Attachment

Attachment
Table of content
(Last update: 05-19-2010)
Synthesis on attachment .........................................................................................................i

The impact of attachment to mother and father at an early age on children’s psychosocial
development through young adulthood (Revised edition)
Karin Grossmann and Klaus E. Grossmann.......................................................................1-8
Disorganization of attachment strategies in infancy and childhood (Revised edition)
Kate Hennighausen and Karlen Lyons-Ruth ......................................................................1-7
Attachment at an early age (0-5) and its impact on children’s development
Marinus van IJzendoorn .....................................................................................................1-5
Attachment in early childhood: Comments on van IJzendoorn, and Grossmann and
Grossmann
Greg Moran ........................................................................................................................1-4
Attachment and its impact on child development: Comments on van IJzendoorn,
Grossmann and Grossmann, and Hennighausen and Lyons-Ruth
Charles H. Zeanah Jr. and Prachi Shah.............................................................................1-6
The impact of attachment-based interventions on the quality of attachment among infants
and young children (Revised edition)
Mary Dozier and Kristin Bernard.......................................................................................1-5
Attachment security and disorganization in maltreating families and orphanages
Marinus H. van IJzendoorn & Marian J. Bakermans-Kranenburg....................................1-7
Attachment-based intervention and prevention programs for young children (Revised
edition)
Byron Egeland ....................................................................................................................1-7
Efficacy of attachment-based interventions (Revised edition)
Diane Benoit .......................................................................................................................1-5
Attachment-based interventions: Comments on Dozier, Egeland, and Benoit
Sheree L. Toth .....................................................................................................................1-4
Supporting families to build secure attachment relationships: Comments on Benoit,
Dozier, and Egeland
Femmie Juffer, Marian J. Bakermans-Kranenburg and Marinus H. van IJzendoorn .......1-7
Early day care and infant-mother attachment security
Jay Belsky............................................................................................................................1-6
To read Voices from the Field on these articles, consult the Encyclopedia at:
http://www.child-encyclopedia.com/en-ca/parents-child-attachment/perspectives.html
To read the Key Messages related to this topic, consult the Encyclopedia at:
http://www.child-encyclopedia.com/en-ca/parents-child-attachment/key-messages.html
Synthesis on attachment
(Published online November 26, 2006)
How important is it?
All infants require attention, comfort and a sense of security. Infants who feel
threatened will turn to their caregiver for protection and comfort; over time, the
caregiver’s response helps mold the relationship into a pattern of interaction.
Bowlby’s attachment theory describes the importance of the early relationship that
develops between the infant and the primary caregiver. This affective bond, called
attachment, provides the foundation for the child’s later social, emotional and even
cognitive development. In addition, attachment relationships continue to influence
thoughts, feelings, motives and close relationships throughout life.
Research shows that secure attachment is a protective factor that leads to more
optimal developmental outcomes, while children with insecure attachment are more
prone to social and maladjustment problems and children with disorganized
attachment are at highest risk for psychopathology and poor outcomes.
What do we know?
To assess the quality of attachment in infancy, researchers often use a standardized

separation-reunion method called the Strange Situation Procedure, in which infants’
reactions to being reunited with their caregiver after a brief separation are used to
assess how much trust the children have in the accessibility of their attachment
figure.
There are four patterns of infant-caregiver attachment. Infants who actively seek
proximity to their caregivers on reunion, communicate their feelings of stress and
distress openly and then readily return to exploration are classified as secure. This
type of attachment is believed to develop when the caregiver consistently responds
to the child’s distress in a sensitive manner. Infants who ignore or avoid the
caregiver after being reunited are classified as insecure-avoidant. This is believed to
develop when the caregiver consistently responds to the child’s distress in ways that
are rejecting.
Infants who combine strong contact maintenance with contact resistance, or who
remain inconsolable without being able to return to explore the environment, are
classified as insecure-ambivalent. This develops when the caregiver responds in ways
that are inconsistent and unpredictable. Finally, some infants do not seem able to
resort to a single, organized attachment pattern. This is called disorganized
attachment, and is believed to develop when the caregiver displays unusual and
ultimately frightening behaviours in the presence of the child.
Encyclopedia on Early Childhood Development i

©2006 Centre of Excellence for Early Childhood Development
For a normative population, it is reported that about 62% of infants are classified as
secure, 15% as insecure-avoidant, 8% as insecure-ambivalent and 15% as
disorganized.1
Secure attachment is considered a protective factor as it has been associated with

better developmental outcomes in areas such as self-reliance, self-efficacy, empathy
and social competence in toddlerhood, school-age and adolescence. Infants with
insecure attachment have been shown to be at risk for later adaptation problems
such as conduct disorder, aggression, depression and anti-social behaviour.
Children with disorganized attachment are at the highest risk for psychopathology.
There is a high percentage of attachment disorganization among children who have
been victims of maltreatment. An array of parental behaviours has been linked to
infant disorganization. These include affective communication errors (such as
contradictory responses to infant signals), parental withdrawal, negative-intrusive
responses, role-confused responses, disoriented responses and frightened or
frightening behaviours.
Negative life events (such as divorce) can compromise attachment security, but
differences in attachment security result primarily from the children’s interactions
with their social environment during the first few years of life. Parenting therefore
plays a crucial role. For this reason, preventive interventions in early childhood have
enormous potential to alter behavioural and developmental trajectories, especially in
high-risk families.
What can be done?
To improve long-term developmental outcomes of infants and children, prevention

and intervention programs should focus on promoting secure parent-infant
attachment. Attachment-based interventions often target specific issues, such as
parental sensitivity, behaviours and state of mind. However, exclusive focus on
behavioural training for parent sensitivity rather than a focus on sensitivity plus
support, or a focus on sensitivity plus support plus internal representations (e.g.,
individual therapy), the use of video feedback and brief (5- to 16-session)
interventions focusing on parental sensitivity seem the most effective in improving
attachment security, and also have yielded positive results with adoptive parents. In
addition, the intervention site (home versus office) and the presence of multiple risk
factors did not affect efficacy, but interventions conducted with clinically referred
patients/clients and those that included fathers were more effective than
interventions without such characteristics.
A few sensitivity-focused interventions have had some impact on disorganized

attachment as well. However, it is believed that interventions focusing on atypical
parental behaviours (e.g., failing to keep a child safe, failing to comfort a distressed
child, laughing while the child is distressed, asking for affection and reassurance
from the child, or threatening to harm) are most likely to reduce disorganized
attachment. To date, attachment-based interventions have focused primarily on
precursors of insecure attachment, rather than disorganized attachment. Future
studies should therefore evaluate interventions for their potential to prevent
disorganized attachment.
Currently, the research evidence for enhancing the attachment relationship favours
brief, highly targeted interventions, once the child is at least six months old.
Encyclopedia on Early Childhood Development - ii –

However, more comprehensive, long-term interventions or other types of

interventions may be necessary for some high-risk families. A number of important
issues still need to be studied before definitive conclusions can be reached on how to
best promote secure attachment in different types of families. These include the
durability of the effects of the interventions, the mechanisms contributing to their
efficacy, and their effectiveness in real-world arenas (as opposed to clinical trials)
with different types of families.
Nonetheless, it is clear that service providers should be trained in the use of

attachment-based techniques that have proven to be effective. Attachment-based
intervention programs should be incorporated into existing home visitation and
parent education programs, while policies should identify means by which families
can access consistent parenting and psychological support throughout their child’s
life. Economic analyses now clearly indicate the cost-effectiveness, both in dollars
and in human suffering, of providing services to families with infants, before
psychopathology develops.
Reference
1. van IJzendoorn MH, Schuengel C, Bakermans-Kranenburg MJ. Disorganized

attachment in early childhood: Meta-analysis of precursors, concomitants,
and sequelae. Development and Psychopathology 1999;11(2):225–249.
Encyclopedia on Early Childhood Development - iii –

The Impact of Attachment to Mother and Father
and Sensitive Support of Exploration at an Early Age
on Children’s Psychosocial Development through Young
Adulthood
KARIN GROSSMANN, PhD
KLAUS E. GROSSMANN, PhD
University of Regensburg, GERMANY
(Published online April 4, 2005)
(Revised August 31, 2007)
(Revised October 9, 2009)
Topic
Attachment
Introduction
Bowlby’s and Ainsworth’s approach to personality development relied on ethology1,2 and
cross-cultural research3, preserving the central questions of traditional psychoanalysis2
and drawing on the concept of mental representation as suggested by cognitive
psychology. The ethological approach implies: a) a careful description and classification
of infant and child behaviour4; b) reference to a posited environment of evolutionary
adaptedness for humans, as evidenced by young humans’ intense responsiveness to being
left alone in a strange environment with strange people; and c) analyzing the function of
emotions and behaviours in a social context.5 Attachment serves to ensure protection and
care, and secure attachment serves to relieve distress, restore physiological homeostasis
and encourage exploration. The impact of attachment in terms of biology and
neurobiology has also been documented in recent studies. 7,18 For example, it is through
attachments relationships, that young children first learn to link emotions to external
events in a linguistically meaningful manner. Further, non-pathological attachment
relationships are the basis for becoming emotionally, socially and cognitively
acculturated.6
In the early years, attachment relationships to parents and consistent caregivers are the
predominant and most influential relationships in children’s lives. These relationships set
the stage for infants’ physiological functioning, their emotional and cognitive
interpretations of social- and non-social experiences, their language development, and
their acquisition of meaning about themselves and others in complex social situations.
Later, the attachment relationships mediate children’s acceptance and acquisition of their
culture.14 Joint attention appears to be the central process;8 it emerges at around nine
months, at the height of stranger anxiety. In this way, nature ensures that infants learn
first about their family’s culture in the mother tongue. Attachment relationships that were
Encyclopedia on Early Childhood Development 1

