Child Psychiatry Hum Dev DOI 10.1007/s10578-014-0506-y

ORIGINAL ARTICLE

Associations Between Parental Attachment and Course of Depression Between Adolescence and Young Adulthood Tea Agerup • Stian Lydersen • Jan Wallander Anne Mari Sund

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Ó Springer Science+Business Media New York 2014

Abstract A study of the associations of maternal, paternal and peer attachment with the course of depression from adolescence to young adulthood. In the Youth and Mental Health study 242 adolescents completed the Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime version for depressive disorders at age 15 and 20. Attachment was measured with the inventory for parent and peer attachment, separately for mother, father, and peers, at age 15. Multinomial logistic regression, indicated insecure attachment relationships with both parents, but not with peers, and were associated with the course of depression. Less secure attachment to mothers was associated with becoming depressed. Less secure attachment to both parents was associated with becoming well and remaining depressed. These results suggest attachment relationships with parents as potential influences on the course of depression and may provide important framework for clinical work with adolescents and young adults. Keywords Depression
Adolescence
Young adulthood
Parent–child attachment

Introduction Depression in adolescence and young adulthood is a common mental health concern. Numerous factors are implicated as influencing the development of depression in young people, such as, biological [1], genetic [2], cognitive [3] developmental and interpersonal factors [4]. Social relationships are T. Agerup (&)
S. Lydersen
J. Wallander
A. M. Sund Norwegian University of Science and Technology, Trondheim, Norway e-mail: [email protected]

important for all development [5], including mental health for the adolescent and young adult [6]. The security of the attachment with parents early in life, as well as with peers later in childhood through adulthood, are important characteristics of social relationships [7] that may play a role in depression during adolescence and young adulthood [8]. Depression The main diagnostic categories for depression in the Diagnostic and Statistical Manual-IV are Major Depressive Disorder, Dysthymia, and Depressive Disorder Not Otherwise Specified (NOS) [9].Yet most studies on adolescents with clinical depression have focused only on Major Depressive Disorder [10, 11], and few have included the other types of depression [12–15]. Trends in psychopathology during the adolescent years and into young adulthood show an increase in depression, especially for females [16]. Depression prevalence rises sharply after puberty [17, 18], peaking at 6–11 % in early adulthood [19–21]. Lifetime prevalence is estimated at 5–12 % for men and 10–25 % for women, implicating that millions of people and their families experience the negative consequences of depression. The consequences of depression in adolescence commonly include academic failure, poor peer relations, behavioral problems, conflict with parents and authority figures, low self-esteem, substance abuse and interruption in development [22]. Whereas sex differences are not noticeable in early adolescence, depression becomes distinctly female- dominant from mid-adolescence and remain so through adulthood [19, 23, 24]. Longstanding depression in adolescence is a powerful predictor of continued mental health problems in adulthood [25–27], underscoring a need to examine influences on the course of depression across these developmental phases.

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Parent and Peer Attachment Parents are arguably the strongest social influence for almost all children [28–32]. Attachment is one aspect of the relationship between a child and a parent, with its purpose being to make a child feel safe, secure and protected. Also, attachment is argued to be a foundation for course of mental health [33]. Depending on the quality of the attachment, the parent serves as a secure base from which the child can explore the environment and, when necessary, return to find comfort [29, 34]. From attachment follows the capacity to form close, satisfying relationships and a constructive, insightful understanding of other people [35]. The attachment relationship is not considered to be fixed, as further experiences and conceptual growth can influence change. However, when positive attachment is maintained, the sense of security will remain [35]. The transition of primary attachment from parents to peers occurs gradually from ages 6 to 7 into adolescence and continues into adulthood [36, 37]. This transition takes place when children seek other attachment objects than parents. When the parent relationship is insecure, this transition usually takes place at an earlier age. The sense of self is reflected in the relationships to both parents and peers. Therefore it is important not only to examine parent attachment in adolescents, but also peer attachment to more fully illuminate the role of attachment on psychosocial development during this developmental period. In late adolescence, young people experiencing more secure mother and father attachment, report less conflict with their parents and less loneliness than earlier in their life [38]. Insecure parent attachment on the other hand predicts later development of symptoms of depression and anxiety [38–42] and make young adults more vulnerable to depressive symptoms [43]. Growing up with insecure attachment can lead to development of significant psychopathology, including a higher tendency for substance abuse and conduct disorders [44]. Similarly, insecure peer attachment, including romantic partner, serves as a predictor for symptom development of depression [38, 40, 45– 50].

longitudinal studies of the potential influence of attachment on changes in clinical depression during the developmental period from adolescence to young adulthood [19, 27], despite the reported increased incidence during this period. When examining parental attachment, previous studies mostly explored either parents jointly without differentiation or just mothers [46]. Attachment has rarely been examined independently with mothers and fathers [57, 58]. Although some research has addressed peer attachment, most has focused on parent attachment, as parent attachment is considered primary for child development [29, 59]. A secure peer attachment pattern has been viewed as a continuation of parent attachment [60], but this is not inevitable and may be inconsistent [61]. Therefore different relationships may reflect different attachment patterns [62] and peers may make unique contributions to a sense of security in young people [63, 64] and therefore on mental health. There is a need to examine clinical depression in samples drawn from the community to increase the generalizability of results pertaining to depression in adolescence and young adulthood and its possible causes [44, 65]. This also applies to research into depression in young adults, where most studies have focused on self-reported symptoms of depression [39, 43]. When community studies have been conducted, on the relationship between attachment and depression they have relied on self-report of depressive symptomology rather than diagnosed depression. This has limited the implications that can be drawn from the findings to inform clinical work. Aim and Hypothesis The aim of this research is to examine associations of attachment to mothers, fathers, and peers with the observed course of clinical depression from mid-adolescence into early adulthood in a community sample. We hypothesize that less secure attachment is associated with a more serious course of depression, such that depression either develops or, if already present, remains between the ages of 15 and 20 years.

