Main study findings and their relation to past research

'

4.2.1 Social cognition in care-leavers

This study is the first to demonstrate impairments in social cognition in young people leaving the public care system. Importantly, these deficits were identified using a task that resembled the demands of everyday-life social cognition (Dziobek et al., 2006a), and allowed for stylistic dysfunctions of mentalising to be analysed separately (e.g. inferences characterised by lack of TOM, reduced TOM or excess TOM). Rather than lacking theory of mind capacity, care-leavers were shown to have developed alternate social cognitive strategies that made them more likely to over-interpret social

information in interpersonal contexts. '

No comparable research has focused on social cognition amongst care-leavers. Some studies have demonstrated that looked after children (Barone & Lionetti, 2012a; Lewis-Morrarty et al., 2012; Pears & Fisher, 2005) and those who have experienced early trauma (see Section 1.7.6.1) present with deficits in social cognitive abilities. These studies have typically used classical measures of theory of mind, which are most suited to detecting the presence or absence of social cognitive abilities.

However, there is evidence that children and adolescents who have been maltreated are more likely to make hostile attributions of peers’ behaviour (Price & Glad, 2003) and interpret facial expressions as angry or fearful (Leist & Dadds, 2009; Masten et

al., 2008; Pollak et al., 2000). These biases in information processing have some

parallels with the tendency to make overly complex mental state inferences identified among care-leavers in the current study. For example, misinterpretation of the

external features of others may increase the tendency to make over-interpretative inferences about their emotions, thoughts and intentions. However, further research is required to elucidate the links between specific aspects of social information

processing and ‘real life’ social cognition. In addition, the majority of this research has been carried out with young children. Comparing young adults with those in childhood is problematic given the profound changes that occur in the brain regions thought to be responsible for social cognition through childhood and adolescence

(Blakemore, 2008a, 2008b; Blakemore et al., 2007). A previous study using the MASC identified more pronounced deficits in social cognition among adults diagnosed with borderline personality who presented with post-traumatic stress disorder (Preisler et al., 2010). In particular, greater impairments in social cognition were noted amongst those who had experienced ‘sexual assault by a known assailant’. Similarly, women with PTSD related to childhood abuse have been shown to have deficits in the recognition of complex mental states from emotionally salient facial expressions (Nazarov et al., 2014). These findings lend some support to theoretical predictions that past trauma interferes with the capacity to ‘mentalise’ (Fonagy, 1989; Fonagy, 1991) and could help explain the finding of impaired social cognition among care-leavers – a group who have experienced disproportionately high levels of early trauma compared to those in the general population.

Care-leavers are at high risk of experiencing psychological difficulties and, as identified in this study, are more likely to have difficulties with emotional regulation than young people raised by their birth parents. As such, it is appropriate to compare the findings from this study which other studies that have investigated social

cognition in clinical groups. As described in Section 1.7, there is evidence that a broad range of mental health problems are associated with differential performance on the MASC. Care-leavers in this study were more likely to make over-interpretative mental state inferences. Similar findings have been reported in individuals diagnosed with borderline personality disorder (Sharp et al., 2013; Sharp et al., 2011b),

persistent somatoform pain disorder (Schönenberg et al., 2014), as well as amongst dependent cocaine users (Preller et al., 2013). This pattern of results is interesting in the context of the findings of the current study. In particular, there is growing

evidence that excessive interpretation of the mental states of others seems to be more common in groups with prominent difficulties with emotional regulation. In contrast, this study found no evidence that care-leavers are more likely to make ‘reduced TOM’ or ‘no TOM’ errors, which contrasts with studies that have utilised the MASC to assess social cognition in individuals with ‘mood disorders’ (Montag et al., 2010; Wolkenstein et al., 2011).

