depressive disorder (n = 63), Somatoform disorder and/or Other Anxiety disorder (n = 51), Somatoform disorder and/or Any ED (n = 60), and Any Anxiety group including PD and/or Other Anxiety disorder (n = 24). Across all groups, psychiatric illness was associated with significantly worse asthma control (p < .01). Participants in Any Anxiety group, OR = 4.61, 95% CI [1.90, 11.15], Somatoform and/or Any Depressive disorder, OR = 2.06, 95% CI [1.04, 4.09] and Somatoform and/or Other Anxiety disorder, OR = 2.75, 95% CI [1.35, 5.60] were at higher risk for asthma-related Emergency Room (ER) visits compared to controls. However only Somatoform and/or Any Depressive disorder, OR = 3.67, 95% CI [1.60, 8.72], Somatoform and/or Other Anxiety disorder, OR = 5.50, 95% CI [2.34, 12.74], and Somatoform and/or Any ED, OR = 4.98, 95% CI [2.14, 11.60] group membership were risk factors for asthma-related hospitalizations. Results suggest that while comorbid psychiatric disorders generally negatively impact asthma illness management, different psychiatric comorbidities appear to have disparate effects upon illness management outcomes.     

Diverse multi-week physical activity programs reduce ADHD symptoms: A systematic review and meta-analysis

ObjectivePhysical activity (PA) has been proposed as an adjunct treatment and secondary prevention intervention for attention-deficit hyperactivity/impulsivity disorder (ADHD) and oppositional defiant disorder (ODD). However, meta-analyses testing effects on symptoms and functional impairment have yielded conflicting results.MethodsA systematic search of eight databases yielded 15 randomized controlled trial and 2 quasi-experimental design studies—including N = 881 youth (M = 9.75 years, 71% male)—that tested the effects of multi-week PA programs on symptoms and impairment of children with [or at-risk for] ADHD and/or ODD.ResultsRandom effects meta-analyses favored PA groups on omnibus ADHD measures (g = −0.42, 95%CI[-0.62;-0.21]), combined ADHD symptoms (g = −0.50, 95%CI[-0.82;-0.17]), inattention (g = −0.41,95%CI[-0.82; 0.00]), and hyperactivity/impulsivity (g = −0.30, 95%CI[-0.56;-0.04]). Heterogeneity was moderate across studies (I² = 49%, 95%CI[12%-to-70%]). Significant differences favored PA programs whether inclusion required diagnosis, programs augmented frontline treatments, and active or passive comparison groups were utilized.ConclusionDiverse PA programs can reduce ADHD symptoms, especially where they intentionally pursue this end.     

Executive Functioning and Non-Verbal Intelligence as Predictors of Bullying in Early Elementary School

Executive function and intelligence are negatively associated with aggression, yet the role of executive function has rarely been examined in the context of school bullying. We studied whether different domains of executive function and non-verbal intelligence are associated with bullying involvement in early elementary school. The association was examined in a population-based sample of 1,377 children. At age 4 years we assessed problems in inhibition, shifting, emotional control, working memory and planning/organization, using a validated parental questionnaire (the BRIEF-P). Additionally, we determined child non-verbal IQ at age 6 years. Bullying involvement as a bully, victim or a bully-victim in grades 1–2 of elementary school (mean age 7.7 years) was measured using a peer-nomination procedure. Individual bullying scores were based on the ratings by multiple peers (on average 20 classmates). Analyses were adjusted for various child and maternal socio-demographic and psychosocial covariates. Child score for inhibition problems was associated with the risk of being a bully (OR per SD?=?1.35, 95%CI: 1.09–1.66), victim (OR per SD?=?1.21, 95%CI: 1.00–1.45) and a bully-victim (OR per SD?=?1.55, 95%CI: 1.10–2.17). Children with higher non-verbal IQ were less likely to be victims (OR?=?0.99, 95%CI: 0.98–1.00) and bully-victims (OR?=?95%CI: 0.93–0.98, respectively). In conclusion, our study showed that peer interactions may be to some extent influenced by children’s executive function and non-verbal intelligence. Future studies should examine whether training executive function skills can reduce bullying involvement and improve the quality of peer relationships.     