Limitations in Prior Research

Method

Previous studies support the connection between attachment and depression in adolescents. However, most studies have been cross-sectional [51–53]. We are aware of only a few longitudinal studies on attachment and depression in young people, which report that insecure attachment to parents predicts depression in adolescents [42, 54, 55]. However, these studies are limited to retrospective selfreport of symptoms of depression, and are not concerned with clinical depression [39, 56]. We are not aware of any

Participants and Procedure

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The Youth and Mental Health Study [12] is a longitudinal study carried out in Central Norway with a population of 390,000 in 1999, including Trondheim, the third largest city in Norway (population 146,000). There were three data collection waves (see flow chart in Fig. 1). In the first wave (T1) conducted in 1998, a representative sample of 2,792 8th and 9th graders (mean age 13.7 years) from 22 schools

Child Psychiatry Hum Dev

T1

N=2464

T2

N=2432

MFQ=26 N=231

unknown N=2190

Invited to interview N=228

Invited to interview N=136

Interviewed N=220

Missing MFQ N=11

Declined interview

Interviewed N=125

N=11

Total interview Youth Sample N= 345

Parents invited N=345x2

Adolescent Diagnosis

Parents parcipated N= 434(79%)

Mothers N=267

Major Depression N=46

Minor Depression N=48

No Depression N=251

Fathers N=167

Young Adults contacted N=265

T3

Phone interview N=242

Major Depression N=83

Minor Depression N=23

Arion N=13

No Depression N=136

Fig. 1 Flow chart of the Youth and Mental Health Study

was selected according to urbanity and geography, from a total population of 9,292, applying a clustered sample method with the schools as sampling units. The schools were drawn according to size within four strata (1) City of Trondheim (n = 484, 19.5 %), (2) Suburbs of Trondheim (n = 432, 17.5 %), (3) Coastal region (n = 405, 16.4 %), and (4) Inland region (n = 1,143, 46.4 %) [66]. At T1, 2,464 (88.3 %) completed a self-report questionnaire and

were reassessed at T2 with the same questionnaire in 1999, one year later (mean age 14.9 years). At T2, (106) 4.3 % of the adolescents from T1 did not participate and were replaced by 72 (3 %) new participants from a group of non responders at T1, who had changed their mind about participating at T2, resulting in n = 2,432 at T2. The T1 and T2 questionnaires were administered by trained teachers during regular school hours.

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Child Psychiatry Hum Dev Table 1 Sociodemographic characteristics of the sample at T2 (age 15) and its distribution among participants and nonparticipants at T3 (age 20)

Age 15 N = 345 n (%)

Age 20 Non-participants N = 103 n (%)

Age 20 Participants N = 242 n (%)

250 (72.5)

64 (62.1)

186 (76.9)

95 (27.5)

39 (37.9)

56 (23.1)

Sex Females Males Parental SES Professional/executive (upper class)

33 (9.6)

11 (10.7)

22 (9.1)

Upper middle class

85 (24.6)

19 (18.4)

66 (27.3)

Lower middle class

80 (23.2)

21 (20.4)

59 (24.4)

Manual worker

142 (41.2)

52 (50.5)

90 (37.2)

No information

5 (1.4)

0 (0.0)

5 (2.1)

316 (91.6)

92 (89.3)

223 (92.1)

9 (2.6)

1 (1.0)

8 (3.3)

20 (5.8)

10 (9.7)

11 (4.6) 156 (64.5)

Ethnicity Both parents Norwegian One parent Norwegian Both parents non Norwegian Living arrangement Living with both parents

221 (64.1)

65 (63.1)

Living with either parent alone

62 (17.9)

20 (19.5)

42 (17.3)

With one parent and step parent

47 (13.6)

14 (13.6)

33 (13.6)

Sharing time between parents Other

11 (3.2) 4 (1.2)

3 (2.9) 1 (1.0)

8 (3.3) 3 (1.2)

In addition, at T2 a subset (n = 364, 14.8 %) was invited for a follow-up clinical interview using the KiddieSchedule for Affective Disorders and Schizophrenia-Present and Lifetime version (K-SADS-PL) [67] based on scores on the Mood and Feeling Questionnaire (MFQ, see below) [68]. All high scorers (C26, n = 228, 62.6 %) and a sample of low and medium scorers (0–6/7–26, n = 136, 37.4 %) were invited for this clinical interview phase. The sample of low and medium scorers was selected by matching at random one low/middle scorer on age-andgender for approximately every two high scorers. 364 were selected and 345 (94.8 %) (72.5 % females, mean age = 15 years) completed the interview, including 220 (63.8 %) with high and 125 (36.2 %) with low/middle MFQ scores. Their parents were also invited to complete a questionnaire and the K-SADS interview, which 240 (69.6 %) mothers and 159 (46.1 %) fathers did, such that in 274 cases (79 %) at least one parent participated. At T3, in 2004, 5 years after T2, the interview-subset from T2 was invited to complete the same questionnaire and the K-SADS interview, this time by telephone n = 242 (76.9 % females mean age = 20.0 years) assessing depressive diagnoses at T3 and retrospectively for the period from T2 to T3 [67]. All assessments were approved by the Regional Committee for Medical Research Ethics, Central Norway, and

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the local school authorities of the two counties as well as the school boards. Prior to T1 written informed consent, based on The Norwegian Data Inspectorate standards, was obtained from parents and students. The incentive for the students was a lottery draw for an iPod music player. Measures and Variables Demographic information (see Table 1) used in the present analyses was collected in the interview at T2. The following measures relevant to the present study were completed by the T2 subset interview sample and repeated at T3. Depressive Symptoms A Norwegian translation of the original version of Mood and Feelings Questionnaire (MFQ) [68] measured depressive symptom level at the screening phase. This version covers the DSM-III-R criteria for major depression with 33 items plus one item added from the parent version, yielding the total score ranges 0–68, with higher scores reflecting worse symptoms. The MFQ is reported to have high internal consistency and test–retest stability [69–71]. It was found valid in identifying mood disorders among youth of diverse clinical characteristics and demographics [72]. In