The findings from the current study are inconsistent with studies that have noted superior or ‘intact’ social cognition in those presenting with difficulties with

emotional regulation (see Roepke et al. (2013) for a review). However, the majority of these studies utilised measures of social cognition that focus on recognition of facial affect (Domes et al., 2009; Fertuck et al., 2009; Schilling et al., 2012b) or which lack ecological validity (Arntz et al., 2009; Dziobek et al., 2006a; Ghiassi et

al., 2010; Roepke et al., 2013). The current study utilised the MASC, which has

higher ecological validity (Dziobek et al., 2006a) and is sensitive to qualitatively different inferences in relation to the mental state of others. The findings from the current study are consistent with a wealth of research that suggests that rather than

lacking social cognitive abilities, those with problems regulating their emotions (e.g.

those often diagnosed with borderline personality disorder) present with qualitative differences in how they process social information (Arntz & Ten Haaf, 2012; Barnow

et al., 2009; Fertuck et al., 2009; Franzen et al., 2011; Preisler et al., 2010; Ritter et al., 2011; Roepke et al., 2013; Veen & Arntz, 2000).

The current study did not identify significant differences between care-leavers and non care-leavers when looking specifically at cognitive and emotional mental state reasoning. It is thought that the abilities to infer the cognitive and emotional mental states of others represent distinct but overlapping components of social cognition (Blair, 2005; Decety & Meyer, 2008; Singer, 2006). The findings from the current study contrast with previous research that has found that those meeting diagnostic criteria for a range of psychiatric diagnoses differ in the their ability to process the cognitive and emotional mental states of others. For example, those with borderline personality disorder (Preisler et al., 2010; Ritter et al., 2011) and bipolar disorder (Montag et al., 2011) have been shown to have more pronounced deficits in cognitive, rather than emotional, mental state reasoning, whereas the opposite was found to be true amongst those with persistent somatoform pain disorder (Schönenberg et al., 2014). In the current study, between-group comparisons of different mental state modalities approached statistical significance, which suggests that the failure to identify differences when looking specifically at cognitive and emotional mental state reasoning might represent issues with statistical power in the current study.

Another striking finding from this study was the relative poor performance of both the care-leaver and non care-leaver groups when compared to published data. Overall performance on the MASC amongst care-leavers was significantly worse than a group

of adolescent inpatients and cocaine users, as well as of groups meeting diagnostic criteria for depression, bipolar affective disorder and narcissistic personality disorder. Care-leavers’ performance was comparable to that of clinical groups meeting

diagnostic criteria for borderline personality disorder, paranoid schizophrenia and somatoform pain disorder. Likewise, the average MASC total score among young people in the comparison group was significantly worse than that found for several other ‘control’ groups assessed in previous research studies. It is unclear to what extent this relatively poor performance is due to the complex psychological needs of the population in this study, generational effects, cultural influences, socioeconomic factors and/or the emerging development of social cognitive capacity through adolescence and into early adulthood. Most previous studies that have utilised the MASC to measure social cognition in relation to psychological difficulties have recruited groups with a mean age above 30 years of age. This contrasts with the young adults included in this study. This difference may partially account for the relatively poor performance on the MASC observed in the current study. It is well recognised that the late teens through the early twenties are years of profound change and personal growth (Arnett, 2007). We are only just starting to understand the complexities of the normal development of social cognition through this period (Miller, 2012), but the available evidence suggests that adolescence and early adulthood represents a critical period for the development of brain areas thought to influence social cognition (Blakemore, 2008a, 2008b; Blakemore et al., 2007). Correspondingly, there is evidence from a number of studies that social cognitive ability improves through adolescence and early adulthood (Dumontheil et al., 2010; Mestre et al., 2009).

4.2.2 Emotional regulation in care-leavers

This study found evidence that young people leaving the care-system reported significantly greater difficulties with emotional regulation compared with young people raised by their birth parents. There is a relative paucity of research that has sought to characterise psychological difficulties in young people leaving the care system. However, it is well recognised that looked after children are at greater risk of experiencing psychological problems (Ford et al., 2007) and longitudinal studies suggest that this vulnerability extends into adulthood (Buchanan et al., 2000; Cheung & Buchanan, 1997; Power et al., 2002). The findings from the current study suggest

that the complex psychological problems experienced by looked after children and young people leaving care (Andrew et al., 2013; Ford et al., 2007; Tarren-Sweeney, 2008), may in part be underpinned by difficulties with emotional regulation.