©2005-2009 Centre of Excellence for Early Childhood Development
Grossmann K, Grossmann KE
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vital for infant survival during human evolution9 continue to influence thoughts, feelings
and motives and therefore close relationships throughout life. Early experiences of care,
and the attachment relationship with the caregiver, have a long lasting impact on the
child’s reactivity to stress.18
Within the framework of modern evolutionary biology, attachment theory focuses on the
“gene-selfish” interest of children in receiving as much of their parents’ physical as well
as psychological resources as possible.5,9 In terms of Trivers’10 parent-offspring conflict
paradigm, attachment theory focuses on the offspring’s side of the conflict, and on the
parent’s willingness or unwillingness to invest in any particular individual offspring.
However, parental lifespan planning may help to explain possible differences in parental
investment in care and differential parental sensitivity towards different children.26 This
may also explain the moderate concordance of patterns of attachment even in
monozygotic twins.11
Subject
Attachment theory posits a causal relationship between individuals’ experience with their
parents or attachment figures and their capacity to form affectional bonds later on. If a
child receives tender loving care when in need, and support for autonomy during
exploration from mother as well as father, such experiences are assumed to a) give the
child a sense of worth, a belief in the helpfulness of others and enable the child to explore
the environment with confidence; b) be an optimal precondition for mutually supportive,
enduring adult partnerships; and c) provide a model for later parenthood.12,6 Confident,
competent exploration is equivalent to our concept of “secure” exploration.13 Combining
the concept of secure attachment with secure exploration yields the concept of
“psychological security” that we advocate.13
Problems
Originally, attachment research provided only one method to assess quality of attachment
in infancy, using a separation-reunion paradigm (the strange situation). However,
research results indicated a low validity of the infant-father strange situation assessment
for predicting subsequent psychosocial development.15 Rather, father-child interactive
quality during play or exploration, and sensitive challenges to the young child’s
competencies seem to be better predictors of child development.16,24 Another challenge to
attachment research is more a measurement than a conceptual issue: How do behavioural
patterns of infant attachment become patterns of verbal discourse about attachment
later?23
Research Context
Two longitudinal studies of children’s social and emotional development in not-at-risk
middle-class two-parent families were started in the mid- and late 1970s: the Bielefeld
project, or Project 1, which started with the birth of the infants, and the Regensburg
project, or Project 2, which started when the infants were 11 months old.19 The children’s
experiences in the domains of attachment and exploration were assessed in infancy,
childhood and adolescence, with both mother and father using standardized or free
observations. Semi-structured interviews about family matters were conducted with the

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parents on many occasions and later with the children. Representations of attachment
were assessed at ages 10, 16 and 22, representations of friendship at 16, and
representations of partnership at 20 or 22. For the analysis of early influences on the
representation of close relationships, data on child attachment and exploratory strategies,
maternal and paternal sensitivity and support were aggregated for the periods of infancy
(birth to age three), childhood (five to 10) and adolescence (16 to 18)19. In addition, we
conducted various studies in other cultures,20 adding to the long tradition of cross-cultural
research on attachment.21
Key Research Questions

How does the capacity to make affectional bonds develop? How predictive are the
qualities of infants’ attachment to mother and father during the first two years and their
experiences of sensitive support during exploration for adolescents’ and young adults’
partnership representations? What are the roots of young adults’ representation of
attachment relationships?
Research Results
Our longitudinal projects revealed several major findings:19
1. Security in attachment and partnership representation at the age of 22 was significantly

predicted from security of attachment in adolescence and childhood. Precursors of the
ability to present a clear discourse about attachment issues were already observable at
ages 6 and 10 years.22,23
2. Mothers’ as well as fathers’ sensitive supportiveness, acceptance of the child and

appropriate challenging behaviours, each in its own right and taken together, were
powerful predictors of internal working models of close relationships in young adulthood.
3. Mothers’ and fathers’ sensitivity during joint play with their children in various
settings in the first six years of life contributed significantly to the child’s later quality of
partnership representation. Parental sensitivity during play was characterized by parental
support, and behaviours that promote cooperation and independent problem solving.
4. In contrast to some other longitudinal studies of attachment development, patterns of

attachment shown by the infants in the strange situation to the mother at 12 months or to
the father at 18 months did not predict representation of attachment beyond childhood in
either project. The single most influential variable in Project 1 was the fathers’ sensitive
challenging behaviour during play with their 24- month-old toddlers.19
5. Project 1 is an example of the complexity of developmental pathways beyond infancy.

By the end of the first year, only 33% of infants had shown a secure pattern of attachment
to the mother and only 41% to the father in the strange situation. Still, a secure pattern of
attachment to the mother predicted more optimal development up to the age of 10. We
argued that the high proportion of avoidance in this sample was due to German cultural
demands for early self-reliance in the 1970s and did not necessarily indicate parental
rejection as indicated by maternal sensitivity.17

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6. In Project 1, an insecure pattern of attachment in infancy was predictive of less optimal

subsequent emotional and social development only if the child also lacked the experience
of sensitive, supportive mothering and fathering in the domain of exploration. Even more
importantly, parental rejection during middle childhood, traumatic experiences like the
loss of a close friend, parental separation and parental actual or pending loss were most
likely associated with adolescents’ insecure representation of attachment.25
7. By age 22, however, a number of subjects had reflected thoroughly on their attachment
experience such that parental divorce was no longer a major but only a mediating
variable. The most powerful predictor of attachment and partnership representation at age
22, was the child’s representation of maternal and paternal support during middle
childhood age and mothers’ and/or fathers’ rejection of the child, as indicated in a lengthy
semi-structured interview when the children were 10 years old.27
8. The socio-emotional development of the not-at-risk children in both projects was

influenced throughout the years of immaturity by many factors that were often
independent of each other. Infant attachment quality to mother and father were
independent of each other, as was maternal and paternal play sensitivity towards the
toddler. Parental rejection during middle childhood was not predicted by infant
attachment security, nor was parental divorce or loss. Each factor could divert the child’s
developmental pathway towards a more adaptive or a more non-adaptive direction. 19,27
Our own cross-cultural research on Japanese and Trobriand infants confirmed three of the
four core hypotheses of attachment theory21: 1. Infant attachment to at least one caring
adult is universal; 2. the secure pattern of attachment was also the norm in both groups;
and 3. security of attachment is positively related to competence.5,20 In our recent review,
we summarize many studies that support the concept of psychological security indicating
the combined influence of secure exploration and secure attachment. Psychological
security was linked to cognitive competence, flexible gender-role behaviour, as well as
resourceful transition and adaptions within the school system.13
Conclusion
Young children’s experiences of sensitive, accepting, supportive mothers and fathers start
a pathway of positive psychosocial development for the child. Such experiences in the
domains of attachment as well as exploration are at the roots of secure models of close
relationships and healthy self-reliance in the academic domain.28 They are likely to be
carried forward to other close relationships in childhood, adolescence and young
adulthood. Changes in parental acceptance or disruption of the family can alter the
pathway in either direction, temporarily or permanently.6,19
The child’s subjective experiences can best be assessed by open-minded, reliable

observations of quality of interactions in structured situations3 and by semi-structured
interviews that allow for a discovery of new categories. Analyses of the adaptive
functioning of the attachment system must focus on adverse experiences, irritations and
negative emotions. Analyses of secure exploration must focus on challenges to the child’s

ATTACHMENT
competencies. Appropriate emotional responses to real events and attempted appropriate

solutions with the help of other trusted persons are reliable indicators of security of
exploration.
Implications for the Policy and Services Perspective

Throughout the early years, caregiver sensitivity implies an understanding and correct
interpretation of and prompt and appropriate responses to the young child’s non-verbal as
well as verbal expressions. A prerequisite for sensitivity is pacing the interactions
according to the child’s rhythms, in both good and bad moods. Variations in the quality
of maternal caregiving shape the neurobiological systems that regulate stress reactions.18
Higher sensitivity was found in mothers and fathers who valued attachments based on
their recollections of being accepted themselves and sensitively cared for as a child.27
Likewise, in close relationships with non-parental caregivers or mentors in which the
child feels safe and secure, the child will make ample use of joint attention to social and
non-social objects and events. Learning is most effective if the child feels valued by the
mediating person.29
Parents who have experienced difficult childhoods themselves or who have an infant with
special needs benefit from help in three pivotal domains: 1) understanding child
development in all domains; 2) learning to respond sensitively to their individual child;30
3) finding enjoyment and sufficient time for sensitive, supportive interactions with the
child in attachment- and exploration-relevant situations. In subsequent years, support in
more domains become important, such as finding invested, knowledgeable mentors and
educators for the child and monitoring the child’s friendship group.. This is especially
important when parents’ own education or acculturation leave too many gaps. Secure
attachment is a necessary but not sufficient prerequisite for becoming a cooperative,
valuable and accepted member of one’s group and society. Secure exploration must
complement secure attachments so that children can successfully meet the many
challenges posed by their social relationships.