Child Psychiatry Hum Dev

addition, the MFQ correlates strongly with Children’s Depression Inventory [70, 73]. Depression Diagnoses K-SADS-PL [67] is a well-established semi-structured diagnostic interview designed to assess present and past episodes of psychopathology among children and adolescents on Axis I of the DSM-III-R and IV-TR. To maintain consistency, it was also used for the young adult participants at T3. The severity of each identified individual symptom is rated on a 0–3 scale, with a score of 3 representing the threshold for clinical manifestation. Experienced clinicians, trained in psychopathology and the use of K-SADS- PL, and blind to the MFQ score of the participants, conducted the interviews face-to face at T2 and by telephone at T3, with an experienced child psychiatrist (one of the authors AMS) serving as the standard there was good inter-rater reliability for all K-SADS symptoms with Cohen’s j = 0.71 at the end of training prior to T2 interviews. Interview integrity was maintained during T2 and T3 with an average j = 0.83 and 0.80, respectively, for all screening symptoms [12]. With 79 % of the adolescents having at least one parent as an informant, diagnostic assessments were based on information obtained from all available informants. A diagnosis of current depressive disorder was established at T2, age 15, and any depression occurring from age 15 to 20 at T3. The K-SADS-PL includes 30 items to address all DSMIV-TR symptoms for a depressive episode. Diagnosis of current depressive disorders included Major Depressive Disorder (MDD) and Dysthymia. Functional impairment, defined as a Childhood- Global Assessment of Symptoms (C-GAS) [74] score below 71, was a requirement for a diagnosis of MDD or Dysthymia. Diagnoses of MDD (T2 n = 25) or Dysthymia (T2 n = 9) were then pooled and termed Major Depression for the analysis to provide a sufficient number of participants in a category with moderatesevere depression in this community sample. In addition, a diagnosis of Depressive Disorder Not Otherwise Specified (NOS) [18] required at least two depressive symptoms being identified lasting for at least 2 weeks [12], which was termed Minor Depression for the analysis. Thus, the 242 participants who completed the diagnostic interview at both T2 and T3 were classified into one of three categories separately at age 15 and for the period between ages 15 and 20: Major Depression (MDD and Dysthymia, T2 = 63, T3 = 83), Minor Depression (T2 = 45, T3 = 23) or No Depression (T2 = 134, T3 = 136). Attachment Inventory of Parent and Peer Attachment (IPPA) revised version [75] was developed to assess adolescents’

perceptions of the positive and negative affective and cognitive dimension of relationships with mother, father, and close friends, and in particular how well these figures serve as sources of psychological security based on attachment theory [33]. Three broad dimensions are assessed; degree of mutual trust and respect (e.g. ‘‘My mother/father/friends respect my feelings’’), quality and extent of spoken communication (e.g., ‘‘I tell my mother/ father/friends about my problems and troubles’’), and alienation in the form of feelings of anger and interpersonal isolation (e.g., ‘‘My mother/father/friends do not understand what I am going through these days’’). In the revised version used in the present study [7], the IPPA consists of 25 items each addressing mother and father, and 9 items addressing peers, which are responded to on a five-point Likert scale (1 = ‘‘Almost never or never true’’ to 5 = Almost always or always true’). The shorter peer scale was developed for space considerations and because earlier research had identified peer attachment as having lower correlation with maladjustment than attachment to parents [38]. Thus 9 items were selected from the 25 items constituting the original peer attachment scale that had the highest loading in a factor analyses [75]. Sum scores were calculated separately for the mother, father, and peers scales, with the Alienation subscale items being reverse scored. On a dimensional measure high scores reflect secure attachment in the relationship. Internal consistency Cronbach alpha in the present sample for mother attachment was .91, father attachment .92, and peer attachment .82 [42]. Validity is supported by findings, for example, that among late adolescents, parental attachment is related to Family and Social Self subscale scores from the Tennessee Self Concept Scale and to most subscales on the Family Environmental Scale [76]. Studies have shown that the IPPA correlates to self and family dimensions in a way that is consistent with theoretical expectations [75]. Statistical Analyses With three categories representing the outcome variable of depression diagnosis (Major, Minor, and No Depression) at 15 and from 15 to 20 years of age, respectively, we first used cross tabulations to describe prevalence of depression at both time points as well as change over time. Next, we used multinomial logistic regression to examine the relationships of adolescent attachment to mother, father, and peers at age 15, with course of depression diagnosis between ages 15 and 20 as the dependent variable. These analyses were adjusted for the adolescent age and sex. With three diagnostic categories possible at both ages, nine patterns of course of depression diagnosis was examined as the dependent variable, but most patterns contained a small number of participants. For the multinomial logistic regression, we merged

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Child Psychiatry Hum Dev Table 2 Prevalence of depression diagnoses of interview sample at ages 15 and 20

Table 3 Descriptive statistics for IPPA scores to mother, father, and peers

Age 15

Depression group

Mother Mean (sd) N

Father Mean (sd) N

Peers Mean (sd) N

Remained well

95.1 (15.7)

88.8 (14.5)

22.7 (5.3)

Age 20 No

Total Age 15 Minor

Major

Total sample (n = 242) No

95

14

25

134 (55.4%)

N = 95

N = 92

N = 89

N = 93

Minor Major

24 17

2 7

19 39

45 (18.6%) 63 (26.0%)

Became depressed

88.1 (19.5)

84.3 (14.7)

24.1 (4.7)

N = 39

N = 38

N = 37

N = 38

136 (56.2%)

23 (9.5%)

83 (34.3%)

242 (100%)

Became well

85.0 (22.8)

79.4 (16.4)

22.3 (5.7)

