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Ciencias Psicológicas

versión impresa ISSN 1688-4094versión On-line ISSN 1688-4221

Cienc. Psicol. vol.16 no.2 Montevideo dic. 2022  Epub 01-Dic-2022

https://doi.org/10.22235/cp.v16i2.2684 

Original Articles

Adult attachment styles and emotional regulation in the population of Quito, Ecuador

Elena Díaz-Mosquera1 
http://orcid.org/0000-0002-6093-2614

Marie-France Merlyn Sacoto2 
http://orcid.org/0000-0001-6171-2691

Grace Latorre Vaca3 
http://orcid.org/0000-0001-9213-9568

1 Pontificia Universidad Católica del Ecuador, Ecuador, endiaz@puce.edu.ec

2 Pontificia Universidad Católica del Ecuador, Ecuador

3 Pontificia Universidad Católica del Ecuador, Ecuador


Abstract:

The aim of this study was to explore the association between adult attachment styles and emotion regulation. Two hundred and ninety students between the ages of 18 and 25 participated (M = 21.18; SD = 2.86), coming from various university careers of two higher education institutions in Quito (Ecuador); they were selected by chance grouping. Two instruments were used for the measurement. The first one was the Experiences in Close Relationships-Revised (ECR-R) scale, validated in the Ecuadorian context, which was used to evaluate the type of attachment in romantic relationships. The second instrument was the Difficulties in Emotion Regulation Scale (DERS), in its original version translated into Spanish, used to assess difficulties in emotional regulation. The results showed that secure attachment occurs in a higher percentage of female participants (60 %), that there are no differences by sex in the emotional regulation indicators (p > .05) and that, in the studied population, there is an association between insecure adult attachment styles and emotional dysregulation (p < .05). It is concluded that positive role models of self and of others, as well as low levels of anxiety and avoidance, present in the secure attachment style, are protective factors that contribute to emotional regulation.

Keywords: attachment; adulthood; affected; emotion; self-control

Resumen:

El objetivo de este estudio fue explorar la asociación entre estilos de apego adulto y regulación emocional. Participaron 290 estudiantes de 18 a 25 años (M = 21.18; DE = 2.86), procedentes de varias carreras universitarias de dos instituciones de educación superior de Quito (Ecuador), seleccionados por agrupamiento casual. Para la medición se utilizaron dos instrumentos. El primero fue la escala Experiences in Close Relationships-Revised (ECR-R), validada en el contexto ecuatoriano, con la que se evaluó el tipo de apego en las relaciones de pareja. El segundo instrumento fue la escala Difficulties in Emotion Regulation Scale (DERS), en su versión original traducida al castellano, empleada para evaluar dificultades en regulación emocional. Los resultados demostraron que el apego seguro se presenta en mayor porcentaje en las participantes mujeres (60 %), que no existen diferencias por sexo en los indicadores de regulación emocional (p > .05) y que, en la población estudiada, hay una asociación entre estilos inseguros de apego adulto y desregulación emocional (p < .05). Se concluye que los modelos positivos de sí mismo y de los demás, así como los niveles bajos de ansiedad y evitación, presentes en el estilo de apego seguro, constituyen factores protectores que contribuyen a la regulación emocional.

Palabras clave: apego; adultez; afecto; emoción; autocontrol

Resumo:

O objetivo da presente investigação foi explorar a associação entre estilos de apego adulto e regulação emocional. Participaram 290 alunos com idades entre 18 e 25 anos (M = 21.18; DP = 2.86), provenientes de vários cursos universitários de duas instituições de educação superior de Quito, selecionados por agrupamento ao acaso. Dois instrumentos foram usados para a medição. O primeiro foi a escala Experiences in Close Relationships-Revised (ECR-R), validada no contexto equatoriano, que foi utilizada para avaliar o tipo de apego nas relações de casal. O segundo instrumento foi a escala Difficulties in Emotion Regulation Scale (DERS), na sua versão original traduzida para o espanhol, que foi utilizada para avaliar as dificuldades na regulação emocional. Os resultados mostraram que o apego seguro está presente em maior porcentagem nas participantes mulheres (60 %), que não há diferenças por sexo nos indicadores de regulação emocional (p > 0,05) e que, na população estudada, há associação entre estilos de apego adulto inseguro e desregulação emocional (p < 0,05). Conclui-se que os modelos positivos de si e dos outros, bem como os baixos níveis de ansiedade e evitação, presentes no estilo de apego seguro, constituem fatores de proteção que contribuem para a regulação emocional.