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REFERENCES
1. Ainsworth MDS, Bowlby J. An ethological approach to personality development.

American Psychologist 1991;46(4):333-341.
2. Bowlby J. By ethology out of psycho-analysis: An experiment in inter-breeding.
Animal Behaviour 1980;28(Aug):649-656.
3. Ainsworth MDS. Infancy in Uganda: Infant care and the growth of love.
Baltimore: Johns Hopkins University Press; 1967.
4. Hinde R. Ethology and attachment theory. In: Grossmann KE, Grossmann K,
Waters E, eds. Attachment from infancy to adulthood: The major longitudinal
studies. New York, NY: Guilford Press; 2005:1-12.
5. Grossmann KE, Grossman K. Universality of human social attachment as an
adaptive process. In: Carter CS, Ahnert L, Grossmann KE, Hrdy SB, Lamb ME,
Porges SW, Sachser N, eds. Attachment and bonding: A new synthesis.
Cambridge, Mass: The MIT Press; 2005:199-229. Dahlem Workshop Report 92.
6. Sroufe LA, Egeland B, Carlson EA, Collins, WA. The development of the person.
The Minnesota study of risk and adaptation from birth to adulthood. New York:
Guilford Press; 2005.
7. Coan JA. Toward a neuroscience of attachment. In: Cassidy J, Shaver PR, eds.
Handbook of attachment: Theory, research, and clinical applications. 2nd ed. New
York, NY: Guilford Press; 2008:241-265.
8. Tomasello M. The cultural origins of human cognition. Cambridge, Mass:
Harvard University Press; 1999.
9. Hrdy, S.B. Evolutionary context of human development: The cooperative
breeding model. In: Carter CS, Ahnert L, Grossmann KE, Hrdy, SB, Lamb ME,
Porges SW, Sachser N, eds. Attachment and bonding: A new synthesis.
Cambridge, Mass: The MIT Press; 2005:9-32. Dahlem Workshop Report 92.
10. Trivers RL. Parent-offspring conflict. American Zoologist 1974;14(1):249-264.
11. van IJzendoorn M, Moran G, Belsky J, Pederson D, Bakermans-Kranenburg MJ,
Kneppers K. The similarity of siblings’ attachments to their mother. Child
Development 2000;71(4):1086-1098.
12. Bowlby J. Attachment and loss. Vol. 1: Attachment. 2nd ed. New York: Basic
Books; 1999.
13. Grossmann K, Grossmann KE, Kindler H, Zimmermann P. A wider view of
attachment and exploration: The influence of mothers and fathers on the
development of psychological security from infancy to young adulthood. In:
Cassidy J. Shaver PR, eds. Handbook of attachment: Theory, research, and
clinical applications. 2nd ed.. New York, NY: Guilford Press; 2008:857-879.
14. Grossmann KE, Grossmann K, Waters E, eds. Attachment from infancy to
adulthood: The major longitudinal studies. New York, NY: Guilford Press; 2005.
15. Lamb ME, Lewis C. The development and significance of father-child
relationships in two-parent-families. In: Lamb ME, ed. The role of the father in
child development. 4th ed. Hoboken, NJ: John Wiley & Sons Inc; 2004 :272-306.
16. Grossmann K, Grossmann KE, Fremmer-Bombik E, Kindler H, Scheuerer-
Englisch H, Zimmermann P. The uniqueness of the child-father attachment

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relationship: Fathers’ sensitive and challenging play as a pivotal variable in a 16-

year longitudinal study. Social Development 2002;11(3):307-331.
17. Grossmann K, Grossmann KE, Spangler G, Suess G, Unzner L. Maternal
sensitivity and newborns orientation responses as related to quality of attachment
in northern Germany. Monographs of the Society for Research in Child
Development 1985;50(1-2):233-256.
18. Fox NA, Hane AA. Studying the biology of human attachment In: Cassidy J,
Shaver PR, eds. Handbook of attachment: Theory, research, and clinical
applications. 2nd ed. New York, NY: Guilford Press; 2008: 217-240.
19. Grossmann K, Grossmann KE, Kindler H. Early care and the roots of attachment
and partnership representations in the Bielefeld and Regensburg Longitudinal
Studies. In: Grossmann KE, Grossmann K, Waters E, eds. Attachment from
infancy to adulthood: The major longitudinal studies. New York, NY: Guilford
Press; 2005:98-136.
20. Grossmann KE, Grossmann K, Keppler A. Universal and culturally specific
aspects of human behavior: The case of attachment. In: Friedlmeier W,
Chakkarath P, Schwarz B, eds. Culture and human development: The importance
of cross-cultural research to the social sciences. New-York, NY: Psychology
Press; 2005:75-97.
21. van IJzendoorn MH, Sagi A. Cross-cultural patterns of attachment: Universal and
contextual dimensions. In: Cassidy J. Shaver PR, eds. Handbook of attachment:
Theory, research, and clinical applications. 2nd ed. New York, NY: Guilford
Press;1999: 713-734.
22. Grossmann KE, Grossmann K, Winter M, Zimmermann P. Attachment
relationships and appraisal of partnership: From early experience of sensitive
support to later relationship representation. In: Pulkkinen L, Caspi A, eds. Paths
to successful development: Personality in the life course. New York, NY:
Cambridge University Press; 2002:73-105.
23. Grossmann KE. Old and new internal working models of attachment: The
organization of feelings and language. Attachment and Human Development
1999;1(3):253-269.
24. Parke R, Dennis J, Flyr ML, Morris KL, Killian C, McDowell DJ, Wild M.
Fathering and children’s peer relationships. In: Lamb ME, ed. The role of the
father in child development. 4th Ed. Hoboken, NJ: John Wiley & Sons Inc;
2004 :307-340.
25. Zimmermann P, Fremmer-Bombik E, Spangler G, Grossmann KE. Attachment in
adolescence: A longitudinal perspective. In: Koops W, Hoeksma JB, van den
Boom DC, eds. Development of interaction and attachment: Traditional and non-
traditional approaches. Amsterdam, Netherlands: North-Holland;1997: 281-292
26. Hrdy SB. Mother nature: A history of mothers, infants, and natural selection. 1st
Ed. New York, NY: Pantheon Books; 1999.
27. Grossmann K, Grossmann KE. Bindungen. Das Gefüge psychischer Sicherheit.
[Attachment. The composition of psychological security]. Stuttgart, Germany:
Klett-Cotta; 2004.

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28. Larose S, Bernier A, Tarabulsy GM. Attachment state of mind, learning

dispositions, and academic performance during the college transition.
Developmental Psychology 2005; 41(1):281-289.
29. Pianta RC. Enhancing relationships between children and teachers. Washington,
DC: American Psychological Association; 1999.
30. Van den Boom DC. The influence of temperament and mothering on attachment
and exploration: An experimental manipulation of sensitive responsiveness
among lower-class mothers with irritable infants. Child Development
1994;65(5):1457-1477.
To cite this document:
Grossmann K, Grossmann KE. The impact of attachment to mother and father at an early age on children’s
psychosocial development through young adulthood. Rev ed. In: Tremblay RE, Barr RG, Peters RDeV,
Boivin M, eds. Encyclopedia on Early Childhood Development [online]. Montreal, Quebec: Centre of
Excellence for Early Childhood Development; 2009:1-8. Available at: http://www.child-
encyclopedia.com/documents/GrossmannANGxp_rev.pdf. Accessed [insert date].
Copyright © 2005-2009
This article is funded by the Centre of Excellence for Early Childhood Development
(CEECD), the Strategic Knowledge Cluster on ECD (SKC-ECD) and the Alberta
Centre for Child, Family and Community Research