N = 41

N = 40

N = 39

N = 41

Total age 20

Bold values represent a worsening and italic values represents an improvement in diagnosis from age 15 to 20

‘‘minor’’ and ‘‘major’’ depression into one category, termed Any Depression, giving four patterns of change. Those with No Depression at both ages, labeled as Remained Well (n = 95), were defined as the reference category and compared to those who: (1) had No Depression at age 15 but received a diagnosis of Any Depression (either Minor or Major) at age 20, labeled as Became Depressed (n = 39); (2) had Any Depression diagnosis at age 15 but received No Depression diagnosis at age 20, labeled as Became Well (n = 41); and (3) remained with Any Depression diagnosis at both ages 15 and 20, labeled as Remained Depressed (n = 67). The IPPA is a dimensional measure reflecting perceived attachment along a scale without any cut-off. In the descriptive statistics high scores reflect more secure attachment, while in the logistic regression analysis the scale scores were reversed so that high score reflect less secure attachment to facilitate interpretation. Ninety- five percent confidence intervals (CI) are reported where relevant. Twosided p values \0.05 were considered to indicate statistical significance. SPSS 19 was used for statistical analyses.

Results Attrition Of the 345 participants at age 15, 103 (29.9 %) did not participate at age 20. The demographic constitution of the sample collected at age 15 and compared to the prevalence at age 20 are shown in Table 1. Comparisons between those who completed the assessment at age 20 and those who did not indicated there were no significant differences on demographic variables except for sex. The proportion of males participating at age 20 was 23 % compared to 38 % at age 15 (v2 = 7.849, p = 0.005). Moreover, as has been elaborated elsewhere [77], participants and nonparticipants at age 20 had approximately the same distribution in depression diagnosis at age 15.

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Remained depressed

86.1 (18.7)

80.8 (18.2)

23.2 (5.7)

N = 67

N = 67

N = 65

N = 67

Total

89.8 (18.9)

84.2 (16.3)

23.0 (5.4)

N = 242

N = 237

N = 230

N = 239

Prevalence of Depression Over Time Depression prevalence and change between ages 15 and 20 are shown in Table 2. These results have been reported fully elsewhere [77] and do not represent the main aim of the present study. However, briefly, of those with No Depression at age 15, 71 % remained as such at age 20, whereas 10 % developed Minor Depression and 19 % Major Depression. For those with Minor Depression at age 15, 53 % improved to No Depression, 5 % remained with Minor Depression, and 42 % developed Major Depression at age 20. Finally for those with Major Depression at age 15, 27 % improved to No Depression and 11 % to Minor Depression at age 20, whereas 62 % remained with Major Depression. Parent and Peer Attachment Descriptive statistics for attachment to mother, father, and peers are reported in Table 3 for the total sample and the four defined groups, based on depression course, from age 15 to 20. Results from the multinomial logistic regression analyses, testing associations between depression course as the dependent variable and maternal, paternal, and peer attachment as the independent variables, are shown in Table 4. In Table 4, the attachment variables were reversed to facilitate interpretation, such that ORs above 1.00 mean that less secure attachment is associated with increased risk of being in the indicated depression course group. For example for the group ‘‘Became depressed’’, the estimated OR is 1.023 per unit less secure maternal attachment on the IPPA scale. This means that individuals reporting less secure maternal attachment are significantly more likely to be in the ‘‘Became Depressed’’ group than the ‘‘Remained Well’’ group (mean 88.1 vs 95.1, see Table 3). In general, maternal and paternal attachment, but not peer attachment,

Child Psychiatry Hum Dev Table 4 Multinomial logistic regression with depression group as dependent variable, and maternal, paternal and peer attachment as covariates one at a time Depression group (dependent variable)

Predictor variable

OR

Became depressed (n = 39)

Female sex

1.330

.57–3.09

Adolescent age

1.048

.567–1.939

.880

Maternal insecure attachment

1.023

1.002–1.045

.035

Paternal insecure attachment

1.020

.994–1.045

.128

.955

.882–1.035

.262

1.394

.603–3.222

.437

Peer insecure attachment Became well (n = 41)

Remained depressed (n = 67)

Female sex

95 % CI

p

.507

Adolescent age

1.233

.675–2.255

.495

Maternal insecure attachment

1.032

1.011–1.054

.003

Paternal insecure attachment

1.039

1.014–1.065

.002

Peer insecure attachment

1.029

.958–1.105

.433

Female sex

4.470

1.732–11.536

.002

Adolescent age

1.528

.893–2.612

.121

Maternal insecure attachment

1.031

1.012–1.050

.001

Paternal insecure attachment

1.034

1.012–1.057

.002

Peer insecure attachment

1.026

.961–1.094

.443

The reference group was ‘‘Remained well’’ (n = 95). Bold indicates significant predictor. In this table, the attachment variables have been reversed, such that OR above one means that insecure attachment is associated with higher risk. All analyses were adjusted for age and sex

showed associations with course of depression. More specific as indicated in Table 4, less secure maternal attachment was associated with being classified as Became Depressed [OR 1.02, 95 % CI (1.00, 1.05), p = .04], Became Well [OR 1.03, 95 % CI (1.01, 1.05), p = .003] and Remained Depressed [OR 1.03, 95 % CI (1.01, 1.05), p = .001] in this period. Less secure paternal attachment was associated with being classified both as Became Well [OR 1.04, 95 % CI (1.01, 1.07), p = .002) and Remained Depressed [OR 1.03, 95 % CI (1.01, 1.06), p = .002].