Palavras-chave: apego; idade adulta; afeto; emoção; autocontrole

Interest in the study of emotions was present in the investigations of Bowlby (1973), who focused on the causes and consequences of the type of attachment that children establish with their caregiver figures. Attachment functions as a pattern of control and regulation of stress and affects the manner in which children react to separation and reunion with their caregivers, in such a way that, in conflict situations, children with secure attachment have an easier time managing their negative emotions and restoring emotional balance and trust in others (Bowlby, 1973).

In this sense, the relationship with primary caregivers is a fundamental element in the development of emotional regulation (Mikulincer & Shaver, 2016; Shaver & Mikulincer, 2014), a process through which people manage their positive and negative emotions, as well as the behavior resulting from them (Gómez & Calleja, 2017; Guzmán-González et al., 2014).

Several studies have suggested that the skills involved in this process take place within a dynamic and multifaceted system that begins in childhood (Adrian et al., 2011; Graell & Lanza, 2014) and is sustained by childhood attachment, which lays the foundations for the regulation of emotions throughout life (Girme et al., 2021).

In recent decades, there has been growing interest in studying emotional regulation in adulthood, from the perspective of attachment. Hazan & Shaver (1987) define adult attachment as a biosocial process through which affective ties are generated in the couple with the same pattern acquired with the parents during childhood. This occurs because the model of interaction between the child and his parents takes place in a social context and, therefore, tends to become a representational system (Marrone, 2009). This system was defined by Bowlby (1973) as an internal operating model of self and other, reflecting how the child feels about himself and others, depending on how sensitive and responsive they have been their attachment figures. What is represented in the mind of the child and, later, of the adult, is the type of relationship, not the parent; therefore, attachment behavior is organized around these mental representations that continue throughout the life cycle (Marrone, 2009).

Following Bowlby’s approach, Bartholomew & Horowitz (1991) proposed that, in adult attachment, the internal model of oneself is linked to the subject’s representations of their own worth and that make them feel worthy or not of care and affection, while the model of the other is linked to the expectations of availability and receptivity that the subject has of other people. Bartholomew & Horowitz (1991) suggested that both models could be presented positively or negatively, giving rise to four adult attachment styles: secure, preoccupied, fearful and rejecting (also called avoidant/neglected). In 1998, based on their studies, Brennan et al. defined two dimensions in adult attachment: anxiety in the absence of the attachment figure, related to the model of oneself, and avoidance of intimacy based on previous experiences, related to the model of the other. This is summarized in Figure 1.

Figure 1:  Adult attachment styles 

The internal operative model influences the way people interpret events (Shaver & Mikulincer, 2014); this interpretation, in turn, is part of a broader process: the generation of emotion. Every time people are exposed to a situation, processes of attention, interpretation and finally emotional response are triggered in them (Gross, 1999). Authors such as Gross (1999) have studied this subject emphasizing emotional regulation, the process by which people exert an influence on their emotions, the circumstances in which they appear and the way in which they experience and express them. Gross’ model (1999) divides emotional regulation strategies into two large groups: those focused on the antecedents of the emotion and regulation focused on the emotional response (Hervás & Moral, 2017). Although this model is the most widespread and researched, it has some limitations such as not distinguishing or clarifying which of the strategies could become maladaptive, emphasizing those focused on the antecedents and not on the consequents, which could promote the avoidance of the emotion (Hervás & Moral, 2017). Against this approach there are others that analyze the regulation of emotion once it is already produced, called models of emotional processing. Thus, in the model of Hervás (2011), emotional regulation is made up of six tasks that the individual performs: openness, attention, labeling, acceptance, analysis and emotional modulation; each of them allows optimal processing, but can fail and emotional regulation loses effectiveness (Hervás, 2011).

The failure of the process is called emotional dysregulation and is defined as “the diminished capacity to experience and differentiate a wide range of emotions, as well as to monitor, evaluate and modify intense emotional states through the activation of different strategies, whether they are emotional, cognitive or behavioral” (Menevichian et al., 2017, p. 66). Initially, emotional dysregulation was described in relation to psychological disorders, such as borderline, histrionic and post-traumatic stress disorders (Linehan, 2003), but it is also studied within general emotional processing. Faustino & Vasco (2020) describe, for example, six difficulties that can occur in emotional processing and that are at the base of dysregulation: problematic reaction to situations, lack of meaning or understanding of emotions, presence of unfinished business, self-criticism, self-interruption or avoidance of inner experience ad vulnerability.

