1. The impact of attachment and depression symptoms on multiple risk behaviors in post-war adolescents in northern Uganda Okello J, Nakimuli-Mpungu E, Klasen F, Voss C, Musisi S, Broekaert E & Derluyn I. 8th PCAF Pan African Psychotrauma Conference Nairobi,Kenya 12-16 th July 2015

2. Background Prior to 2006 Northern Uganda had experienced over 20 years of armed conflict between the Ugandan government and the rebel group Lord’s Resistance Army (LRA). Characterised by abduction, indoctrinations and conscription in (child)soldiering, mass internal displacement(camps)

3. Background In post-war context, we have previously shown: Depression symptoms are associated with multiple risk behaviors(Okello et al.,2013) and Depression symptoms mediate the relationship between trauma and multiple risk behavior(Okello et al.,2013) Parental attachments are protective against depression symptoms in post-war adolescents(Okello et al.,2014). literature indicates that low levels of attachment may sensitize individuals to increased multiple risk behaviors when depression symptoms exist. We examined the interactive effects of attachment and depression symptoms on multiple risk behavior.

4. shortcomings Research has relied upon(main-effects) models in which depression symptoms and attachment quality directly predict risk behavior outcomes. Limited data on whether low or insecure attachment adds independently to the risk associated with depression symptoms, Or If insecure attachment and depression symptoms interact in predicting risk behaviors among post-war adolescents. A few prior studies have specifically linked insecure attachment to risk behaviors.

5. Shortcomings Developmental sequelae associated with insecure attachment and depression symptoms remain contentious:  Some studies suggest insecurely attached individuals react more negatively to depression symptoms than individuals not similarly depressed  Others have found the opposite: insecurely attached individuals less reactive to the effects of depression symptoms than individuals without these symptoms  Thus, there is evidence to suggest that secure attachment acts both as protective and risk factor

6. Objective We examined the interactional effects of attachment and depression symptoms on multiple risk behavior. Our anticipation was that each of paternal, maternal and peer attachment would moderate the association between depression symptoms and multiple risk behaviors. We further expected that both insecure attachments (defined as low scores of attachment) and depression symptoms would be associated with increasing odds of multiple risk behavior

7. Cumulative model High attachment Depression multiple risk behavior Low attachment

8. Methods We recruited 551 secondary school adolescents in Gulu district, northern Uganda in Aug-Sept 2010. Self reports used:  Hopkins Symptom Checklist-37A:depression symptoms  Inventory of Parent and Peer Attachment: attachment  Youth Self Report(aggression, rule-breaking, suicidal behavior, substance use) and sexual risk behavior  Multiple risk behavior:3 or more

9. Results Gender differences in baseline characteristics, exposure, depression symptoms, multiple risk behaviors and attachment, have been described and discussed in detail elsewhere (Okello et al., 2013, 2014). Boys were significantly older than girls whereas girls were significantly more likely to be double orphans, have lost both parents, living with relatives, siblings or both parents, and to have divorced or separated parents. Significantly more girls than boys reported stressful war experiences, adverse childhood events, and depression symptoms. Further, girls reported significantly higher paternal and maternal attachment than boys. Peer attachment and multiple risk behaviors were comparable across gender.

10. Discussion :major findings Only a maternal attachment-by-depression interaction effect was found. When maternal attachment is high, increasing levels of depression symptoms are associated with increasing multiple risk behaviors. Conversely, when maternal attachment is low, increasing levels of depression symptoms are associated with decreasing multiple risk behaviors.

11. Maternal attachment security moderates the association between depression symptoms and multiple risk behavior.

12. Major Finding 1: Only maternal attachment moderated the link between depression symptoms and multiple risk behaviors. Possible explanations include: depression symptoms remain potent irrespective of the level of paternal and peer attachment. adolescents engage in more emotionally intimate interactions, both positive and negative with their mothers than with fathers and that attachment to peers only becomes important in the absence of parental figures. Alternatively, the severity of the war-related outcomes found in our sample may be too low for the effects of general models of attachment to father and peers to become evident.

13. Major finding 2: Depression symptoms associated with an increase in multiple risk behaviors among those with high maternal attachment. Results inconsistent with: a)Our proposed moderator hypothesis that high or secure attachment dominates when present and minimizes the effects of depression symptoms b)Previous findings in which high maternal attachment is expected to diminish the impact of depression symptoms on multiple risk behaviors

14. Major finding 3:low maternal attachment emerged as a protective factor primarily in the context of high depression symptoms a)Contrasts our anticipation that at low attachment, the effects of depression symptoms on multiple risk behavior would emerge. b)Consistent with the notion that secure maternal attachment only plays a protective role in some situations.

15. Can low maternal attachment be protective in the context of high depression symptoms? Insecure children may learn to over or under regulate their affect and behavior in reaction to caretakers who selectively respond to their emotional needs The buffers of the adolescent's ecosystem may prevent the behavior of the insecurely attached adolescent from becoming dysfunctional Insecure attachment patterns may compromise exploration, self- confidence and mastery of the environment, which would otherwise serve as preconditions for risk behavior participation. Secure attachment may be more protective in situations of lower risk, such as when depression symptoms are low. Conversely, in situations of high depression symptoms such as in clinical samples, the protective effects of secure attachment is lost or overwhelmed. Insecure patterns maybe adaptive, as they are suitable responses to caregiver unresponsiveness. As such insecure adolescents are less likely than securely attached adolescents to socialize with their peers and thus enact/participate in risk behaviors.

16. Limitations Cross-sectional design limitations of social desirability/recall biases of retrospective self-report data, and the limited ability to address the directionality of the observed effects definitively Screening instruments not diagnostic and concurrent assessment of depression and attachment problematic and both may be correlated.

17. Implications Maternal attachment appears to serve as a protective factor and risk factor Support for links between attachment security and multiple risk behaviors to be conceptualized in terms risk-resilience terms The moderating effect of maternal attachment was specific to depression, but efforts at replication in other mental health symptoms are encouraged to determine the extent to which this relationship is generalizable.

18. Publications J. Okello, E. Nakimuli-Mpungu, F. Klasen, C. Voss, S. Musisi, E. Broekaert,I. Derluyn).T he impact of attachment and depression symptoms on multiple risk behaviors in post-war adolescents in northern Uganda. Journal of Affective Disorders 180 (2015) 62–67 Okello J, Nakimuli-Mpungu E, Musisi S, Broekaert E & Derluyn I.(2013). War- related trauma exposure and multiple risk behaviors among school-going adolescents in northern Uganda: The mediating role of depression symptoms. Journal of Affective Disorders, 151, 715-721. Okello J, Nakimuli-Mpungu E, Musisi S, Broekaert E & Derluyn I.(2014). The Association between Attachment and Mental Health Symptoms among School- going Adolescents in Northern Uganda: the Moderating Role of War-related Trauma. Plos One 9(3):e88494