Discussion In general both maternal and paternal insecure attachment, but not peer attachment, were associated with depression course from adolescence into young adulthood. Less secure maternal attachment was more likely to be present in the three groups experiencing depression in this period: The

group that was not depressed at 15 but became depressed over the next 5 years, the group that was depressed at 15 but became well, as well as the group who was depressed at age 15 and remained depressed. The similarity in the groups reporting less security in the maternal relationship is that all include adolescents who manifested depression some-time during this developmental period, either already at age 15 or in the ensuing 5 years. Also adolescents reporting less secure paternal attachment were clinically depressed at age 15, and then either remained depressed or became well. Thus our hypothesis was only partially supported. Rather than being associated only with a stable course of depression (Remained Depressed) or developing depression (Became Depressed), findings indicate that on the whole insecure parental attachment is associated with presence of depression in off- spring more generally at age 15 and onward to age 20. We are not aware of any other studies that have examined associations between maternal, paternal, and/or peer attachment and clinical depression in the general population using a longitudinal perspective on the developmental period from age 15 to 20. Whereas this study makes a novel contribution, this also makes it difficult to compare the present findings to those reported previously. Most often attachment has been examined as a concept not differentiating between maternal and paternal attachment [40, 51] or with both parents combined, as parental attachment [39, 42]. Whereas other longitudinal studies have found that insecure attachment is associated with depression in adolescents [39, 42, 43, 62], these studies were different from the present one in that they relied on self-report symptom measures of depression rather than clinical diagnosis. In contrast, most research on parental attachment and adolescent depression has been based on cross-sectional data. For example, similar to our findings, clinically depressed adolescents receiving psychiatric care reported less secure parental attachment, but no differentiation was made between attachment to mothers and fathers [38]. Similar results have been reported in other cross sectional studies, both focused on pre- to young adolescents [51, 78– 80] and older adolescents to young adults [40, 81]. Yet again, these groups of studies have relied on self-reported depression symptoms rather than clinically diagnosed depression. The bulk of studies on the link between parental attachment and adolescent depression have hypothesized that the former is a causal factor for the latter. Whereas findings from a number of studies have, as reviewed here, been consistent with this hypothesis, the opposite cannot be ruled out, that depression in offspring can affect attachment to parents. We are aware of only one longitudinal study examining this alternative hypothesis, which indeed found that self-reported depressogenic personality in adolescence

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predicted a subsequent decrease in maternal attachment over time [54]. This could reflect the transition of relative importance of parental and peer attachment. Indeed, one study found, also using the IPPA, that perceptions of attachment varied among fourth, sixth and eighth graders, where the youngest described parents as most trusting and communicative and the older youth compensated with peers [82]. Research is needed employing a prospective longitudinal design where both differentiated parental attachment and clinical depression are measured repeatedly over time in an adolescent cohort from early adolescence ideally into young adulthood. Research into peer attachment related to depression has both been relatively sparse and produced inconsistent results. Two studies with similar findings to the present study, although using self-report for measuring depression, showed no significant association between depression and insecure peer attachment [49, 83]. However, other studies on insecure peer attachment reported links to stable patterns of depressive symptoms in adolescence [38, 62]. None of these studies examined both peer and parental attachment to enable comparisons or illuminate possible shifts in their relative importance over development.

that could be examined in the analyses. The aforementioned strength of the population sample can also limit generalizability in that the sample is from the mid-region of Norway, including one moderately sized city as well as rural areas. The last data collection in the present data was concluded in 2004, at which time DSM-III and DSM-IV was used. Recently DSM-5 was published with the relevant difference of Minor depression in our study is equivalent to Unspecified Depressive Disorder in the DSM-5. Also Dysthymia has been replaced by Persistent Depressive Disorder encompassing both chronic MDD and Dysthymia [18]. However, since these two conditions, MDD and dysthymia, are grouped together in the present analyses of the sample, this change would probably have no effect on the results. Another concern for this study is that the last data collection took place around 10 years ago and could possibly be dated. However, we are not aware of any major changes in the Norwegian society, except better household economies and the doubling of immigration during the last 10 years [85, 86], changes which might have influenced the results in unknown ways. Finally, discussion of causality is necessarily limited, as with all correlation studies.

Strengths and Limitations

Summary

Among the strengths of this study are that the adolescent sample was selected from a relatively large, school based representative sample, drawn from both urban and suburban schools, and represented the socioeconomic diversity of the these communities, thereby broadening the generalizability of these findings. The weighted sample provided for an over-inclusion of adolescents reporting depressive symptoms. Clinical assessments were completed blindly by clinicians with excellent integrity using a well-standardized structured diagnostic interview. The use of two waves from a longitudinal cohort study allowed for the prediction of changes of depression diagnosis over 5 years. This study examined prospectively associations between parent and peer attachment and clinical depression in a population sample from adolescence to young adulthood. Also, this is one of a few studies that have studied attachment to fathers separately from mothers. Limitations to the present study include the use of selfreport measures for attachment, which introduces potential bias. Attachment patterns can be measured based on interview, for example the Adult Attachment Interview [84], where the emphasis is on how the adolescent describe their attachment experiences. Regarding the adolescents, we were only able to collect information required to diagnose depression and did not obtain information on comorbid disorders. Also the sample size was limited, which restricted the recommended number of predictors

The present study supports previous research associating depression in adolescence with insecure attachment to parents. Yet, this study uniquely examined the course of clinical depression from adolescence to young adulthood in relationship to both maternal and paternal attachment as well as peer attachment. We found that less secure attachment to parents, either mother or father, is associated with an increased likelihood of experiencing depression by mid-adolescence and into young adulthood, but did not find any associations to peer attachment. Depression is costly for society. When adolescents are insufficiently treated it necessarily affects their development and preparation for adulthood. This study along with others suggests that a non-trivial portion of depressed adolescents do not improve and remain depressed in young adulthood [21, 87, 88]. Clinical professionals should be encouraged to consider attachment to both mother and father in clinical work with adolescents and young adults. Given the reported association, when the adolescent experiences depression it might not be sufficient to treat only the adolescent if insecure attachment to the parents is present. Extending the treatment to include the parents, if indicated, and the relationship among the family members could be more efficient and ultimately better help the depressed adolescent. At the most general level, our findings underscore that important relationships of the patient should be considered in clinical work.