What makes labour and birth traumatic? A survey of intrapartum ‘hotspots’

Evidence suggests between 1% and 6% of women develop post-traumatic stress disorder (PTSD) after childbirth. ‘Hotspots’ are moments of extreme distress during traumatising events that are implicated in symptoms of PTSD. This cross-sectional internet survey of hotspots examined (1) the content of intrapartum hotspots and (2) whether particular events, cognitions or emotions during hotspots are related to PTSD. Women (N?=?675) who experienced a difficult or traumatic birth completed a questionnaire composed of a validated measure of PTSD, questions concerning the existence of hotspots, and a newly developed measure of emotions and cognitions during hotspots. The majority of women (67.4%) reported at least one hotspot during birth and 52.9% had re-experiencing symptoms of these hotspots. Women were more likely to have PTSD if hotspots involved fear and lack of control (odds ratio (OR) 1.30, 95% CI 1.17–1.43) or intrapartum dissociation (OR 1.12, 95% CI 1.05–1.19). Risk of PTSD was higher if hotspots concerned interpersonal difficulties (OR 4.34, 95% CI 2.15–8.77) or obstetric complications (OR 3.35, 95% CI 1.64–6.87) compared to complications with the baby.     

What makes labour and birth traumatic? A survey of intrapartum 'hotspots'

Evidence suggests between 1% and 6% of women develop post-traumatic stress disorder (PTSD) after childbirth. 'Hotspots' are moments of extreme distress during traumatising events that are implicated in symptoms of PTSD. This cross-sectional internet survey of hotspots examined (1) the content of intrapartum hotspots and (2) whether particular events, cognitions or emotions during hotspots are related to PTSD. Women (N?=?675) who experienced a difficult or traumatic birth completed a questionnaire composed of a validated measure of PTSD, questions concerning the existence of hotspots, and a newly developed measure of emotions and cognitions during hotspots. The majority of women (67.4%) reported at least one hotspot during birth and 52.9% had re-experiencing symptoms of these hotspots. Women were more likely to have PTSD if hotspots involved fear and lack of control (odds ratio (OR) 1.30, 95% CI 1.17-1.43) or intrapartum dissociation (OR 1.12, 95% CI 1.05-1.19). Risk of PTSD was higher if hotspots concerned interpersonal difficulties (OR 4.34, 95% CI 2.15-8.77) or obstetric complications (OR 3.35, 95% CI 1.64-6.87) compared to complications with the baby.     

Synesthesia in children with difficulties in written language learning

We tested whether the acquisition of grapheme-color synesthesia during childhood is related to difficulties in written language learning by measuring whether it is more frequent in 79 children receiving speech and language therapy for such difficulties than in the general population of children (1.3%). By using criteria as similar as possible to those used in the reference study (Simner et al., 2009), we did not identify any synesthete (Bayesian 95% credible interval [0, 4.5]% for a flat prior). The odds of the null model (no difference between 0/79 and 1.3%) over alternative models is 28 (Bayes Factor). A higher prevalence of grapheme-color synesthetes among children with learning difficulties is therefore very unlikely, questioning the hypothesis of a link between synesthesia and difficulties in language acquisition. We also describe the difficulty of diagnosing synesthesia in children and discuss the need for new approaches to do so.     

Efficacy of a Therapist-Assisted Self-Help Internet-Based Intervention Targeting PTSD,Depression, and Insomnia Symptoms After a Disaster: A Randomized Controlled Trial

This study aimed at evaluating the efficacy of an online CBT intervention with limited therapist contact targeting a range of posttraumatic symptoms among evacuees from the 2016 Fort McMurray wildfires.One hundred and thirty-six residents of Fort McMurray who reported either moderate PTSD symptoms (PCL-5 ≥ 23) or mild PTSD symptoms (PCL-5 ≥ 10) with moderate depression (PHQ-9 ≥ 10) or subthreshold insomnia symptoms (ISI ≥ 8) were randomized either to a treatment (n = 69) or a waitlist condition (n = 67). Participants were on average 45 years old, and mostly identified as White (82%) and as women (76%). Primary outcomes were PTSD, depression, and insomnia symptoms. Secondary outcomes were anxiety symptoms and disability. Significant Assessment Time × Treatment Condition interactions were observed on all outcomes, indicating that access to the treatment led to a decrease in posttraumatic stress (F[1,117.04] = 12.128, p = .001; d = .519, 95% CI = .142–.895), depression (F[1,118.29] = 9.978, p = .002; d = .519, 95% CI = .141–.898) insomnia (F[1,117.60] = 4.574, p = .035; d = .512, 95% CI = .132–.892), and anxiety (F[1,119.64] = 5.465, p = .021; d = .421, 95% CI = .044–.797) symptom severity and disability (F[1,111.55] = 7.015, p = .009; d = .582, 95% CI = .200–.963). Larger effect sizes (d = 0.823–1.075) were observed in participants who completed at least half of the treatment. The RESILIENT online treatment platform was successful to provide access to specialized evidence-based mental health care after a disaster.     

