National School of Public Health / Oswaldo Cruz Foundation (Ensp/Fiocruz), Rio de Janeiro, Brazil.
National Institute of Infectious Diseases/ Oswaldo Cruz Foundation (NIID/Fiocruz), Rio de Janeiro, Brazil.
BMC Pediatr. 2023 Aug 17;23(1):403. doi: 10.1186/s12887-023-04215-7.
Attachment influences the development and the formation of the self and subjectivity and, just as early adverse events, may be related to the occurrence of mental disorders, suicidal behavior, and self-harm throughout life. This study aimed to analyze the effect of mental representation of attachment in children on suicidal behavior and self-harm throughout childhood and adolescence, considering the mediating role of internalizing problems.
Based on a cohort of 500 students (mean age 8 years, SD 1.2) sampled from public schools in a Brazilian southeastern metropolis, 316 children were followed for eight years in three waves (2006, 2008, 2012). The following data from the research baseline (2005) were used: family drawing, maternal and family variables, and sociodemographic data. The mental representation of attachment (independent variable) was measured by the Family Drawing Global Scale, discriminating between secure attachment and non-secure attachment. Suicidal behavior/self-harm (dependent variable) and internalizing problems were evaluated in three research waves through CBCL and YSR (ASEBA). Descriptive analysis, calculation of frequencies and p-values of the variables of interest, as well as modeling of structural equations, were performed.
The prevalence throughout the study was: 17.1% [CI 13.3-20.8] for suicidal ideation and 8.9% [CI 5.6 - 12.2] for self-harm; there was a recurrence at one time in 16.5% [IC 12.6 - 20.3] and in two or more moments in 4.1% [CI 2.0 - 6.3] of the sample. Female gender (p = 0.035), internalizing disorders (p < 0.01), and non-secure attachment (p = 0.035) were associated with the occurrence of suicidal behavior/self-harm. The modeling indicated that 92,2% of the total effect of attachment (p = 0.069) on suicidal behavior/self-harm was due to direct effect, the other 7,8% of the effect being mediated by internalizing problems, adjusted for the confounding variables sex, skin color/race, and social stratum. The total effect showed a positive value, which indicates an increase in suicidal behavior/self-harm when the non-secure attachment is present. The approximate OR of non-secure attachment on the total effect (direct + indirect) was 1.15, indicating that, when adjusting for confounding variables, there was a 15% increase in suicidal behavior/self-injury from non-secure attachment.
The study supports the hypothesis that there is a relationship between disruptive attachment patterns (non-secure attachment) developed during infancy and suicidal and self-harm behavior during childhood and adolescence. These findings validate the concern about the first thousand days of childhood as a critical period for child growth and development, but also for the mental health of children and adolescents.
依附关系影响着自我和主体性的发展和形成，就像早期的不良事件一样，可能与一生中精神障碍、自杀行为和自残的发生有关。本研究旨在分析儿童依恋心理表征对儿童期和青春期自杀行为和自残的影响，同时考虑到内化问题的中介作用。
基于从巴西东南部大都市公立学校抽取的 500 名学生（平均年龄 8 岁，标准差 1.2）的队列，对 316 名儿童进行了为期 8 年的 3 次随访（2006 年、2008 年、2012 年）。研究基线（2005 年）使用了以下数据：家庭绘画、母亲和家庭变量以及社会人口统计学数据。依恋的心理表征（自变量）通过家庭绘画全球量表进行测量，区分安全依恋和不安全依恋。通过 CBCL 和 YSR（ASEBA）在三个研究波次中评估自杀行为/自残（因变量）和内化问题。进行了描述性分析、感兴趣变量的频率和 p 值计算以及结构方程建模。
整个研究期间的患病率为：自杀意念 17.1%[95%CI 13.3-20.8]，自残 8.9%[95%CI 5.6-12.2]；在 16.5%[95%CI 12.6-20.3]的样本中存在一次性复发，在 4.1%[95%CI 2.0-6.3]的样本中存在两次或更多次复发。女性（p=0.035）、内化障碍（p<0.01）和不安全依恋（p=0.035）与自杀行为/自残的发生有关。模型表明，依恋对自杀行为/自残的总效应（p=0.069）的 92.2%归因于直接效应，其余 7.8%的效应由内化问题介导，调整了性别、肤色/种族和社会阶层等混杂变量。总效应呈正值，表明不安全依恋时自杀行为/自残增加。非安全依恋对总效应（直接+间接）的近似 OR 为 1.15，表明在调整混杂变量后，非安全依恋导致自杀/自残行为增加 15%。
该研究支持这样一种假设，即婴儿期形成的破坏性依恋模式（不安全依恋）与儿童期和青春期的自杀和自残行为之间存在关系。这些发现验证了对生命最初 1000 天的关注，即儿童成长和发展的关键时期，也是儿童和青少年心理健康的关键时期。