Disorganization of Attachment Strategies
in Infancy and Childhood
KATE HENNIGHAUSEN, PhD
KARLEN LYONS-RUTH, PhD
Harvard Medical School, USA
(Published online May 4, 2005)
(Revised June 4, 2007)
(Revised January 12, 2010)
Topic
Attachment
Introduction
The attachment relationship between parent and child refers to those aspects of the
relationship that serve to regulate the infant’s stressful arousal or sense of felt security.
The quality of regulation of fearful affect available in attachment relationships is
fundamental to the developing child's freedom to turn attention away from issues of
threat and security toward other developmental achievements, such as exploration,
learning and play. Under normal conditions, an adequately functioning attachment
relationship buffers the infant against extreme levels of fearful arousal. However, the
attachment relationship may also malfunction. Based on accumulated research findings,
disorganized and controlling forms of attachment behaviour are now thought to represent
signs of malfunction of the attachment relational system. Both caregiver and infant
contribute to the infant-caregiver negotiations that occur around distress and comfort, as
well as to the potential defensive adaptations that may result from those negotiations.
Disorganized attachment behaviours in infancy

Disorganized attachment strategies, or contradictory and un-integrated behaviours toward
the caregiver when comfort is needed, can first be identified at 12 months of age. For
example, freezing, huddling on the floor and other depressed behaviours in the presence
of the caregiver when under stress are part of the coding criteria for disorganized
behaviours. Contradictory approach-avoidance behaviours toward the caregiver when
under stress are also indicators of a disorganized strategy, as shown in Table 1. These
various contradictory and un-integrated behaviours are thought to indicate the infant’s
inability to organize a coherent strategy for eliciting comfort from the caregiver and are
differentially associated with increased release of stress hormones.1,2 Disorganized
attachment behaviours may occur in combination with other insecure behaviours that are
part of an avoidant or ambivalent attachment strategy. Many disorganized behaviours,
however, are displayed in combination with behaviours that are usually part of a secure
strategy, such as protesting separation, seeking contact with mother at reunion and

Hennighausen K, Lyons-Ruth K
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ceasing distress after being picked up. Infants who display disorganized versions of
secure strategies constitute a slight majority (approx. 52%) of infants classified as
disorganized.3,4
Controlling attachment patterns in childhood

By three to six years of age, the child has acquired more cognitive capability to represent
and think about the caregiver’s emotional states. Over this age range, the disorganized
attachment behaviours of many infants are gradually replaced by controlling forms of
attachment strategies.4 Controlling attachment behaviours take two very different forms,
termed controlling-punitive and controlling-caregiving. Controlling-punitive behaviour is
characterized by the child's attempts to maintain the parent’s attention and involvement
through hostile, coercive or more subtly humiliating behaviours when attachment
concerns are aroused. Controlling-caregiving behaviour is characterized by the child's
attempts to maintain the parent’s attention and involvement by entertaining, organizing,
directing or giving approval to the parent. Both disorganized attachment strategies in
infancy and controlling attachment strategies in the preschool years are associated with
preschool and school-aged aggression and psychopathology.5 In addition, disorganized
attachment in infancy remains predictive of elevated levels of dissociative symptoms and
overall psychopathology in late adolescence.6,7
Parental behaviours related to disorganized/controlling attachment strategies

An increased incidence of infant disorganization is observed in the context of parental
psychopathology, but not in the context of infant illness or physical disability.8,9 A meta-
analysis has also confirmed that parental lapses of reasoning or discourse style during
loss or trauma-related portions of the Adult Attachment Interview (termed an Unresolved
State of mind) are associated with infant disorganization, r=.31.10 However, the
mechanisms underlying this association remain to be established. Almost half of
disorganized infants (47%)10 do not have parents with unresolved states of mind. Main
and Hesse11 have advanced the hypothesis that if the parent herself arouses the infant's
fear, this will place the infant in an unresolvable paradox regarding whether to approach
the parent for comfort. This is because the parent becomes both the source of the infant's
fear and the haven of safety. Animal research also makes clear that withdrawing parental
behaviours that fail to soothe the infant’s fearful arousal are associated with enduring
hyper-arousal of the stress response system.12,13 Therefore, Lyons-Ruth, Bronfman and
Atwood suggest that both fearful affect generated by the parent and fearful affect
generated from other sources in the context of parental emotional unavailability may
contribute to infant disorganization.14,15 A spectrum of parental behaviours has been
shown by meta-analysis to be associated with infant disorganization. These behaviours
include parental withdrawal, negative-intrusive responses, role-confused responses,
disoriented responses, frightened or frightening behaviours, and affective communication
errors, including contradictory responses to infant signals and failure to respond to clear
affective signals from the infant.16
Intervening with disorganized/controlling families

Intervention programs designed to modify disorganized attachment strategies have
generally focused on the infancy period. Treatment goals have usually included building

ATTACHMENT
a warm and responsive therapeutic relationship to provide a corrective attachment

experience for the parent. Further goals include helping the parent understand the effects
of prior relationships on current feelings and interactions; coaching the parent on
sensitive, age-appropriate responses to the child's attachment signals; and connecting the
family to additional resources. Recent randomized, controlled intervention trials provide
strong experimental evidence that disorganized attachment processes are amenable to
change. Among both depressed middle-income mothers and low-income maltreating
mothers, thoughtful and sustained interventions (> 40 sessions) were associated with
significant reductions in infant disorganized attachment relative to randomized untreated
controls.17,18 The positive potential of early interventions is buttressed by evidence
outside the attachment field that interventions for stressed low-income parents are both
cost-effective and show positive long-term effects on child antisocial behaviour into early
adulthood.19,20,21
Conclusions
Disorganized attachment processes are early predictors of both internalizing and
externalizing forms of psychopathology from the preschool period onward. These
attachment processes are distinct from child temperament and appear to reside in child-
caregiver relational processes rather than in the child or parent alone. Attachment
disorganization is likely to constitute a broad relational risk factor for psychopathology
that cuts across conventional diagnostic categories and interacts with individual
biological vulnerability, producing a range of psychiatric symptoms. Variability in
behavioural profiles within the disorganized group suggests that multiple etiological
models may be needed. Differing biological vulnerabilities interacting with differing
experiences of loss, abuse and/or chronically hostile or neglecting relationships may lead
to quite different developmental trajectories and adult outcomes. Current frontiers include
investigation of gene-environment interaction in the etiology of disorganized
attachment,22,23,24,25 and differentiation of correlates and outcomes related to
indiscriminate attachment behaviour compared to disorganized attachment behaviour.
26,27
Implications for Policy and Services

Much more emphasis is needed on funding, assessment and provision of early services to
families with infants before the expensive developmental trajectories associated with
child psychopathology begin to unfold. We now have an array of observational methods
to evaluate the quality of the infant-parent attachment relationship by the age of 18
months, before the onset of more serious behaviour problems.16 Service providers in
contact with young families need more training in using and interpreting these early
observational tools. Finally, econometric analyses now clearly indicate the effectiveness,
in cost-savings and in preventing human suffering, of providing early services to families
in infancy, before the long-term developmental trajectories associated with child
psychopathology consume increasing societal resources.28

ATTACHMENT
TABLE 1
Indices of Infant Disorganization and Disorientation in the Presence of the Parent
1. Sequential display of contradictory behaviour patterns, such as strong attachment

behaviour followed by avoidance or disorientation;
2. Simultaneous display of contradictory behaviour patterns, such as strong avoidance

with strong contact-seeking, distress or anger;
3. Undirected, misdirected, incomplete and interrupted movements and expressions;
4. Stereotypes, asymmetrical movements, mistimed movements and anomalous postures;
5. Freezing, stilling or “slow-motion” movements and expressions;
6. Direct indices of apprehension regarding the parent;
7. Direct indices of disorganization or disorientation in the presence of the parent, such as

disoriented wandering, confused or dazed expressions, or multiple, rapid changes of
affect.
Note: See Main & Solomon3 for complete descriptions.
REFERENCES
1. Spangler G, Grossmann K. Individual and physiological correlates of attachment

disorganization in infancy. In: Solomon J, George C, eds. Attachment
disorganization. New York, NY: Guilford Press; 1999:95-124.
2. Hertsgaard L, Gunnar M, Erickson MF, Nachmias M. Adrenocortical responses to
the strange situation in infants with disorganized/disoriented attachment
relationships. Child Development 1995;66(4):1100-1106.
3. Main M, Solomon J. Procedures for identifying infants as
disorganized/disoriented during the Ainsworth Strange Situation. In: Greenberg
MT, Cicchetti D, Cummings EM, eds. Attachment in the preschool years: Theory,
research and intervention. Chicago, Ill: University of Chicago Press; 1990:121-
160.
4. NICHD Early Child Care Research Network. Child-care and family predictors of
preschool attachment and stability from infancy. Developmental Psychology
2001;37(6):847-862.

