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OBJECTIVE: Individuals with eating disorders are known to have higher rates of insecure attachment compared to community controls, but the factors underlying this finding are poorly understood. We conducted the first meta-analysis comparing attachment in eating disorder samples compared to community controls that included quality assessment, publication bias and moderation analysis. METHOD: We pre-registered our meta-analysis (CRD42019146799) and followed PRISMA guidelines. We searched PsychINFO, Embase, Medline, CINAHL, and Scopus for publications. Attachment scores were extracted, and Cohen's d calculated for each study using a random effects model. RESULTS: In total, 35 studies were included in the meta-analysis and six studies were summarized in a narrative review. Eating disorder samples showed higher rates of insecure attachment compared to community controls, with a large effect size, across measurement methods and different attachment dimensions. Blinding of assessors moderated effect sizes for attachment interview studies, but no other moderators were significant. DISCUSSION: Risk of insecure attachment is elevated in individuals with eating disorders, albeit heterogeneity is high and largely unexplained. Clinicians may need to take this into account in their work, particularly given the association between attachment insecurity and challenges to therapeutic alliance. Future studies comparing eating disorder samples with community samples should control for general psychopathology. PUBLIC SIGNIFICANCE: Attachment is a broad concept referring to a person's thoughts, feelings and behaviors in relation to close others. This systematic review and meta-analysis found that individuals with eating disorders are lower in attachment security than community controls, regardless of attachment construct or measurement approach. Attachment may be relevant in influencing eating disorder recovery, the development of therapeutic alliance, and potentially clinical outcomes, although more research is needed.

Apego en individuos que padecen trastornos de la conducta alimentaria en comparación con controles comunitarios: una revisión sistemática y metaanálisis. OBJETIVO: Se sabe que las personas que padecen trastornos de la conducta alimentaria tienen tasas más altas de apego inseguro en comparación con los controles comunitarios, pero los factores subyacentes a este hallazgo son poco conocidos. Realizamos el primer metaanálisis que comparó el apego en muestras de personas que padecen trastornos de la conducta alimentaria en comparación con controles comunitarios que incluyeron evaluación de la calidad, sesgo de publicación y análisis de moderación. MÉTODO: Se pre-registró nuestro metaanálisis (CRD42019146799) y seguimos las guías PRISMA. Se realizaron búsquedas de publicaciones en PsychINFO, Embase, Medline, CINAHL y Scopus. Se extrajeron las puntuaciones de apego y se calculó la d de Cohen para cada estudio utilizando un modelo de efectos aleatorios. RESULTADOS: En total, se incluyeron 35 estudios en el metaanálisis y seis estudios se resumieron en una revisión narrativa. Las muestras de personas que padecen trastornos de la conducta alimentaria mostraron tasas más altas de apego inseguro en comparación con los controles comunitarios, con un gran tamaño del efecto, a través de métodos de medición y diferentes dimensiones de apego. El cegamiento de los evaluadores moderó los tamaños del efecto para los estudios de entrevistas de apego, pero ningún otro moderador fue significativo. DISCUSIÓN: El riesgo de apego inseguro es elevado en individuos que padecen trastornos de la conducta alimentaria, aunque la heterogeneidad es alta y en gran medida inexplicable. Los clínicos pueden necesitar tener esto en cuenta en su trabajo, particularmente dada la asociación entre la inseguridad del apego y los desafíos a la alianza terapéutica. Los estudios futuros que comparen muestras de individuos que padecen trastornos de la conducta alimentaria con controles comunitarios deben controlar la psicopatología general.

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Prospective studies of infants at risk for autism spectrum disorder have provided important clues about the early behavioural symptoms of autism spectrum disorder. Diagnosis of autism spectrum disorder, however, is not currently made until at least 18 months of age. There is substantially less research on potential brain-based differences in the period between 6 and 12 months of age. Our objective in the current study was to use magnetic resonance imaging to identify any consistently observable brain anomalies in 6-9 month old infants who would later develop autism spectrum disorder. We conducted a prospective infant sibling study with longitudinal magnetic resonance imaging scans at three time points (6-9, 12-15, and 18-24 months of age), in conjunction with intensive behavioural assessments. Fifty-five infants (33 'high-risk' infants having an older sibling with autism spectrum disorder and 22 'low-risk' infants having no relatives with autism spectrum disorder) were imaged at 6-9 months; 43 of these (27 high-risk and 16 low-risk) were imaged at 12-15 months; and 42 (26 high-risk and 16 low-risk) were imaged again at 18-24 months. Infants were classified as meeting criteria for autism spectrum disorder, other developmental delays, or typical development at 24 months or later (mean age at outcome: 32.5 months). Compared with the other two groups, infants who developed autism spectrum disorder (n = 10) had significantly greater extra-axial fluid at 6-9 months, which persisted and remained elevated at 12-15 and 18-24 months. Extra-axial fluid is characterized by excessive cerebrospinal fluid in the subarachnoid space, particularly over the frontal lobes. The amount of extra-axial fluid detected as early as 6 months was predictive of more severe autism spectrum disorder symptoms at the time of outcome. Infants who developed autism spectrum disorder also had significantly larger total cerebral volumes at both 12-15 and 18-24 months of age. This is the first magnetic resonance imaging study to prospectively evaluate brain growth trajectories from infancy in children who develop autism spectrum disorder. The presence of excessive extra-axial fluid detected as early as 6 months and the lack of resolution by 24 months is a hitherto unreported brain anomaly in infants who later develop autism spectrum disorder. This is also the first magnetic resonance imaging evidence of brain enlargement in autism before age 2. These findings raise the potential for the use of structural magnetic resonance imaging to aid in the early detection of children at risk for autism spectrum disorder or other neurodevelopmental disorders.

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