The current research tells us little about the factors that cause emotional regulation difficulties in this population. However, it seems likely that a combination of

experiences prior to, during and transitioning from care interfere with the capacity to develop adaptive skills in emotional regulation. The mentalisation based model, as well as many other psychological orientations, highlight the importance of early attachment relationships, as well as the negative impact of trauma, on the

development of effective strategies to regulate emotions (Fonagy, 1989; Fonagy, 1991; Hughes, 2004; Linehan et al., 1991). Sadly, the majority of children coming into care have experienced trauma and disturbances in early attachment relationships and these are often perpetuated by frequent placement changes and ongoing

difficulties in care (Andrew et al., 2013; Shook et al., 2011). These factors are likely to play an important part in explaining difficulties with emotional regulation observed among care-leavers in the current study. It is also possible that the transition from care itself might be interpreted as overwhelming by some – which could lead to perceived difficulties regulating emotions. Indeed, previous studies have reported a worsening of psychological difficulties and an increase in maladaptive coping strategies (e.g. substance misuse) among young people in the first 12-15 months after they leave the care system (Dixon, 2008; Ward et al., 2003). In the current study insufficient

information was obtained about care-leaver’s past experiences to test the relationship between prior abuse and neglect, experiences in care and emotional regulation.

4.2.3 Adult romantic attachment in care-leavers

This study found that care-leavers had higher levels of attachment anxiety and attachment avoidance in romantic relationships than young people raised by their birth parents. This contrasts with a previous study in this population, which found similar mean scores across the two attachment dimensions when comparing care- leavers with demographically matched non care-leavers. Paull (2013) reported higher mean scores across both attachment dimensions in her comparison group compared with non care-leavers in the current study. The reasons for this difference are not

clear. The current study recruited non care-leavers from the same population as the study by Paull (2013) and a comparison of the demographic characteristics indicates that the two studies included non care-leavers with similar profiles in terms of gender, age, living arrangements and educational qualifications. One difference is that the earlier study included a higher proportion of non care-leavers who had received therapy (37.2%), compared with the current study (25.7%). This might indicate that there were more attachment-related psychological difficulties among non care-leavers in the study by Paull (2013). The mean scores across the two attachment dimensions amongst non care-leavers in the current study were comparable with other studies which have utilised the ECR-R to measure romantic attachment style in young adults recruited from the general population (Bosmans et al., 2010; Fraley et al., 2011).

Findings from the current study are consistent with research that has demonstrated that former adoptees tend to have less secure attachment styles as adults (Borders et

al., 2000; Feeney et al., 2007). Finding of high levels of attachment insecurity in care-

leavers is also consistent with conclusions from the meta-analysis by Van Den Dries

et al. (2009) that reported fewer secure attachments and more disorganised

attachments in fostered and adopted children, compared to children raised by their birth families. However, it is important to recognise that the measure of adult romantic relationship used in the current study differs from the measures of infant attachment utilised in the studies included in the meta-analysis by Van Den Dries et

al. (2009). Furthermore, elevated attachment anxiety and avoidance in adult romantic

relationships isn’t necessarily an indicator of attachment styles in other relationships (Baldwin et al., 1996). Likewise, research that questions the continuity of attachment style over time, especially amongst those who experience difficult life events (Lewis

et al., 2000; Weinfield et al., 2000), cautions against assuming that anxious and

avoidant attachment styles in adulthood reflect earlier attachment representations.

Finally, it is important to note that, despite the statistical significance of the associations, care-leaver status only explained 16% of the variance in attachment. This suggests that other factors, not captured by comparing care-leavers with non care-leavers, were important in forming the internal working models of self and others that underpin adult romantic attachment type. For example, experiences of secure attachment relationships in care (Dozier et al., 2001; Pace & Zavattini, 2011; Steele et

al., 2008) and adoptive parent bond (Feeney et al., 2007) have been shown to be

important predictors of attachment in young people who have spent time in care. Additionally, the measure of adult romantic attachment used in the current study is likely to be sensitive to recent relationship events (Feeney et al., 2007), which in part will be governed by the behaviour of the young person’s romantic partner (Kobak & Madsen, 2008).

4.2.4 Adult romantic attachment and emotional regulation

This study found that higher attachment anxiety, but not attachment avoidance, was associated with greater difficulties with emotional regulation. This indicates that those who are highly preoccupied and fearful within adult romantic relationships perceive themselves as having greater difficulties with emotional regulation than highly secure and dismissive individuals. A care-leaver group interaction was not significant, suggesting that the relationship between attachment and emotional regulation is similar for care-leavers and non-care leavers. A possible explanation is that those with negative internal working models of themselves (e.g. those that score highly on the attachment anxiety dimension) feel unable to handle their own negative emotions and need others to resolve their stress. This low perceived self-efficacy, could lead to hyper-vigilant screening of the environment and/or preoccupation with the availability of attachment figures – which leads to overwhelming negative emotions (Brenning & Braet, 2013).