ATTACHMENT
5. Lyons-Ruth K, Jacobvitz D. Attachment disorganization: Genetic factors,

parenting contexts, and developmental transformation from infancy to adulthood.
In: Cassidy J, Shaver P, eds. Handbook of attachment: Theory, research, and
clinical applications. 2nd ed. New York, NY: Guilford Press; 2008: 666-697.
6. Carlson EA. A prospective longitudinal study of attachment disorganization/
disorientation. Child Development 1998;69(4):1107-1128.
7. Ogawa JR, Sroufe LA, Weinfield NS, Carlson EA, Egeland B. Development and
the fragmented self: Longitudinal study of dissociative symptomatology in a
nonclinical sample. Development and Psychopathology 1997;9(4):855-879.
8. Goldberg S, Gotowiec A, Simmons RJ. Infant-mother attachment and behaviour
problems in healthy and chronically ill preschoolers. Development and
Psychopathology 1995;7(2):267-282.
9. van IJzendoorn MH, Goldberg S, Kroonenberg PM, Frenkel OJ. The relative
effects of maternal and child problems on the quality of attachment: A meta-
analysis of attachment in clinical samples. Child Development 1992;63(4):840-
858.
10. van IJzendoorn MH. Adult attachment representations, parental responsiveness,
and infant attachment: A meta-analysis on the predictive validity of the Adult
Attachment Interview. Psychological Bulletin 1995;117(3):387-403.
11. Main M, Hesse E. Parents’ unresolved traumatic experiences are related to infant
disorganized attachment status: Is frightened and/or frightening parental
behaviour the linking mechanism? In: Greenberg MT, Cicchetti D, Cummings
EM, eds. Attachment in the preschool years: Theory, research and intervention.
Chicago, Ill: University of Chicago Press; 1990:161-182.
12. Coplan JD, Andrews MW, Rosenblum LA, Owens MJ, Friedman S, Gorman JM,
Nemeroff CB. Persistent elevations of cerebrospinal fluid concentrations of
corticotropin-releasing factor in adult nonhuman primates exposed to early-life
stressors: Implications for the pathophysiology of mood and anxiety disorders.
Proceedings of the National Academy of Sciences of the United States of America
1996;93(4):1619-1623.
13. Francis D, Diorio J, Liu D, Meaney MJ. Nongenomic transmission across
generations of maternal behaviour and stress responses in the rat. Science 1999;
286(5442):1155-1158.
14. Lyons-Ruth K, Bronfman E, Parsons E. Atypical attachment in infancy and early
childhood among children at developmental risk. IV. Maternal frightened,
frightening, or atypical behaviour and disorganized infant attachment patterns.
Monographs of the Society for Research in Child Development 1999;64(3):67-96.
15. Lyons-Ruth K, Bronfman E, Atwood G. A relational diathesis model of hostile-
helpless states of mind: Expressions in mother-infant interaction. In: Solomon J,
George C, eds. Attachment disorganization. New York, NY: Guilford Press;
1999:33-70.
16. Madigan S, Bakermans-Kranenburg MJ, van IJzendoorn MH, Moran G, Pederson
DR, Benoit D. Unresolved states of mind, anomalous parental behavior, and
disorganized attachment: A review and meta-analysis of a transmission gap.
Attachment and Human Development 2006;8(2):89-111.

ATTACHMENT
17. Toth SL, Rogosch FA, Manly JT, Cicchetti D. The efficacy of toddler-parent
psychotherapy to reorganize attachment in the young offspring of mothers with
major depressive disorder: A randomized preventive trial. Journal of Consulting
and Clinical Psychology 2006;74(6):1006-1016.
18. Cicchetti D, Rogosch FA, Toth SL. Fostering secure attachment in infants in
maltreating families through preventive interventions. Development and
19. Olds D, Henderson CJr, Kitzman H, Eckenrode J, Cole R, Tatelbaum R. The
promise of home visitation: Results of two randomized trials. Journal of
Community Psychology 1998;26(1):5-21.
20. Schweinhart LJ, Barnes H, Weikart D. Significant benefits: The High/Scope Perry
Preschool study through age 27. Ypsilanti, MI: High/Scope Press; 1993.
21. Lally JR, Mangione PL, Honig AS. The Syracuse University Family Development
Research Program: Long-range impact on an early intervention with low-income
children and their families. In: Powell DR, ed. Parent education as early
childhood intervention: Emerging directions in theory, research and practice.
Westport, CT: Ablex Publishing; 1988:79-104. Annual advances in applied
developmental psychology; vol. 3.
22 . Lakatos K, Toth I, Nemoda Z, Ney K, Sasvari-Szekely M, Gervai J. Dopamine
D4 receptor (DRD4) gene polymorphism is associated with attachment
disorganization in infants. Molecular Psychiatry 2000;5(6):633-637.
23. Gervai J, Novak A, Lakatos K, Toth I, Danis I, Ronai, Z, Nemoda Z, Sasvari-
Szekely M, Bureau JF, Bronfman E, Lyons-Ruth K. Infant genotype may
moderate sensitivity to maternal affective communications: Attachment
disorganization, quality of care, and the DRD4 polymorphism. Social
Neuroscience 2007;2(3-4):307-319.
24. van IJzendoorn MH, Bakermans-Kranenburg M. DRD4 7-repeat polymorphism
moderates the association between maternal unresolved loss or trauma and infant
disorganization. Attachment and Human Development 2006;8(4):291-307.
25. Roisman GI, Fraley RC. A behavior-genetic study of parenting quality, infant
attachment security, and their covariation in a nationally representative sample.
Developmental Psychology 2008;44(3):831-839.
26. Zeanah CH, Smyke AT, Koga SF. Bucharest Early Intervention Project Core
Group; Attachment in institutionalized and community children in Romania.
Child Development 2005;76(5):1015-1028.
27. Lyons-Ruth K, Bureau JF, Riley CD, Atlas-Corbett AF. Socially indiscriminate
attachment behavior in the Strange Situation: Convergent and discriminant
validity in relation to caregiving risk, later behavior problems, and attachment
insecurity. Development and Psychopathology 2009;21(2):355-372.
28. Karoly LA, Greenwood PW, Everingham SS, Hoube J, Kilburn R, Rydell P,
Sanders M, Chiesa J. Investing in our children: What we know and don’t know
about the costs and benefits of early childhood interventions. Santa Monica, CA:
RAND Corporation; 1998. Available at:
http://www.rand.org/publications/MR/MR898/. Accessed January 4, 2010.

ATTACHMENT
Hennighausen K, Lyons-Ruth K. Disorganization of attachment strategies in infancy and childhood. Rev

ed. In: Tremblay RE, Barr RG, Peters RdeV, Boivin M, eds. Encyclopedia on Early Childhood
Development [online]. Montreal, Quebec: Centre of Excellence for Early Childhood Development;
2010:1-7. Available at: http://www.child-encyclopedia.com/documents/Hennighausen-
LyonsRuthANGxp_rev.pdf. Accessed [insert date].

Attachment at an Early Age (0-5) and its
Impact on Children’s Development
MARINUS VAN IJZENDOORN, PhD
Leiden University, NETHERLANDS
(Published online May 4, 2005)
Topic
Attachment
Introduction
What is attachment? Children are considered to be attached if they tend to seek proximity
to and contact with a specific caregiver in times of distress, illness and tiredness.1
Attachment to a protective caregiver helps infants to regulate their negative emotions in
times of stress and distress and to explore the environment, even if it contains somewhat
frightening stimuli. Attachment, a major developmental milestone in the child’s life,
remains an important issue throughout the lifespan. In adulthood, attachment
representations shape the way adults feel about the strains and stresses of intimate
relationships, including parent-child relationships, and the way in which the self is
perceived.
Development of attachment
Attachment develops in four phases.1 In the first phase — indiscriminately orienting and
signalling to people — the baby seems “tuned” to certain wave-lengths of signals from
the environment. These signals are mostly of human origin (e.g. the sound of voices).
During the second phase, probably first by smell and then by sight, the baby develops
preference for one or more caregivers — the phase of orienting and signalling to one or
several specific persons. Not until the infant is able to show active attachment behaviour,
such as actively seeking proximity to and following the attachment figure, does the infant
enters the third phase, the phase of attachment proper — staying near a specific person by
means of signalling and movement. Children enter the fourth phase of the goal-corrected
partnership when they can imagine the parent or caregiver’s plans and perceptions and fit
their own plans and activities according to these.
Explaining individual differences in attachment

Ainsworth et al.2 observed one-year-old infants with their mothers in a standardized
stressful separation procedure, the Strange Situation Procedure (SSP). The reactions of
the infants to their reunion with the caregiver after a brief separation were used to assess
how much trust the children had in the accessibility of their attachment figure.
The procedure consists of eight episodes, of which the last seven ideally take three
minutes. Infants are confronted with three stressful components: an unfamiliar
environment, interaction with a stranger, and two short separations from the caregiver.