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References 1. Caspi A, Sugden K, Moffitt TE, Taylor A, Craig IW, Harrington H et al (2003) Influence of life stress on depression: moderation by a polymorphism in the 5-HTT gene. Science 301(5631):386–389 2. Rice F, Harold G, Thapar A (2002) The genetic aetiology of childhood depression: a review. J Child Psychol Psychiatry 43(1):65–79 3. Ingram RE, Trenary L, Odom M, Berry L, Nelson T (2007) Cognitive, affective and social mechanisms in depression risk: cognition, hostility, and coping style. Cogn Emot 21(1):78–94 4. Cicchetti D (1993) Developmental psychopathology—reactions, reflections, projections. Dev Rev 13(4):471–502 5. Hartrup WW, Laursen B (1999) Relationships as developmental contexts: Retrospective themes and contemporary issues. In: WACBL (ed) Relationships as developmental contexts 6. Copeland WE, Adair CE, Smetanin P, Stiff D, Briante C, Colman I et al (2013) Diagnostic transitions from childhood to adolescence to early adulthood. J Child Psychol Psychiatry 54(7):791–799 7. Armsden GC, Greenberg MT (1989) The inventory of parent and peer attachment: preliminary test manual. University of Washington (available from Mark Greenberg, [email protected]), Seattle 8. Rudolph KD, Flynn M, Abaied JL (2008) A developmental perspective on interpersonal theories of youth depression. In: Hankin JZABL (ed) Handbook of depression in children and adolescents. Guilford Press, New York 9. Association AP (2000) Diagnostic and statistic manual of mental disorders. Washington, DC 10. Barbe RP, Williamson DE, Bridge JA, Birmaher B, Dahl RE, Axelson DA et al (2005) Clinical differences between suicidal and nonsuicidal depressed children and adolescents. J Clin Psychiatry 66(4):492–498 11. Jaffee SR, Moffitt TE, Caspi A, Fombonne E, Poulton R, Martin J (2002) Differences in early childhood risk factors for juvenile-onset and adult-onset depression. Arch Gen Psychiatry 59(3):215–222 12. Sund AM, Larsson B, Wichstrom L (2011) Prevalence and characteristics of depressive disorders in early adolescents in Central Norway. Child Adolesc Psychiatry Ment Health 5(1):28 13. Allen NB, Kuppens P, Sheeber LB (2012) Heart rate responses to parental behavior in depressed adolescents. Biol Psychol 90(1):80–87 14. Vander Stoep A, Adrian MC, Rhew IC, McCauley E, Herting JR, Kraemer HC (2012) Identifying comorbid depression and disruptive behavior disorders: comparison of two approaches used in adolescent studies. J Psychiatr Res 46(7):873–881 15. Sihvola E, Keski-Rahkonen A, Dick DM, Pulkkinen L, Rose RJ, Marttunen M et al (2007) Minor depression in adolescence: phenomenology and clinical correlates. J Affect Disord 97(1–3):211–218 16. Costello EJ, Copeland W, Angold A (2011) Trends in psychopathology across the adolescent years: what changes when children become adolescents, and when adolescents become adults? J Child Psychol Psychiatry 52(10):1015–1025 17. Thapar A, Collishaw S, Pine DS, Thapar AK (2012) Depression in adolescence. Lancet 379(9820):1056–1067 18. Association AP (2013) Diagnostic and statistical manual of mental disorders-5. American Psychiatric Association, Washington 19. Hankin BL, Abramson LY, Moffitt TE, Silva PA, McGee R, Angell KE (1998) Development of depression from preadolescence to young adulthood: emerging gender differences in a 10-year longitudinal study. J Abnorm Psychol 107(1):128–140 20. Haarasilta L, Marttunen M, Kaprio J, Aro H (2001) The 12-month prevalence and characteristics of major depressive episode in a representative nationwide sample of adolescents and young adults. Psychol Med 31(7):1169–1179

21. Costello EJ, Erkanli A, Angold A (2006) Is there an epidemic of child or adolescent depression? J Child Psychol Psychiatry 47(12):1263–1271 22. Lemstra M, Neudorf C, D’Arcy C, Kunst A, Warren LM, Bennett NR (2008) A systematic review of depressed mood and anxiety by SES in youth aged 10–15 years. Can J Public Health 99(2):125–129 23. Pettit JW, Lewinsohn PM, Seeley JR, Roberts RE, Yaroslavsky I (2010) Developmental relations between depressive symptoms, minor hassles, and major events from adolescence through age 30 years. J Abnorm Psychol 119(4):811–824 24. Twenge JM, Nolen-Hoeksema S (2002) Age, gender, race, socioeconomic status, and birth cohort differences on the children’s depression inventory: a meta-analysis. J Abnorm Psychol 111(4):578–588 25. Jonsson U, Bohman H, von Knorring L, Olsson G, Paaren A, von Knorring AL (2011) Mental health outcome of long-term and episodic adolescent depression: 15-year follow-up of a community sample. J Affect Disord 130(3):395–404 26. Kasen S, Cohen P, Skodol AE, Johnson JG, Smailes E, Brook JS (2001) Childhood depression and adult personality disorder: alternative pathways of continuity. Arch Gen Psychiatry 58(3):231–236 27. Naicker K, Galambos NL, Zeng Y, Senthilselvan A, Colman I (2013) Social, demographic, and health outcomes in the 10 years following adolescent depression. J Adolesc Health 52(5):533–538 28. Bronfenbrenner U (1986) Ecology of the family as a context for human development: research perspectives. Dev Psychol 22(6): 723 29. Bowlby J (1969) Attachment and loss. Hogarth P.; Institute of Psycho-Analysis, London 30. Bowlby J (1980) Sadness and depression. Basic Books, New York 31. Bornstein MH, Suwalsky JT, Breakstone DA (2012) Emotional relationships between mothers and infants: knowns, unknowns, and unknown unknowns. Dev Psychopathol 24(1):113–123 32. Gage MG, Christensen DH (1991) Parental role socialization and the transition to parenthood. Fam Relat 40(3):332–337 33. Bowlby J (1988) A secure base: clinical applications of attachment theory. Routledge, London 34. Waters E, Cummings EM (2000) A secure base from which to explore close relationships. Child Dev 71(1):164–172 35. Thompson RA (2008) Early attachment and later development, familiar questions, new answers. In: Cassidy J, Shaver PR (eds) Handbook of attachment, theory, research, and clinical applications. The Guildford Press, New York 36. Bowlby J (1997) Attachment : vol. 1 of the ‘‘Attachment and loss’’ trilogy. Pimlico, London 37. Ainsworth MDS (1978) Patterns of attachment : a psychological study of the strange situation. Lawrence Erlbaum Associates; distributed by Halsted Press Division of Wiley, Hillsdale, NJ 38. Armsden GC, McCauley E, Greenberg MT, Burke PM, Mitchell JR (1990) Parent and peer attachment in early adolescent depression. J Abnorm Child Psychol 18(6):683–697 39. Lee A, Hankin BL (2009) Insecure attachment, dysfunctional attitudes, and low self-esteem predicting prospective symptoms of depression and anxiety during adolescence. J Clin Child Adolesc Psychol Off J Soc Clin Child Adolesc Psychol Am Psychol Assoc Div 53 38(2):219–231 40. Cooper ML, Shaver PR, Collins NL (1998) Attachment styles, emotion regulation, and adjustment in adolescence. J Pers Soc Psychol 74(5):1380–1397 41. Overbeek G, Vollebergh W, Engels RCME, Meeus W (2003) Parental attachment and romantic relationships: associations with emotional disturbance during late adolescence. J Couns Psychol 50(1):28–39