The question that arises from this is: what differentiates people who have good emotional regulation from those who do not? Some research suggests that the key may lie in the type of attachment developed. In fact, several studies demonstrate the association between adult attachment and emotional regulation (Mayorga-Parra & Vega, 2021; Mónaco et al., 2021). Securely attached adults have been found to have lower levels of emotional turmoil, feel less threatened by stressful events, develop the ability to experience and express their emotions, and do not get lost in negative worries and memories (Guzmán-González et al., 2016; Mikulincer & Shaver, 2003; Shaver & Mikulincer, 2014). On the other hand, insecure attachment styles are related to regulatory difficulties such as the exacerbation of discomfort in stressful situations and the ease of activation of sad memories, which generates a propagation of negative emotion and cognitive block (Girme et al., 2021; Guzmán-Gonzáles et al., 2016; Hanoos, 2020).

The importance of analyzing the relationship between attachment and emotional dysregulation lies in the fact that both concepts are pointed out as possible antecedents of problems in adulthood, such as aggressive and/or violent behavior (Renn, 2006). Likewise, insecure attachment is related to different psychological conditions in which emotional dysregulation is present, such as anxiety disorders, depression, somatization, OCD, borderline disorder and problematic substance use (Milozzi & Marmo, 2022).

This research focuses on the stage from 18 to 25 years of age, a stage that appeared in industrialized countries in the 21st century, as access to higher education increased with the consequent postponement of milestones such as marriage and children (Arnett, 2008). Although it is a period of life with many opportunities, young people also face several challenges, such as the difficulty of accessing the labor market, and of establishing or maintaining a relationship. These and other challenges that they must face demand the activation of emotional regulation strategies that, if absent, could give rise to imbalances.

Based on the above, the objective of this research was to explore the presence of the association between adult attachment styles and emotional regulation in young people from two higher education institutions in Quito, in order to provide contextualized data on this reality and promote better care of the studied population.

Materials and Method

Participants

Two hundred and ninety young people between 18 and 25 years old participated (M = 21.18; SD= 2.86), from two higher education institutions in Quito, 39.9 % men and 60.1 % women. Regarding the presence of caregiver figures during the first 18 years of life, 92.7 % (n = 269) reported having relied on the mother, and 67.9 % (n = 97) on the father. At the time of application of the instruments, 45.9 % (n = 133) stated that they were in a relationship. Casual pooling was done to select participants, as classrooms from various majors were visited to recruit student volunteers.

Instruments

Two instruments were used: Experiences in Close Relationships-Revised (ECR-R) scale and the Difficulties in Emotion Regulation Scale (DERS).

The ECR-R (Fraley et al., 2000) is the product of the revision of the original test by Brennan et al. (1998). The version used in this research corresponds to the Ecuadorian validation (Díaz-Mosquera et al., 2021), carried over from the Peruvian model (Nóblega et al., 2018). It is made up of 27 items that are phrases about emotional states associated with couple relationships, distributed into three factors: Anxiety (13 items), Avoidance direct items (5 items) and Avoidance inverse items (9 items); the first of them corresponds to the anxiety dimension and the last two to de avoidance dimension of the original test. These dimensions result in four attachment styles in couple relationships (Fraley, 2012): secure, preoccupied, rejecting and fearful. The response scale ranges from totally disagree (1) to totally agree (5) (Zambrano et al., 2009). Regarding the internal consistency of the ECR-R, in this study a Cronbach’s alpha of .916 was obtained in the Anxiety dimension/factor, and .870 in the Avoidance dimension (Avoidance direct items: α = .721; Avoidance inverse items: α = .905). These findings are similar to those reported in other studies. (Díaz-Mosquera et al., 2021; Kooiman et al., 2012; Nóblega et al., 2018; Zambrano et al., 2009).