van IJzendoorn M
ATTACHMENT
Three patterns of attachment can be distinguished on the basis of infants' reactions to the
reunion with the parent or other caregiver. Infants who actively seek proximity to their
caregivers on reunion, communicate their feelings of stress and distress openly and then
readily return to exploration are classified as secure (B). Infants who do not seem to be
distressed and ignore or avoid the caregiver after being reunited (although physiological
research shows their arousal)3 are classified as insecure-avoidant (A). Infants who
combine strong contact maintenance with contact resistance, or remain inconsolable
without being able to return to explore the environment, are classified as insecure-
ambivalent (C). Besides the classic tripartite ABC classifications, Main and Solomon4
proposed a fourth classification, disorganized attachment (D), which is not discussed
here.
An overview of all American studies with non-clinical samples (21 samples with a total
of 1,584 infants, conducted between 1977 and 1990) shows that about 67% of the infants
were classified as secure, 21% as insecure-avoidant and 12% as insecure-ambivalent.5 A
central issue in attachment theory and research is what causes some infants to develop an
insecure attachment relationship while other infants feel secure.
Research Context
The basic model of explaining differences in attachment relationships assumes that
sensitive or insensitive parenting determines infant attachment (in-)security. Ainsworth2
and colleagues originally defined parental sensitivity as the ability to perceive and
interpret children’s attachment signals correctly and respond to these signals promptly
and adequately. Lack of responsiveness or inconsistent sensitivity has indeed been found
to be associated with insecurity in children, and consistent sensitive responsiveness with
secure bonds.6
However, some proponents of the behavioural genetic approach have declared most
correlational findings on child development to be seriously flawed because they are based
on traditional research designs focusing on between-family comparisons, which confound
genetic similarities between parents and children with supposedly shared environmental
influences.7 Harris,8 for example, claims that there is an urgent need to radically rethink
and de-emphasize the role of parents in child development. Despite the prevalence of this
current of thought, attachment theory continues to emphasize the important role of
parental sensitivity.

Crucial research questions explore the causal role of sensitive parenting in the
development of infant attachment security. These questions have been addressed in twin
studies comparing attachments of mono- and dizygotic twins within the same family, and
in experimental intervention studies designed to enhance parental sensitivity in order to
improve the infant attachment relationship.
Recent Research Results

Four twin studies on child-mother attachment security using behavioural genetic
modelling have been published to date. Three of the four studies document a minor role
for genetic influences on differences in attachment security and a rather substantial role
for shared environment.9,10,11 The fourth study, the Louisville Twin Study,12 investigated
van IJzendoorn M
ATTACHMENT
the quality of attachment in twin pairs with an adapted separation-reunion procedure

originally designed to assess temperament. The large role shared environmental factors
play in attachment (about 50% in the Bokhorst et al. study)11 is remarkable. Differences
in attachment relationships are mainly caused by nurture rather than nature, although the
bias to become attached is inborn.
Is sensitive parenting the core ingredient of the shared environment? Twenty-one

correlational studies have replicated a significant but modest association between parental
sensitivity and infant attachment (r = .24, N = 1099). But only experimental interventions
can definitely prove Ainsworth’s original hypothesis. In 24 randomized intervention
studies (n = 1280), both maternal sensitivity and children’s attachment security were
assessed as outcome measures. In general, attachment insecurity appeared more difficult
to change than maternal insensitivity. When interventions were more effective in
enhancing parental sensitivity, they were also more effective in enhancing attachment
security, which experimentally supports the notion of a causal role of sensitivity in
shaping attachment.13
Conclusions
Attachment, the affective bond of infant to parent, plays a pivotal role in the regulation of
stress in times of distress, anxiety or illness. Human beings are born with the innate bias
to become attached to a protective caregiver. But infants develop different kinds of
attachment relationships: some infants become securely attached to their parent, and
others find themselves in an insecure attachment relationship. These individual
differences are not genetically determined but are rooted in interactions with the social
environment during the first few years of life. Sensitive or insensitive parenting plays a
key role in the emergence of secure or insecure attachments, as has been documented in
twin studies and experimental intervention studies. In the case of attachment theory, the
nurture assumption8 is indeed warranted. Numerous findings confirm the core hypothesis
that sensitive parenting causes infant attachment security, although other causes should
not be ruled out.
Implications for Social Policy

The most important policy and mental-health implication is that parenting does matter for
infants’ socio-emotional development. Parents are therefore entitled to receive social
support from policy-makers and mental-health workers to do the best job they can in
raising their vulnerable children. Sensitive parenting is hard work and does not come
naturally to many parents, who have to find their way even if they had few positive
childhood experiences of their own. It takes a village to raise a child,14 so parents need to
rely on good-quality non-parental care to combine childrearing with other obligations.
Furthermore, many parents may profit from rather brief preventive interventions that help
them become more sensitive to their infants’ attachment signals. From our meta-analysis,
we concluded that the most effective interventions for enhancing sensitive parenting and
infant attachment security used a moderate number of sessions and a clear-cut
behavioural focus, starting no sooner than six months after birth. From an applied
attachment perspective, young parents should be given access to preventive support
programs that incorporate these evidence-based insights.

van IJzendoorn M
ATTACHMENT
REFERENCES
1. Bowlby J. Attachment. New York, NY: Basic Books; 1969. Attachment and loss;
vol. 1.
2. Ainsworth MDS, Blehar MC, Waters E, Wall S. Patterns of attachment: a
psychological study of the strange situation. Hillsdale, NJ: Lawrence Erlbaum
Associates; 1978.
3. Spangler G, Grossmann KE. Biobehavioral organization in securely and
insecurely attached infants. Child Development 1993;64(5):1439-1450.
research, and intervention. Chicago, Ill: University of Chicago Press; 1990:121-
160.
5. van IJzendoorn MH, Goldberg S, Kroonenberg PM, Frenkl OJ. The relative
effects of maternal and child problems on the quality of attachment: A meta-
analysis of attachment in clinical samples. Child Development 1992;63(4):840-
858.
6. De Wolff MS, van IJzendoorn MH. Sensitivity and attachment: A meta-analysis
on parental antecedents of infant attachment. Child Development 1997;68(4):571-
591.
7. Rowe DC. The limits of family influence: genes, experience, and behavior. New
York, NY: Guilford Press; 1994.
8. Harris JR. The nurture assumption: Why children turn out the way they do. New
York, NY: Free Press; 1998.
9. Ricciuti AE. Child-mother attachment: A twin study. Dissertation Abstracts
International 1992;54:3364. University Microfilms No. 9324873.
10. O’Connor TG, Croft CM. A twin study of attachment in preschool children. Child
Development 2001;72(5):1501-1511.
11. Bokhorst CL, Bakermans-Kranenburg MJ, Fearon RMP, van IJzendoorn MH,
Fonagy P, Schuengel C. The importance of shared environment in mother-infant
attachment security: A behavioral genetic study. Child Development
2003;74(6):1769-1782.
12. Finkel D, Matheney APJr. Genetic and environmental influences on a measure of
infant attachment security. Twin Research 2000;3(4):242-250.
13. Bakermans-Kranenburg MJ, van IJzendoorn MH, Juffer F. Less is more: Meta-
analyses of sensitivity and attachment interventions in early childhood.
Psychological Bulletin 2003;129(2):195-215.
14. Clinton HR. It takes a village: and other lessons children teach us. New York,
NY: Simon & Schuster; 1996.

van IJzendoorn M
ATTACHMENT
van IJzendoorn M. Attachment at an early age (0-5) and its impact on children’s development. In:
Tremblay RE, Barr RG, Peters RDeV, eds. Encyclopedia on Early Childhood Development [online].
Montreal, Quebec: Centre of Excellence for Early Childhood Development; 2005:1-6. Available at:
http://www.child-encyclopedia.com/documents/van_IJzendoornANGxp.pdf. Accessed [insert date].
Copyright © 2005

van IJzendoorn M
Attachment in Early Childhood: Comments on
van IJzendoorn, and Grossmann and Grossmann 1
GREG MORAN, PhD
The University of Western Ontario, CANADA
(Published online July 6, 2005)
Topic
Attachment
Introduction
Attachment theory and research has established for itself a central place in the study of
human social and affective development. Building on the foundational concepts of
Bowlby1 and Ainsworth’s2 translation of these into a framework for empirical study,
researchers worldwide have used attachment as a vehicle to increase our understanding of
the life-long consequences of the human infant’s first relationship and of the factors in
the mother’s own childhood that are central to the shaping of that relationship.
Karin and Klaus Grossmann and Marinus van IJzendoorn are outstanding representatives
of the researchers who have built on the legacy of Bowlby and Ainsworth. They have
taken different but complementary approaches to their tasks. van IJzendoorn provides a
straightforward, authoritative overview of attachment theory and a description of patterns
of attachment relationships.3 His description of research findings focuses on the question
of whether variation in attachment is a function of early social experience with the
caregiver or genetic factors, including temperament. He cites recent behavioural genetic
analyses of attachment in twins that convincingly support the experiential side in this
debate. This evidence is all the more notable because it contrasts sharply with the results
of parallel studies of the origins of many behavioural and personality traits and attitudes
for which evidence of substantial genetic influence has been found.4
The Grossmanns, on the other hand, take a more personal approach to their task,
beginning with an account that stresses attachment’s role, both in evolutionary and
developmental time, in providing the infant with a social apprenticeship with the
caregiver – an opportunity to acquire the social and emotional skills required to adapt to
the society and culture of his or her birth. Their review of research involves extracts from
two extensive longitudinal studies carried out in Germany by the Grossmanns and their
colleagues. These results stress both life-long continuity and the potential for change, for
better or worse, as a result of substantial fluctuations in the social environment.
1
Comments on original paper published by Karin Grossmann & Klaus E. Grossmann in 2005. To have
access to this article, contact us at [email protected]