The association between attachment anxiety and difficulties with emotional regulation is consistent with a wealth of research that indicates that attachment insecurity is more common among adults with a range of psychological problems characterised by emotional dysregulation (Van Ijzendoorn & Bakermans-Kranenburg, 2008).

Likewise, it is consistent with a range of studies, in both children and adults, which have directly tested the relationship between attachment and emotional regulation. Previous research with children has found that parent-child attachment is associated with factors that affect emotional regulation in children, including lower cortisol reactivity (Nachmias et al., 1996), positive anger management strategies (Gilliom et

al., 2002) and more adaptive responses to stress (Contreras et al., 2000; Roque et al.,

2013). Similarly, stylistic ways of regulating affect have been identified in adults that are particular to specific attachment styles. For example, those with insecure

attachments have been shown to over react to negative feelings and to seek the support of others, whereas those who score higher on measures of attachment avoidance suppress their negative feelings and attempt to maximise their distance from others (Brenning & Braet, 2013; Fuendeling, 1998; Wei et al., 2005).

Attachment avoidance was not associated with emotional dysregulation. There are a number of possible explanations for this finding. First, it is possible that those with negative internal working models of others do not perceive themselves as having difficulties with emotional regulation because they value self-reliance, are reluctant to disclose difficulties and are engaged in defensive strategies which promote the

‘idealised self’ (Simard et al., 2011; Wei et al., 2007). In line with this prediction, previous studies have found that those with avoidant attachment styles are less likely to admit ‘self-imperfections’ (Cassidy, 1988). Second, the lack of association might, in part, be due to the fact that the measure of emotional regulation used in this study (i.e. the DERS) is more heavily weighted toward reactive, rather than suppressive, emotional regulation strategies. People who are avoidantly attached are thought to be more likely to use deactivating emotional regulation strategies (e.g. denial), which are less likely to elicit the attention of others, most probably because they have learned that attachment behaviour leads to rejection, punishment or anger instead of comfort (Brenning & Braet, 2013).

4.2.5 Adult romantic attachment and social cognition

This study is the first to test the relationship between attachment and an ecologically valid measure of social cognition. According to attachment theory and the

mentalisation-based theoretical model for the development of psychopathology, social cognition emerges within the context of attachment relationships (Bowlby, 1969; Fonagy & Bateman, 2008). Fonagy et al. (1991) propose that the parent’s capacity to observe and reflect on their child’s mind, within the context of secure attachment relationships, facilitates the child’s general understanding of minds (e.g. social cognition). Likewise, internal working models of self and others are thought to form the basis of future unconscious and automatic inferences about the mental states of others (Bowlby, 1980). As such, we might expect to observe a relationship between adult attachment style and social cognition. This study found that attachment anxiety, but not attachment avoidance, was associated with a greater tendency to make over-

interpretative mental state inferences. Contrary to predictions, interaction analysis indicated that the relationship between attachment and social cognition is similar in care-leavers and non care-leavers. Whilst the cross sectional nature of this study tells us little about causality, it seems plausible that the relationship between attachment and social cognition is transactional. For example, those with high levels of

attachment anxiety are likely to be more vigilant to threat and negative stimuli in interpersonal contexts which could result in them making over-interpretative

inferences about the mental states of others. This in turn is likely to give rise to further attachment anxiety (e.g. misinterpreting benign social interactions as negative, or signs of impending rejection, is likely to heighten attachment anxiety).

The observed association between adult romantic attachment anxiety and over- interpretative mental state inferences is consistent with previous studies that have shown that those with insecure attachments process social information differently to securely attached adults. In particular, previous research has shown that those with insecure attachment representations are primed to attend to and more readily recall negative social stimuli (Atkinson et al., 2009; Maier et al., 2005; Sutin & Gillath, 2009; Zeijlmans Van Emmichoven et al., 2003), as well as being overly attuned to