An examination of the interpersonal model of loss of control eating in children and adolescents

The interpersonal model of binge eating disorder proposes that social problems lead to negative affect which, in turn, precipitates binge eating episodes. However, no study to date has examined this model among youth who report loss of control (LOC) eating. Participants were 219 non-treatment-seeking children and adolescent volunteers, age 8-17 years (13.1 ± 2.8y; 50% female). Children's social problems were assessed by parent report. Youth completed self-report questionnaires of negative affect that assessed depressive symptoms and anxiety. Participants were interviewed to determine the presence or absence of LOC eating in the month prior to assessment. Structural equation modeling analyses found that social problems were positively related to LOC eating presence (p = .02). Negative affect mediated the relationship between social problems and LOC eating (95% CI Product = .00247, .01336). These preliminary results suggest that the interpersonal model of binge eating may describe one possible pathway for the development of LOC eating among non-treatment-seeking youth.     

CAREGIVER'S DEPRESSIVE SYMPTOMS AND YOUNG CHILDREN'S SOCIOEMOTIONAL DEVELOPMENT DELAYS: A CROSS‐SECTIONAL STUDY IN POOR RURAL AREAS OF CHINA

Poverty and its associated factors put people at risk for depression. The aims of this study were to describe the prevalence of depressive symptoms (DS) of primary caregivers and socioemotional development (SED) delays of young children in poor rural areas of China, and to explore the association between them. Cross‐sectional data of 2,664 children aged 3 to 35 months and their primary caregivers were used for analysis. Characteristics of the child, caregiver, and family were collected through face‐to‐face caregiver interviews. DS were assessed by the Zung Self‐Rating Depression Scale (W.W. Zung, 1965, as cited in World Health Organization, 2016b ), and SED was evaluated by the Ages and Stage Questionnaires: Social‐Emotional (J. Squires, D. Bricker, & L. Potter, 1997). The χ² test, stratification analysis, and logistic regression analyses were used to explore the association. Among the caregivers, 40.3% (95% confidence interval [CI] [38.4, 42.1]), reported DS. Caregivers who were male, older and ethnic minorities as well as had a low level of education, a low family income, or more children were more likely to have DS. Of the children, 24.4% (95% CI [22.8, 26.0]) were recognized with SED delays. Older children displayed more delays than did younger children, but no significant differences between males and females were found. SED delays were significantly associated with mother outmigrating, male caregivers, older age, ethnic minorities, and low education or families with a single parent, low‐income, and having more children. Caregivers having DS, odds ratio (OR) = 2.40, 95% CI [1.99, 2.88], was a significant predictor of increased odds of SED delays; other factors were single‐parent family, OR = 1.99, 95% CI [1.37, 2.89], inadequate care, OR = 1.69, 95% CI [1.30, 2.21], physical punishment, OR = 1.61, 95% CI [1.33, 1.95], ethnic minorities, OR = 1.41, 95% CI [1.17, 1.71], and child age in months, OR = 1.03, 95% CI [1.02, 1.04], according to the logistic regression analysis. DS are prevalent among caregivers with young children in poor rural areas. Interventions to improve the mental health of caregivers and their parenting behaviors are needed to improve children's SED.     

Future Well-Being Among U.S. Youth Who Attempted Suicide and Survived

To what extent does a suicide attempt impair a person’s future well-being? We estimated the prevalence of future well-being (FWB) among suicide attempt survivors using a nationally representative sample of 15,170 youths. Suicide attempt survivors were classified as having high FWB if they reported (a) a suicide attempt at Wave I, (b) no suicidal ideation or attempts over the past year at Wave III (7 years after), and (c) a well-being profile at or above the top quartile of nonsuicidal peers. Seventy-five of 574 suicide attempt survivors (∼13%) met criteria for FWB at Wave III, compared to 26% of nonsuicidal peers. Wave I well-being levels, not depressive symptoms, predicted the likelihood of FWB at Wave III (OR = 1.23, 95% CI [1.05, 1.44], p < .05). In conclusion, a nonfatal suicide attempt reduced but did not preclude FWB in a large national sample. The observation that a segment of the population of suicide attempt survivors achieves FWB carries implications for the prognosis of suicidal behavior and the value of incorporating well-being into investigations of suicide-related phenomena.     

