Attachment and psychopathology in children and adolescents A cross-sectional study of children with Type 1 diabetes and their healthy peers

Anja Turin Drouet^1,2*Maja Drobnič Radobuljac^2,3Natasa Bratina^2,4Sašo Karakatič⁵Tadej Battelino^2,4Klemen Dovč^2,4Simona Klemencic^2,4

• ¹Department for Child psychiatry, University Children’s Hospital Ljubljana, Ljubljana, Slovenia
• ²Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
• ³Centre for Mental Health, University Psychiatric Clinic Ljubljana, Ljubljana, Slovenia
• ⁴Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, University Children’s Hospital Ljubljana, University Medical Centre Ljubljana, Ljubljana, Slovenia
• ⁵Institute of Informatics, Faculty of Electrical Engineering and Computer Science, University of Maribor, Maribor, Slovenia

Introduction: Secure attachment develops in early relationships between infants and their caregivers, providing a foundation for emotional security and mental health across the lifespan. In contrast, insecure attachment is associated with maladaptive stress response and an increased risk of both internalizing and externalizing mental health problems. This study examined the association between attachment (in)security and psychopathology in children with Type 1 diabetes (T1D) compared with healthy peers. We also considered caregivers' attachment security and traumatic life events to better understand interacting biopsychosocial factors in children living with a chronic illness. Methods: A group of children with T1D (N=101) and a group of healthy control children (N=106) aged 8-15 years and one of their parents were included in the study. A Child Attachment Interview (CAI) was conducted with the children and a Relationship Structures Questionnaire (ECR-RS) with the parents to assess their attachment security. Stressful life events in the children's lives were recorded using a questionnaire on the traumatic events (LITE). The children's psychopathology was assessed using the Child Behavior Checklist (CBCL) and the Youth Self-Report (YSR). Descriptive analyses and linear regression models were used to analyze the data. Results: Fifty-nine percent of children had secure attachment, 39% were dismissing, and 2% preoccupied; 16% were classified as disorganized. No significant difference in psychopathology was found between children with T1D and their healthy peers. However, insecure/disorganized attachment was associated with higher psychopathology scores. Simple regression showed positive associations between psychopathology and child attachment insecurity, maternal attachment anxiety, and traumatic life events. A more complex model revealed that male sex, the presence of T1D, maternal attachment anxiety in older children, and the interaction between maternal attachment anxiety and traumatic life events were significantly associated with higher levels of psychopathology. Conclusion: Children with insecure, particularly disorganized, attachment showed higher levels of psychopathology. However, when interaction effects were considered, other factors—such as sex, parental attachment, traumatic life events, and chronic illness—emerged as stronger predictors. These findings highlight the importance of attachment-and trauma-informed care that addresses multiple risk factors to support child and family mental health.