Renita Almeida

Attachment theory helps to explain psychopathology, however the clinical applications of such theory within the treatment of child mental health problems are limited. This dissertation aimed to address critical gaps within the translation of attachment and family systems theory into clinical assessment and psychological treatment for child psychopathology. This involved the development and evaluation of Attachment-focused Family Therapy (AFT), using both quantitative and qualitative methods. AFT is the latest adaptation of an existing intervention, Behaviour Exchange Systems Therapy (BEST). The first empirical study outlines the development of AFT’s assessment protocol comprising of a discourse-based coding system, the Caregiver Attachment Discourse Scale (CADS), which is applied to an attachment-based interview for caregivers. Based on a selection of interview transcripts (N = 10), interrater reliability data are presented, with analysis indicating good to excellent reliability. The second empirical study evaluated the efficacy of AFT compared to cognitive behavioural therapy (CBT) in a single-blind pilot randomised controlled trial at a community-based clinic, for children experiencing internalising and externalising problems and their families (N = 30). Findings indicated that AFT elicited significantly greater improvements in internalising (d = 0.85) and externalising symptoms (d = 0.85), relative to controls (internalising d = 0.56; externalising d = 0.52), in addition to improved caregiving behaviours and family functioning. The final study presents translational research, whereby exploration of facilitators and barriers to the dissemination of AFT occurred through interviewing child and family therapeutic services in the community (N = 6). Qualitative analysis revealed broad acceptability of the treatment and enthusiasm of agencies to implement AFT, alongside several key barriers at client, clinician, and organisational levels. Altogether, the implications of our overall findings underscore the value of applying attachment and family systems theory within the assessment and treatment of child psychopathology.

Transgender and gender diverse (hereafter trans) youth are amongst the highest risk of all Australian populations regarding mental health difficulties (AIHW, 2018). Specifically, three quarters of Australian trans youth report a depression or anxiety diagnosis, nearly 80% report self-harming and almost half have attempted suicide (Strauss et al., 2020). Despite this population’s vulnerability, there is a paucity of research and appropriate mental health support is scarce. Most trans youth encounter barriers to accessing care and, crucially, two thirds of Australian trans youth experience ambivalent or rejecting attitudes from their caregivers resulting in poor mental and physical health outcomes across the lifespan (Strauss et al., 2020). Moreover, services for parents to aid their understanding and support of their trans child are scant. Theoretically, self- and other-acceptance are positioned as integral to facilitating sound mental health and wellbeing outcomes for trans individuals ( Johns et al., 2018). A fundamental and formative part of realising self-acceptance for trans individuals is development of one’s gender through support and information-seeking, usually before individuals disclose their gender to any of their support networks (Pohjanen & Kortelainen, 2015). Acceptance by the ‘other’ of trans individuals can take many forms, such as acceptance by peers and partners (Johns et al., 2018). Parental acceptance, however, has been posited as the strongest protective factor against negative health outcomes for trans youth (Bariola et al., 2015). Consequently, this thesis is underpinned by two principal research areas: an exploration of how trans youth use online resources to support their mental health, and consolidate their gender, and a focus on the role of parental acceptance in supporting trans youth. Studies One and Two qualitatively explored the role of initial online information-seeking and the use of avatars in gaming by trans youth. Both studies indicate use of online resources are vital in aiding exploration, development and consolidation of gender in a safe space before disclosing to their support networks. Recommendations are made to improve accessibility and suitability of such resources. Study Three investigated factors influencing parental acceptance of trans youth. Salient factors such as the nature of their child’s gender, and levels of awareness of the child’s gender at time of initial parental awareness were identified. Multiple factors aided acceptance, including information and peer support. We provide recommendations on what may help parents to optimally support their child. Study Four specifically sought to identify the positive aspects of parenting a trans child. Aspects such as personal growth hold salient clinical implications for those working with the parents of trans youth and underscore the importance of an affirmative approach. Study Five explored the parental challenges, facilitators and needs associated with supporting their trans child’s gender. Strong themes emerged around parents’ desires to aid their journey towards increased acceptance, with clear recommendations for development of resources such as good-quality information and engaging with others’ stories, indicating important implications for the development of interventions to promote parental acceptance. Taking findings from studies Three and Four, Study Six comprised the development and trialing of a novel group support program for parents of trans youth. Findings indicate that a program combining evidence-based approaches, foundational information and peer support is experienced positively by parents and holds therapeutic promise. The collective findings of these studies fill crucial gaps in the extant research regarding self- and other- acceptance of trans youth with pragmatic implications for clinical translation to better support the mental health and wellbeing of trans youth.

Parent-child attachment and family relationships significantly contribute to the development of childhood depression and anxiety disorders. However, clinical applications of such findings are currently limited. The overarching objective of this dissertation was to conduct a pilot trial and examine the feasibility of a novel attachment-based family intervention, Behaviour Exchange Systems Therapy- Foundations (BEST-F) in treating internalising symptoms of depression and anxiety disorders in children aged between 3 and 11 years. The first study systematically reviewed studies to describe core features of existing psychological interventions referring to themselves as ‘attachment-based’, which revealed that there were limited attachment-based interventions primarily aimed at improving child and adolescent mental health outcomes. Empirical study two reported quantitative outcomes of an uncontrolled study of 17 families who undertook BEST-F based on parent-report CBCL measures completed at four-timepoints (baseline, pre-, post-intervention, and follow-up). Empirical study three explored qualitative outcomes reported by participants. Results suggested that BEST-F reduced child internalising symptoms by 1 to 1.2 standard deviations, and moved children from the borderline clinical to normal range. Notably, additional reduction in symptoms were reported two months after cessation of treatment. Furthermore, there were reductions in child externalising symptoms and other problems, parental mental health symptoms and disorganised caregiving behaviours. Qualitative reports suggested that participants derived considerable benefits at both dyadic and systemic levels. Finally, translational study four evaluated a BEST training program to ensure effective dissemination of the intervention model to clinical practice. Results revealed that the training was well-received and trainees reported further development in clinical skills including family systems approach, risk assessment and management, and facilitation skills. The findings add to the limited body of literature on attachment-based family interventions designed to treat childhood depression and anxiety disorders.