The second instrument used is the DERS scale (Gratz & Roemer, 2004), in its Spanish version (Hervás & Jódar, 2008). It is an instrument measuring emotion regulation problems. The 36-item self-report scale asks respondents how they are relate to their emotions in order to produce scores on the following six subscales: Non-acceptance of emotional responses (NES, 6 items), Difficulty engaging in goal-directed behaviors (EGB, 5 items), Impulse control difficulties (ICD, 6 items), Lack of emotional awareness (LEA, 6 items), Limited access to emotion regulation strategies (ARS, 8 items), and Lack of emotional clarity (LEC, 5 items). There are five response options, from almost never to almost always. Regarding the internal consistency of the DERS, the Cronbach’s alpha values obtained in this study were: NES = .811; EGB = .821; ICD = .806; LEA = .709; ARS = .860; LEC = .754. These coefficients are within the range reported in the original test (Gratz & Roemer, 2004) and in other studies (e.g., Guzmán-González et al., 2014; Hervás & Jóder, 2008; Lavender et al. 2017; Muñoz-Martínez et al., 2016).

Procedure

Prior authorization, visits to the classrooms of the various careers in the participating institutions were coordinated to disseminate the research. The students who voluntarily agreed to participate filled out a booklet containing: informed consent, personal data sheet, the ECR-R and DERS scales. The information was processed with the statistical package SPSS for Social Sciences (version 25). Ethics Committee for Research on Human Beings of the Pontificia Universidad Católica del Ecuador, Quito campus, approved this study.

Results

Adult Attachment

Regarding adult attachment, evaluated with the ECR-R, Table 1 shows the results of the descriptive statistics of the Anxiety and Avoidance dimensions. As can be seen, the means tend concentrate on the central scores (over 5 points), in addition, none of the factors exceeds the critical value of ± 2 in the asymmetry and kurtosis indices.

Table 1: Descriptive statistics of the ECR-R by dimensions / factors (N = 290) 

Note: M: Mean; SD: Standard deviation; As: Asymmetry; Ku: Kurtosis.

As for the differences by gender, calculated with the t test for independent samples (CI = 95 %), these were recorded significantly (p = .003) only in the Avoidance factor of inverse items, in which the mean score of men (M = 2.53; SD = 0.93) was greater than that of woman (M = 2.20; SD = 0.91).

To obtain attachment styles (Fraley, 2012) the mean obtained by each participant in the dimensions of Anxiety and Avoidance was used, so that scores between 1 and 2.5 were interpreted as low and scores between 2.51 and 5 as high. As seen in Table 2, a higher percentage of female participants show a secure attachment style, on the other hand, insecure attachment styles (worried, rejecting and fearful) are present in 47.9 % of the participating population.

Table 2: Attachment styles in percentages (N = 290) 

Emotional Regulation

Regarding emotional regulation, evaluated with the DERS, Table 3 shows the descriptive statistics corresponding to the six subscales. The means are concentrated in the central score of 5 and none of the subscales exceeds the critical value of ± 2 in the asymmetry and kurtosis indices. There were no significant differences by gender in any of the DERS subscales, using the t-test for independent samples.

Table 3: DERS descriptive statistics by subscales (N = 290) 

Note: NES: Non-acceptance of emotional responses; EGB: Difficulty engaging in goal-directed behaviors; ICD: Impulse control difficulties; LEA: Lack of emotional awareness; ARS: Limited access to emotion regulation strategies; LEC: Lack of emotional clarity. M: Mean; SD: Standard deviation; As: Asymmetry; Ku: Kurtosis.

Attachment and emotional regulation

When comparing the results of both instruments, it was found that six subscales of the DERS were correlated in a statistically significant way with two of the three factors of the ECR-R: Avoidance direct items and Anxiety. It was also found that only the subscales of lack of emotional awareness (LEA) and lack of emotional clarity (LEC) of the DERS were significantly correlated with the Avoidance factor inverse items of the ECR-R (Table 4).

Table 4: Relationship between ECR-R factors and DERS subscales 

Note: NES: Non-acceptance of emotional responses; EGB: Difficulty engaging in goal-directed behaviors; ICD: Impulse control difficulties; LEA: Lack of emotional awareness; ARS: Limited access to emotion regulation strategies; LEC: Lack of emotional clarity. *p < .05; **p < .01.

In reference to the relationship between attachment and emotional regulation, Table 5 presents the descriptive statistics prior to the analysis of variance, as well as the results of the ANOVA test of one factor (F) with their respective degrees of freedom, and the corresponding level of freedom significance (p). As can be seen, there are significant differences (p < .01) between the means of the four attachment styles (secure, preoccupied, rejecting and fearful) on the six subscales of the DERS.