Associations between parent perceived social cognitive factors and child objectively measured physical activity behaviors among preschool-aged children

Grounded in social cognitive theory (SCT), this study sought to examine whether parents perceived social cognitive factors regarding children's physical activity (PA) behaviors were associated with preschool children's moderate-to-vigorous PA (MVPA) levels. A total of 142 Hong Kong parent-child pairs from five preschools/childcare centers completed all assessments in the cross-sectional study. Children’s (42% girls; mean age = 4.52 ± 0.67 years) PA was measured through accelerometers. Parents (74% mothers; mean age = 37.38 ± 4.63 years) completed a paper-based questionnaire assessing the social cognitive factors on their children’s PA participation. The data were analyzed using latent variable structural equation modeling. Findings revealed that the model showed acceptable fit with the data: χ² (23) = 38.14, p = .025, χ²/df = 1.66, CFI = 0.955, TLI = 0.929, RMSEA = 0.068, 90% CI [0.025, 0.106], and SRMR = 0.072. The model accounted for 39.1% of the variance in the PA behavior of preschool-aged children. Structural equation modelling revealed parental self-efficacy (β = 0.29, 95% CI [0.95, 0.49]) and goal setting (β = 0.25, 95% CI [0.06, 0.44]) were directly associated with children’s MVPA. Outcome expectations (β = 0.09, 95% CI [0.01, 0.03]) and goal setting (β = 0.18, 95% CI [0.05, 0.32]) mediated the association between parental self-efficacy and children’s MVPA. Indirect associations of parental self-efficacy from setting goals via parental support (β = 0.15, 95%CI [0.02, 0.30]) and perceived barriers (β = 0.15, 95% CI [0.05, 0.28]) were uncovered. Results supported the use of SCT in understanding how the parents perceived social cognitive factors predict the PA behaviors of young children. This study provides insight into whether these theoretical variables could be modified or promoted in future intervention programs. Enhancing parents’ abilities to ensure preschool-aged children are physically active is of great importance given the global decline in PA among children.     

Avoidance behavior associated with depressive symptoms in patients with implantable cardioverter defibrillators

Objective: Many patients with implantable cardioverter defibrillators experience depressive symptoms. In addition, avoidance behavior is a common problem among patients with implantable cardioverter defibrillators. We examined the association between avoidance behaviors and depressive symptoms in patients with implantable cardioverter defibrillators. Method: We conducted a single-center, cross-sectional study with self-completed questionnaires between May 2010 and March 2011. We measured avoidance behaviors (avoidance of places, avoidance of objects, and avoidance of situations) and depressive symptoms (using the Beck Depression Inventory, Version II) in 119 participants. An avoidance behaviors instrument was developed for this study and we confirmed its internal consistency reliability. Results: Ninety-two (77.3%) patients were aged older than 50 years, and 86 (72.3%) were men. Fifty-one (42.9%) patients reported “avoidance of places”, 34 (28.6%) reported “avoidance of objects”, and 63 (52.9%) reported “avoidance of activity”. Avoidance behavior was associated with increased odds for the presence of depressive symptoms (OR 1.31; 95% CI 1.06–1.62). Conclusions: This was the first study to identify the relationship between avoidance behavior and depressive symptoms among patients with implantable cardioverter defibrillators; however, there are a few methodological limitations.     

Maltreated Children in Out-of-Home Care: The Relation between Attachment Quality and Internalizing Symptoms

Maltreated children in out-of-home care are at high risk for poor relationships with caregivers (i.e., biological parents and substitute caregivers) and high levels of internalizing symptoms. It is unclear if these poor relationships are related to, and account for a large portion of the variance in maltreated children’s internalizing symptoms, above and beyond maltreatment type and out-of-home care factors. This study examined the relation between attachment quality with both biological parents and substitute caregivers and children’s internalizing symptoms within a sample of 493 maltreated children (aged 9–11; 51.0?% male) recently placed in out-of-home care. A series of hierarchical regression models indicated that greater child-reported attachment quality with both biological parents and substitute caregivers was associated with fewer child-reported anxiety (β?=??.15, p?<?.01; β?=??.29, p?<?.001, respectively) and depression symptoms (β?=??.14, p?<?.01; β?=??.28, p?<?.001, respectively) as well as fewer child internalizing symptoms (β?=??.12, p?<?.05; β?=??.14, p?<?.01, respectively). Attachment quality with the biological parent and substitute caregiver each explained a significant proportion of the variance in children’s internalizing symptoms, above and beyond child demographics, maltreatment type, and out-of-home care variables. The study also examined whether children’s attachment with substitute caregivers moderated the relationship between children’s attachment with biological parents and children’s internalizing symptoms. No statistically significant moderation effects were found. Future clinical work should focus on enhancing attachment quality between children and both biological parents and substitute caregivers, as these relationships appear to individually relate to the children’s internalizing symptomology.