Moran G
ATTACHMENT
Research and Conclusions

A critical element in both contributions is the rightful emphasis they place on the role
played by the caregiver in determining the quality of the attachment relationship and thus
in shaping the future social and emotional development of the child. In addition to the
results of twin studies, van IJzendoorn also cites experimental evidence for the critical
place of caregiving in development, citing the results of intervention studies that have
been successful in improving the quality of the attachment relationship through
manipulations that enhance the mother’s sensitivity and responsiveness.3
Neither author comments at length on research on the developmental consequences of

variation in early attachment relationships. An extensive body of research over the past
two decades and more has established a clear link between secure patterns of attachment
in infancy and early childhood and later social adaptation.5 Secure attachment has been
associated with better developmental outcomes than non-secure patterns in areas that
include self-reliance, self-efficacy, empathy and social competence in toddlerhood,
school-age and adolescence. Infants with non-secure attachments have been shown to be
more prone to later problems in adaptation that include conduct disorder, aggression,
depression and anti-social behaviour. It is important to note, however, that much of the
research relating attachment to later developmental outcomes was performed prior to the
use of the disorganized category,6 a pattern of attachment that has been linked
compellingly to more extreme maladaptive developmental outcomes. An unknown
number of disorganized relationships, therefore, were included in these analyses within
the secure and non-secure attachment groups. Additional research is needed to clarify
which, if any, of the associations previously attributed to non-secure patterns are in fact a
function of disorganization.
Implications for Social Policy and Services

The Grossmanns’ emphasis on both the ability of early attachment quality to predict later
social and emotional adaptation and on discontinuities in this process reflects a
fundamental aspect of the role of attachment in development as originally conceptualized
by Bowlby. That is, attachment influences development in a probabilistic rather than a
simple deterministic fashion. This notion is especially important for those hoping to use
an understanding of attachment to develop services or implement social policy. Briefly,
rather than directly determining a particular adaptive or maladaptive outcome, early
attachment experiences are thought to predispose the infant to act and react in a manner
that serves to shape subsequent social experiences, thus launching the child on one
developmental pathway rather than the other. The actual developmental outcome,
however, remains the product of continuing experience, even though these experiences
are, in part, made more or less probable by the quality of the early attachment
relationship. The trajectory can be changed by subsequent social experience, including
deliberate intervention.
Bowlby captured the most important implications of attachment theory and research for
social policy and services in a report that was written over half a century ago:
“Just as children are absolutely dependent on their parents for sustenance, so in
all but the most primitive communities, are parents, especially their mothers,

Moran G
ATTACHMENT
dependent on a greater society for economic provision. If a community values its

children it must cherish their parents.”
John Bowlby, 1951, p.84, WHO Report
Cited by Inge Bretherton (1992)7
Bowlby’s comment to some extent reflects the language and culture of the day, but
remains urgently accurate. Research on attachment over the past three decades has
confirmed his central hypothesis that the sensitivity and responsiveness of the caregiver
is instrumental in shaping the human infant’s first relationship. This relationship, in turn,
has been shown to be a powerful predictor of later important social outcomes. Our efforts
to ensure that this outcome is adaptive rather than maladaptive for both the individual
and society must, therefore, focus on our support of the infant’s caregiver, most often the
mother. In today’s society, this translates most urgently, at a policy level, into ensuring
that families at developmental risk, including single mothers, are provided with the social
and financial resources necessary to provide their children with a supportive social
environment – the prerequisite of a healthy attachment relationship. As suggested by van
IJzendoorn, in many cases this will mean the provision of quality daycare for these same
families. For service-providers, attachment theory and research call for a focus on early
social interaction and on the primary mediator of such interaction, the mother. Patterns of
attachment behaviour and mental representations become less flexible and less open to
change with developmental time. Investment through social policy and service delivery
in the earliest years is thus a more efficient and feasible approach than reactive
intervention delayed until the negative consequences of inadequate early experiences
become apparent.

Moran G
ATTACHMENT
REFERENCES
1. Bowlby J. Attachment. London, England: Hogarth Press; 1969. Attachment and

loss; vol 1.
2. Ainsworth MS, Blehar MC, Waters E, Wall S. Patterns of attachment: A
psychological study of the strange situation. Hillsdale, NJ: Lawrence Erlbaum;
1978.
4. McGuffin P, Riley B, Plomin R. Genomics and behavior: Toward behavioral
genomics. Science 2001;291(5507):1232-1249.
5. Carlson EA, Sampson MC, Sroufe LA. Implications of attachment theory and
research for developmental-behavioral pediatrics. Journal of Developmental and
Behavioral Pediatrics 2003;24(5):364-379.
160.
7. Bretherton I. The origins of attachment theory: John Bowlby and Mary
Ainsworth. Developmental Psychology 1992;28(5):759-775.
Moran G. Attachment in early childhood: Comments on van IJzendoorn, and Grossmann and Grossmann.
In: Tremblay RE, Barr RG, Peters RDeV, eds. Encyclopedia on Early Childhood Development [online].
Montreal, Quebec: Centre of Excellence for Early Childhood Development; 2005:1-4. Available at:
http://www.child-encyclopedia.com/documents/MoranANGxp.pdf. Accessed [insert date].
Copyright © 2005

Moran G
Attachment and its Impact on Child Development:
Comments on van IJzendoorn, Grossmann and Grossmann 1 ,
and Hennighausen and Lyons-Ruth 2
CHARLES H. ZEANAH JR., MD
PRACHI SHAH, MD
Institute of Infant and Early Childhood Mental Health
Tulane University Health Sciences Center, USA
(Published online July 6, 2005)
Topic
Attachment
Introduction
More than 50 years ago, a British child psychiatrist named John Bowlby was
commissioned by the World Health Organization to write a monograph about the mental-
health needs of young children. Bowlby’s conclusion was that “what is believed to be
essential for mental health is that an infant and young child should experience a warm,
intimate and continuous relationship with his mother (or mother substitute – or permanent
mother substitute – one person who steadily mothers him) in which both find satisfaction
and enjoyment.”1 Grossmann and Grossmann, van IJzendoorn, and Hennighausen and
Lyons-Ruth all review the current status of more than 35 years of research that has
affirmed, refined and extended Bowlby’s central thesis. In this commentary, we review
the authors’ interpretations of research, implications for policy, and highlight additional
areas of emphasis.

Several issues and conclusions are reviewed in the sections on attachment and its impact
on child development:
(1) Individual differences in the organization of the young child’s attachment

behaviour expressed towards the caregiver have proven to be reasonably robust predictors
of the child’s subsequent psychosocial adaptation. An important question that has been
the focus of empirical attention and debate concerns the degree to which individual
differences in attachment are attributes of the child or are instead attributes of the child’s
relationship with a specific caregiver. van IJzendoorn concludes that it is “nurture” rather
1
Comments on original paper published by Karin Grossmann & Klaus E. Grossmann in 2005. To have
2
Comments on original paper published by Kate Hennighausen & Karlen Lyons-Ruth in 2005. To have