Table 5: Comparison between attachment styles and emotional regulation subscales 

Note: NES: Non-acceptance of emotional responses; EGB: Difficulty engaging in goal-directed behaviors; ICD: Impulse control difficulties; LEA: Lack of emotional awareness; ARS: Limited access to emotion regulation strategies; LEC: Lack of emotional clarity.

To determine the differences between groups, post hoc analyzes were performed using Tukey’s HSD test, with a CI = 95 %. As can be seen (Table 6), the subscales that report deficits in emotional acceptance, goal-directed behaviors, impulse control, access to regulatory strategies and emotional clarity (NES, EGB, ICD, ARS and LEC), are correlated in a statistically significant way with the preoccupied and fearful attachment styles. Regarding the LEA subscale, there are significant correlations with the rejecting and fearful styles.

Table 6: Correlations between attachment styles and emotional regulation subscales 

Note: NES: Non-acceptance of emotional responses; EGB: Difficulty engaging in goal-directed behaviors; ICD: Impulse control difficulties; LEA: Lack of emotional awareness; ARS: Limited access to emotion regulation strategies; LEC: Lack of emotional clarity.*p < .05; **p < .01; ***p < .001.

Discussion

In reference to adult attachment, significant differences were recorded by gender in the Avoidance factor inverse items, in which the mean score of men was higher than that of women. According to the evaluation of the mentioned items (Díaz-Mosquera et al., 2021), these results would indicate that the male participants, as a group, present more difficulty than female participants in some aspects, such as restoring the partner when in need, being affectionate, sharing personal thoughts and feelings and feeling understood within the couple. These findings would be consistent with sociocultural factors involved in the construction of masculine identity, a subject on which there are several studies (e.g., Heilman et al. 2017; Merlyn, 2020).

It was also found that the secure attachment style is present in a higher percentage of participants. This finding is consistent with the results of meta-analysis by Bakermans-Kranenburg & van IJzendoorn (2009) and other subsequent studies on the subject (e.g., Garrido et al., 2015; Rodríguez, 2021), but differs from studies carried out in the Ecuadorian environment that find a higher prevalence of insecure attachments (Mayorga-Parra & Vega, 2021; Merlyn & Díaz-Mosquera, 2021). These discrepancies observed in the same context would merit new studies to explore what factor caused the observed differences. Additionally, secure attachment is more common in women than in men in the current study, which would reflect that, in general, women present a positive internal model of both, self and others, with low anxiety towards the possible absence of the attachment figure and low avoidance of intimacy. The finding on the association between gender and type of attachment is consistent with the study of Merlyn & Díaz-Mosquera (2021).

Regarding emotional regulation, no significant differences were found by gender, which would indicate that the use of regulatory strategies is similar in both men and women in the participating population. Similar findings have been reported in other studies (e.g., Guzmán-González et al., 2016). On this subject, Hanoos (2020) states that the differences associated with gender in the field of emotional regulation tend to disappear with the advent of adulthood, since there are studies carried out with the adolescent population that do report these differences (e.g., Flores et al., 2019). Subsequent investigations in the Ecuadorian environment could put this approach to the test.

In reference to the comparison between adult attachment and emotional regulation, it was found that the Anxiety and Avoidance direct items factors were significantly correlated with the six subscales of the DERS and that only the subscales of lack of emotional awareness and emotional clarity were correlated significantly with the Avoidance factor inverse items. These results show that both, bonding anxiety and intimacy avoidance, are related to emotional dysregulation in the population studied. The subject in question was addressed in order studies in which similar results have been obtained (Mónaco et al., 2021; Rodríguez, 2021).

In relation to the objective of this research, to explore the association between adult attachment styles and emotional regulation, it was found that the worried and fearful styles were correlated with five of the six subscales of the DERS: lack of emotional acceptance, interference with goal-oriented behaviors, difficulty in impulse control, limited access to regulatory strategies, and lack of emotional clarity. No correlation was found between the deficits indicated in these five subscales with the secure and rejecting styles, in which there is a positive self-model and low anxiety. Lack of emotional awareness was also found to be correlated with fearful and rejecting styles, but not with the preoccupied and secure styles that are characterized by positive mental models of others and low avoidance.