123

Child Psychiatry Hum Dev 42. Sund AM, Wichstrom L (2002) Insecure attachment as a risk factor for future depressive symptoms in early adolescence. J Am Acad Child Adolesc Psychiatry 41(12):1478–1485 43. Jinyao Y, Xiongzhao Z, Auerbach RP, Gardiner CK, Lin C, Yuping W et al (2012) Insecure attachment as a predictor of depressive and anxious symptomology. Depress Anxiety 29(9):789–796 44. Rosenstein DS, Horowitz HA (1996) Adolescent attachment and psychopathology. J Consult Clin Psychol 64(2):244–253 45. Laible DJ, Carlo G, Raffaelli M (2000) The differential relations of parent and peer attachment to adolescent adjustment. J Youth Adolesc 29(1):45–59 46. Raja SN, Mcgee R, Stanton WR (1992) Perceived attachments to parents and peers and psychological well-being in adolescence. J Youth Adolesc 21(4):471–485 47. Rosenfarb IS, Becker J, Khan A (1994) Perceptions of parental and peer attachments by women with mood disorders. J Abnorm Psychol 103(4):637–644 48. Wilkinson RB (2004) The role of parental and peer attachment in the psychological health and self-esteem of adolescents. J Youth Adolesc 33(6):479–493 49. Kullik A, Petermann F (2013) Attachment to parents and peers as a risk factor for adolescent depressive disorders: the mediating role of emotion regulation. Child Psychiatry Hum Dev 44(4): 537–548 50. Wei MF, Heppner PP, Mallinckrodt B (2003) Perceived coping as a mediator between attachment and psychological distress: a structural equation modeling approach. J Couns Psychol 50(4): 438–447 51. Muris P, Meesters C, van Melick M, Zwambag L (2001) Selfreported attachment style, attachment quality, and symptoms of anxiety and depression in young adolescents. Pers Indiv Differ 30(5):809–818 52. Beck R, Taylor C, Robbins M (2003) Missing home: sociotropy and autonomy and their relationship to psychological distress and homesickness in college freshmen. Anxiety Stress Copin 16(2): 155–166 53. Brumariu LE, Kerns KA (2010) Mother-child attachment patterns and different types of anxiety symptoms: is there specificity of relations? Child Psychiatry Hum Dev 41(6):663–674 54. Brenning K, Soenens B, Braet C, Beyers W (2013) Longitudinal dynamics of depressogenic personality and attachment dimensions in adolescence: an examination of associations with changes in depressive symptoms. J Youth Adolesc 42(8):1128–1144 55. Morley TE, Moran G (2011) The origins of cognitive vulnerability in early childhood: mechanisms linking early attachment to later depression. Clin Psychol Rev 31(7):1071–1082 56. Eberhart NK, Hammen CL (2006) Interpersonal predictors of onset of depression during the transition to adulthood. Pers Relatsh 13(2):195–206 57. Kane P, Garber J (2004) The relations among depression in fathers, children’s psychopathology, and father-child conflict: a meta-analysis. Clin Psychol Rev 24(3):339–360 58. Beardslee WR, Gladstone TRG, O’Connor EE (2011) Transmission and prevention of mood disorders among children of affectively ill parents: a review. J Am Acad Child Adolesc Psychiatry 50(11):1098–1109 59. Cassidy J (1999) The nature of the child’s ties. In: Cassidy J, Shaver PR (ed) Handbook of attachment: theory, research, and clinical applications. Guildford Press, New York 60. Allen JP, Hauser ST, Bell KL, Oconnor TG (1994) Longitudinal assessment of autonomy and relatedness in adolescent-family interactions as predictors of adolescent ego development and selfesteem. Child Dev 65(1):179–194 61. Allen JP, McElhaney KB, Land DJ, Kuperminc GP, Moore CW, O’Beirne-Kelly H et al (2003) A secure base in adolescence:

123

62.

63. 64.

65.

66.

67.

68.

69.

70.

71.

72.

73.

74.

75.

76.

77.

78.

