Attachment in cleft lip and palate: a systematic review, and DSED and RAD symptoms in a sample of school referred children with emotional and behavioural difficulties: prevalence and the association with parental coherence and reflective functioning

Peters Corbett, Araminta 2025. Attachment in cleft lip and palate: a systematic review, and DSED and RAD symptoms in a sample of school referred children with emotional and behavioural difficulties: prevalence and the association with parental coherence and reflective functioning. ClinPsy Thesis, Cardiff University. Item availability restricted.

	PDF (DClinPsy Thesis) - Accepted Post-Print Version Restricted to Repository staff only until 14 April 2027 due to copyright restrictions. Download (4MB) | Request a copy
	PDF (Cardiff University Electronic Publication Form) - Supplemental Material Restricted to Repository staff only Download (230kB) | Request a copy

Abstract

Early parent–infant relationships are central to children’s socio-emotional development, shaping regulatory capacities, behavioural adjustment, and long-term psychological health. Attachment theory provides a well-established framework for understanding how variations in caregiver sensitivity and accessibility contribute to the formation of secure or insecure attachment patterns. Infants with congenital medical conditions may be at heightened risk for disruptions to early relational processes due to the combined influence of medical adversity, altered early interactions, and parental stress. Cleft lip and/or palate (CL/P), one of the most common craniofacial conditions worldwide, potentially influences early caregiving and the parent-child relationship through its impact on feeding, early surgical intervention, prolonged medical involvement, and potential alterations to facial expressiveness. Despite these considerations, there has as yet been no synthesis on the research that has examined attachment in infants with CL/P. This thesis aims to address this gap by systematically reviewing the existing empirical literature on attachment in parent-infant dyads where the infant has been born with CL/P. The review identifies, appraises, and synthesises studies that directly assess attachment classifications, representations, or related constructs within the first five years of life. Particular attention is given to the prevalence of insecure attachment styles in infants with CL/P relative to comparison groups, the methodological characteristics of included studies, and the contextual or clinical variables associated with attachment outcomes. Across studies, substantial variability was observed in attachment assessment methods, sample characteristics, and reporting of cleft type and severity. Overall, no significant differences in attachment security were found between CL/P and non-CL/P groups. Various factors associated with attachment outcomes were explored, including maternal mental health, feeding difficulties, surgical timing (and impact on cognitive development), facial appearance, dyadic interactions, and maternal sensitivity. Despite these discrepancies, the synthesis reveals important consistencies in findings and identifies evidence gaps that have implications for both developmental theory and clinical practice. Given the established importance of early attachment for later psychosocial functioning, understanding these relational processes within the context of CL/P is critical for informing early intervention, parental support strategies, and multidisciplinary cleft care. By consolidating the current evidence base, this thesis provides a structured foundation for future research and highlights the need for more rigorous, developmentally informed investigations into attachment in infants with CL/P. The findings underscore the importance of attending to early relational processes within paediatric healthcare pathways and contribute to ongoing efforts to optimise psychosocial outcomes for children born with cleft conditions. Preface: Empirical Study Early caregiving relationships play a foundational role in shaping children’s emotional, behavioural, and social development. Decades of developmental and clinical research have shown that sensitive, responsive caregiving supports resilience, whereas early relational disruptions can heighten vulnerability to later psychological difficulties. Among the most severe, but also the rarest, forms of early relational disturbance are Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED). These disorders are typically associated with significant adversity such as neglect, maltreatment, or repeated changes in primary caregivers. Yet relatively little research has explored how RAD and DSED symptoms present in children living with their biological parents, or in community samples where levels of risk and adversity vary. Even less is known about how parental reflective functioning, or parental representations of the child (particularly the coherence with which parents describe their child and relationship) may relate to these attachment-related difficulties. This is important, as some researchers have suggested that DSED should not be classified as an attachment disorder. The present empirical study in this thesis addresses the gaps in the literature using a sample of 202 parent-child dyads drawn from a school-referred sample in south Wales. Parents completed standardised interview measures of RAD and DSED symptoms, broader socioemotional functioning, and parental reflective functioning, and provided a speech sample coded for parental narrative coherence (PNC). The children were additionally observed for DSED symptoms using a “waiting room observation” method. An exploratory analysis was also conducted with a small subsample of adopted and looked-after children who have typically experienced heightened early adversity. Findings indicated that RAD and DSED symptoms could be reliably identified across this sample of children referred for emerging emotional and behavioural difficulties in school. No correlations were found between overall parental narrative coherence and parental reflective functioning with DSED or RAD symptoms, as was hypothesised. DSED symptoms in particular appeared largely independent of attachment specific processes and more strongly linked with broader externalising behaviours, while RAD symptoms were more related to children’s internalising difficulties, and there was some limited evidence that RAD symptoms were more sensitive to some specific relational/parenting factors. Patterns in the adopted and looked-after subgroup were broadly similar. These findings add to emerging evidence that that DSED and to a lesser extent RAD symptoms are detectable in children without an institutionalised care history and shed light on their association with specific attachment-related/ parenting factors.

Item Type:	Thesis (DClinPsy)
Date Type:	Completion
Status:	Unpublished
Schools:	Schools > Psychology
Subjects:	B Philosophy. Psychology. Religion > BF Psychology
Date of First Compliant Deposit:	14 April 2026
Last Modified:	14 Apr 2026 16:06
URI:	https://orca.cardiff.ac.uk/id/eprint/186358

Actions (repository staff only)

Edit Item