These findings lead to some reflections. It can be interpreted that, in the population studied, people with both secure and rejecting styles accept their emotions, do not allow them to interfere with behaviors aimed at achieving their goals, control their impulses, access regulatory strategies and are clear about of their emotions. However, in the rejecting attachment style there are difficulties in emotional awareness, which does not occur in the secure attachment style. This term, emotional awareness, refers to the ability to realize one’s own emotions and those of others, and includes the ability to capture the emotional climate in a given context, which increases social bonding and facilitates coexistence (Pereira et al., 2019). In fact, Guzmán-González et al. (2016), stated that, although people with rejecting styles do not differ from secure ones in all the subscales of the DERS, the cost and meaning that they have for them would be different and, probably, with negative consequences for their mental health.

These statements are linked to the association found in this study between lack of emotional awareness and fearful and rejecting styles, which share a negative mental model of others and high avoidance. That is, emotional awareness requires positive mental models of others and low avoidance in interpersonal relationships, characteristics that are present in the confident and worried styles. In this sense, it is important to mention one of the conclusions of the study carried out by Monti & Rudolph (2014). They stated that emotional awareness should be considered as one of the key objectives of interventions aimed at depressive symptoms, since it has a high impact on the quality of life, the establishment of social ties and the establishment of social bonds and coexistence of people (Pereira et al., 2019).

Regarding the practical implications of the current study, it is pertinent to point out that these findings can be used in the foundation of public health and well-being policies for the general population and particularly for children and adolescents. Similarly, this research aims to contribute to the work of psychologists in the areas of prevention, promotion and intervention in mental health, through the design and implementation of strategies that generate a positive impact on individual, couple and family well-being. The literature reports that there is a relationship between attachment styles and the choice of different interpersonal emotional regulation strategies (Altan-Atalay, 2019), thus, for example, people with secure attachment seem to have a tendency to experience higher levels of empathy and resorting to cognitive reappraisal instead of emotional repression or rumination (Troyer & Greitemeyer, 2018). This would allow psychological work to be focused on different levels and areas, based on the knowledge generated in this study and other similar ones.

About the limitations of this work, it should be emphasized that the results found correspond to university students between 18 and 25 years of age residing in Quito. The aforementioned inclusion criteria prevent these findings from being extrapolated to groups of the same age who do not have the same educational conditions, as well as to people of other groups and/or residents of other cities. This point is particularly important considering that it is a culturally diverse country. Another aspect that should be considered within the limitations of the study refers to the majority presence of female participants. Therefore, it is recommended that research of this nature be carried out in other spaces and with other age groups, to visualize the relationship between adult attachment styles and emotional regulation in contexts such as the family, work and social environment, which will undoubtedly provide valuable knowledge about the problem. Likewise, it would be interesting to investigate the differences in emotional regulation by gender in adulthood, to test the approaches in this regard (Hanoos 2020) in the Ecuadorian population and contrast them with the findings of this study.

Conclusions

From the results, it is concluded that, in the population studied, there is an association between attachment styles and emotional regulation, which was previously mentioned in other investigations (e.g., Goodall, 2015; Guzmán-González et al., 2016; Hanoos, 2020; Mayorga-Parra & Vega, 2021).

Indeed, the findings of this study allow us to infer that a positive self-model and low anxiety, present in secure and rejecting attachment styles, promote acceptance and emotional clarity, goal-directed behaviors, emotional control and access to regulatory strategies. It is also inferred that secure and concerned styles characterized by positive role models of others and low avoidance, facilitate emotional awareness. Since the deficits mentioned in the emotional regulation subscales of the DERS are in insecure attachment styles and not in secure attachment, this study shows that positive models of self and others, as well as low levels of anxiety and avoidance are positive factors of emotional regulation.

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How to cite: Díaz-Mosquera, E., Merlyn Sacoto, M. F., & Latorre Vaca, G. (2022). Adult attachment styles and emotional regulation in the population of Quito, Ecuador. Ciencias Psicológicas, 16(2), e-2327. https://doi.org/10.22235/cp.v16i2.2327

Authors’ participation: a) Conception and design of the work; b) Data acquisition; c) Analysis and interpretation of data; d) Writing of the manuscript; e) Critical review of the manuscript. E. D. M. has contributed in a, b, c, d, e; M. F. M. S. in a, b, c, e; G. L. V. in a, b, d, e.

Scientific editor in charge: Dra. Cecilia Cracco

Received: September 22, 2021; Accepted: August 22, 2022

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