79.

markers of attachment security in the mother–adolescent relationship. Child Dev 74(1):292–307 Allen JP, Porter M, McFarland C, McElhaney KB, Marsh P (2007) The relation of attachment security to adolescents’ paternal and peer relationships, depression, and externalizing behavior. Child Dev 78(4):1222–1239 Allen JP, Moore C, Kuperminc G, Bell K (1998) Attachment and adolescent psychosocial functioning. Child Dev 69(5):1406–1419 Roisman GI, Madsen SD, Hennighausen KH, Sroufe LA, Collins WA (2001) The coherence of dyadic behavior across parent–child and romantic relationships as mediated by the internalized representation of experience. Attach Human Dev 3(2):156–172 Dinya E, Csorba J, Grosz Z (2012) Are there temperament differences between major depression and dysthymic disorder in adolescent clinical outpatients? Compr Psychiatry 53(4):350–354 Sund AM (2004) Development of depressive symptoms in early adolescence: the youth and mental health study. NTNU, Trondheim Kaufman J, Birmaher B, Brent D, Rao U, Flynn C, Moreci P et al (1997) Schedule for affective disorders and schizophrenia for school-age children-present and lifetime version (K-SADS-PL): initial reliability and validity data. J Am Acad Child Adolesc Psychiatry 36(7):980–988 Angold A, Costello EJ, Winder F (1987) The development of a questionnaire for use in epidemiological studies of depression in children and adolescents. Medical Research Council, London Costello EJ, Angold A (1988) Scales to assess child and adolescent depression: checklists, screens, and nets. J Am Acad Child Adolesc Psychiatry 27(6):726–737 Costello EJ, Benjamin R, Angold A, Silver D (1991) Mood variability in adolescents: a study of depressed, nondepressed and comorbid patients. J Affect Disord 23(4):199–212 Sund AM, Larsson B, Wichstrom L (2001) Depressive symptoms among young Norwegian adolescents as measured by the Mood and Feelings Questionnaire (MFQ). Eur Child Adolesc Psychiatry 10(4):222–229 Daviss WB, Birmaher B, Melhem NA, Axelson DA, Michaels SM, Brent DA (2006) Criterion validity of the mood and feelings questionnaire for depressive episodes in clinic and non-clinic subjects. J Child Psychol Psychiatry 47(9):927–934 Goodyer IM, Herbert J, Tamplin A, Secher SM, Pearson J (1997) Short-term outcome of major depression: II. Life events, family dysfunction, and friendship difficulties as predictors of persistent disorder. J Am Acad Child Adolesc Psychiatry 36(4):474–480 Shaffer D, Gould MS, Brasic J, Ambrosini P, Fisher P, Bird H et al (1983) A childrens global assessment scale (Cgas). Arch Gen Psychiatry 40(11):1228–1231 Armsden GC, Greenberg MT (1987) The inventory of parent and peer attachment—individual-differences and their relationship to psychological well-being in adolescence. J Youth Adolesc 16(5):427–454 Angold A, Weissman MM, John K, Merikangas KR, Prusoff BA, Wickramaratne P et al (1987) Parent and child reports of depressive symptoms in children at low and high risk of depression. J Child Psychol Psychiatry 28(6):901–915 Agerup T, Lydersen S, Wallander J, Sund AM (2014) Longitudinal course of diagnosed depression from ages 15 to 20 in a community sample: patterns and parental risk factors. Child Psychiatry Hum Dev. doi:10.1007/s10578-014-0444-8 Muris P, Mayer B, Meesters C (2000) Self-reported attachment style, anxiety, and depression in children. Soc Behav Personal 28(2):157–162 Roelofs J, Meesters C, ter Huurne M, Bamelis L, Muris P (2006) On the links between attachment style, parental rearing behaviors, and internalizing and externalizing problems in non-clinical children. J Child Fam Stud 15(3):319–332

Child Psychiatry Hum Dev 80. Liu YL (2006) Paternal/maternal attachment, peer support, social expectations of peer interaction, and depressive symptoms. Adolescence 41(164):705–721 81. Muris P, Meesters C, van Den Berg S (2003) Internalizing and externalizing problems as correlates of self-reported attachment style and percieved parental rearing in normal adolescents. J Child Fam Stud 12(2):171–183 82. Nickerson AB, Nagle RJ (2005) Parent and peer attachment in late childhood and early adolescence. J Early Adolesc 25(2):223–249 83. Millings A, Buck R, Montgomery A, Spears M, Stallard P (2012) School connectedness, peer attachment, and self-esteem as predictors of adolescent depression. J Adolesc 35(4):1061–1067 84. George C, Kaplan N, Main M (1985) The adult attachment interview. Department of Psychology, University of California, Berkley 85. Pettersen SV (2014) Nøkkeltall for Innvandring og Innvandrere. [Internet] The Central Beaureau of Statistics Norway (SSB):

SSB; [updated August 25. 2014; cited 2014 07.09.]; http://www. ssb.no/innvandring-og-innvandrere/nokkeltall/innvandring-oginnvandrere 86. Epland J, Kirkeberg MI (2012) Wealth distribution in Norway. Evidence from a new register-based data source. http://www.ssb. no/en/inntekt-og-forbruk/artikler-og-publikasjoner/wealth-dis tribution-in-norway: Statistisk sentralbyra˚; 2012 [cited 2014 07.09.2014]; Reports 2012/35. http://www.ssb.no/en/inntekt-ogforbruk/artikler-og-publikasjoner/wealth-distribution-in-norway 87. Weissman MM, Wickramaratne P, Nomura Y, Warner V, Pilowsky D, Verdeli H (2006) Offspring of depressed parents: 20 years later. A J Psychiatry 163(6):1001–1008 88. Canals J, Domenech-Llaberia E, Fernandez-Ballart J, MartiHenneberg C (2002) Predictors of depression at eighteen. A 7-year follow-up study in a Spanish nonclinical population. Eur Child Adolesc Psychiatry 11(5):226–233

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