Zeanah CH Jr., Shah P
ATTACHMENT
than “nature” that accounts for differences in attachment security. His hypothesis is well
substantiated by the research he cites and is further supported by repeated findings that a
child may have different attachment classifications with different caregivers.2
(2) If attachment patterns reflect relationship characteristics rather than traits in the
child, one would expect that characteristics of dyadic interaction would be associated
with patterns of attachment. The research cited by van IJzendoorn provides support for a
causal role of parental sensitivity in the development of attachment security, though much
less research has addressed the interactive patterns that precede avoidant and resistant
attachment. Research reviewed by Hennighausen and Lyons-Ruth has also demonstrated
that certain parental behaviours, such as withdrawal, negative-intrusive responses, role-
confused responses, disoriented responses, frightened or frightening behaviours and
affective communication errors, which include contradictory responses to infant signals,
are likely to be more evident in the context of certain types of parental psychopathology,
and have been documented to be associated with disorganized attachment.3,4
(3) A central tenet of attachment theory has been that early experiences between
young children and their caregivers provide a model for intimate relationships in later
life. Although this model is believed to be modifiable by subsequent experiences, the
theory has posited a conservative tendency to resist change. These propositions suggest
that in a stable caregiving environment, one would expect to find stable patterns of
attachment, but in environments characterized by significant changes, one would expect
less stability. On balance, these assertions are supported by research, although results
from four longitudinal studies of attachment from infancy to adulthood do not support a
linear relationship,5-8 as these studies do not uniformly demonstrate stability of
attachment classifications from infancy to adulthood. They do, however, provide support
for a relationship between life events and changes in attachment classifications. In the
Grossmanns’ work, negative life events and stresses were also found to compromise
attachment security. Individuals whose attachment classifications changed from secure in
infancy to insecure in adulthood were more likely to have experienced negative life
events (such as divorce), and children who demonstrated insecure attachment in infancy
were more likely to remain insecure if they experienced negative life events. Studies
conducted and reviewed by Grossmann and Grossmann (this volume) have helped
illuminate some of the complexities of developmental pathways.
(4) Hennighausen and Lyons-Ruth rightly emphasize the importance of disorganized

attachment as a component of the study of childhood psychopathology. Although the
secure vs. insecure attachment distinction has some predictive validity, disorganized
attachment has far better documented links with specific types of psychopathology than
do other types of insecurity.4,9 Still, much less is understood about the mechanisms
through which disorganized attachment affects the expression of psychopathology in the
child, and whether it is a specific contributor or a more general marker for
psychopathology in general. Hennighausen and Lyons-Ruth’s emphasis that interventions
with families most at risk for having children with disorganized attachments have shown
promise when they are home-based, intensive and long-lasting is a particularly important
point.

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Additional Issues
What is missing from these contributions is a consideration of attachment in more
extreme populations, such as maltreated or severely deprived young children. In contrast
to the developmental perspective that considers the quality of a young child’s attachment
to a caregiver as a risk or protective factor for the development of psychopathology, the
clinical tradition considers that attachments may be so disturbed as to constitute an
already established disorder. Reactive attachment disorder (RAD) describes a
constellation of aberrant attachment behaviours and other social behavioural anomalies
that are believed to result from “pathogenic care.”10 Two clinical patterns have been
described:
(a) An emotionally withdrawn/inhibited pattern, in which the child exhibits limited or
absent initiation or response to social interactions with caregivers, and a variety of
aberrant social behaviours, such as inhibited, hyper-vigilant or highly ambivalent
reactions; and (b) an indiscriminately social/disinhibited pattern, in which the child
exhibits lack of expectable selectivity in seeking comfort, support and nurturance, with
lack of social reticence with unfamiliar adults and a willingness to “go off” with
strangers.
Although the systematic study of attachment disorders is quite recent, these disorders
have been described for more than half a century. From a handful of recent studies, it
seems clear that signs of attachment disorders are rare to non-existent in low-risk
samples,11-13 increased in higher-risk samples,14,15 and readily identifiable in maltreated16
and institutionalized samples.12,13 Interestingly, the emotionally withdrawn/inhibited type
of RAD is readily apparent in young children living in institutions and in young children
when they are first placed in foster care for maltreatment, but it is rarely evident in
samples of children adopted out of institutions.11,17 In contrast, the indiscriminately
social/disinhibited type of RAD is discernable in maltreated,16 institutionalized12,13,18 and
post-institutionalized children 11,13, 17,19-20
Clearly, there is a need to understand how clinical and developmental perspectives on

attachment interrelate. Some initial suggestions that secure, insecure, disorganized and
disordered attachments could be arrayed on a spectrum of healthy to unhealthy
adaptation21 or that disorganized attachment itself should be considered an attachment
disorder have not been supported by research to date. Instead, the picture that is
beginning to emerge is that the clinical and developmental perspectives on disturbed
attachments offer different ways of understanding disturbances of attachment.
Implications for the Policy and Services

The propensity for human infants to form attachments to their caregivers and for
caregivers to be drawn to care for human infants appears to be hard-wired. Thus,
disturbances of attachment become evident when various factors within the parent, within
the child or within the larger caregiving contexts interfere with a species-typical capacity
to form attachments.
All three contributors describe implications for policy. van IJzendoorn emphasizes that
policies should be developed to encourage parental sensitivity in the infancy period.

ATTACHMENT
Grossmann and Grossmann further emphasize the importance of the parent-child

attachment relationship in older children and adolescents, and by implication,
interventions with families should not only focus on the early childhood period but rather
be aimed at providing consistent support and assistance throughout the child’s
development. Finally, Hennighausen and Lyons-Ruth rightly emphasize that early
intervention for infants and toddlers with disorganized attachment will likely reduce the
need for more expensive interventions once psychopathology has emerged.
No doubt all of the contributors would agree that we already know enough to identify
children at risk for disturbances of attachment and its associated psychopathology.
Nonetheless, preventive interventions, perhaps even before the child is born, have
enormous potential to alter the behavioural and developmental trajectories that may befall
children born into multi-risk families. The contributors further assert that policy and
practice should focus on the early identification of parent-child relationship difficulties in
hopes of providing services that may ameliorate the risk for the development of later
psychopathology.
Policies should identify the means by which families can access consistent parenting and
psychological support throughout the lifetime of their child. Primary health-care
providers and child-care professionals are two groups that have contact with most
families of children and adolescents. How these professionals may best support the needs
of parents and which interventions are most beneficial to enhance parental sensitivity and
infant attachment remains a matter of debate. A recent meta-analysis of early childhood
interventions asserted that brief interventions (<5 sessions) focusing on increasing
maternal sensitivity and enhancing infant attachment security were more effective than
long-term intervention.23 In contrast, Hennighausen and Lyons-Ruth cited evidence that
disorganized attachment responds best to home-based, intensive and long-term
interventions. In other words, from a health-promotion perspective (promoting secure
attachments), shorter and more focused interventions may be preferable, but from a risk-
reduction perspective (reducing disorganized attachment), longer and more intensive
interventions may be necessary. Challenges that remain are demonstrating valid
approaches to identifying different levels of risk in families and cost-effective
interventions to optimize later developmental and behavioural outcomes for young
children.

ATTACHMENT
REFERENCES
1. Bowlby J. Child care and the growth of love. Melbourne, Australia: Penguin
Books; 1953;13.
2. Howes C. Attachment relationships in the context of multiple caregivers. In:
Cassidy J, Shaver PR, eds. Handbook of attachment: Theory, research, and
clinical applications. New York, NY: Guilford Press; 1999:671-687.
3. Lyons-Ruth K, Bronfman E, Parsons E. Atypical attachment in infancy and early
childhood among children at developmental risk. IV. Maternal frightened,
frightening, or atypical behaviour and disorganized infant attachment patterns.
Monographs of the Society for Research in Child Development 1999;64(3):67-96.
4. Green J, Goldwyn R. Annotation: Attachment disorganisation and
psychopathology: new findings in attachment research and their potential
implications for developmental psychopathology in childhood. Journal of Child
Psychology and Psychiatry 2002;43(7):835-846.
5. Hamilton CE. Continuity and discontinuity of attachment from infancy through
adolescence. Child Development 2000;71(3):690-694.
6. Lewis M, Feiring C, Rosenthal S. Attachment over time. Child Development
2000;71(3):707-720.
7. Waters E, Merrick S, Treboux D, Crowell J, Albersheim L. Attachment security
in infancy and early adulthood: A twenty-year longitudinal study. Child
Development 2000;71(3):684-689.
8. Weinfeld NS, Sroufe LA, Egeland B. Attachment from infancy to early adulthood
in a high-risk sample: Continuity, discontinuity, and their correlates. Child
Development 2000;71(3):695-702.
9. Zeanah CH, Keyes A, Settles L. Attachment relationship experiences and
childhood psychopathology. Annals of the New York Academy of Sciences
2003;1008:22-30
10. American Psychiatric Association. Diagnostic and statistical manual of mental
disorders (DSM-IV). 4th ed. Text revision. Washington, DC: American Psychiatric
Association;2000;130.
11. O’Connor TG, Marvin RS, Rutter M, Olrick JT, Britner PA, English and
Romanian Adoptees (ERA) Study Team. Child-parent attachment following early
institutional deprivation. Development and Psychopathology 2003;15(1):19-38.
12. Smyke AT, Dumitrescu A, Zeanah CH. Attachment disturbances in young
children. I: The continuum of caretaking casualty. Journal of the American
Academy of Child and Adolescent Psychiatry 2002;41(8):972-982.
13. Zeanah CH, Smyke AT, Koga S, Carlson E. Attachment in institutionalized
children. Paper presented at: Biennial meeting of the Society for Research in
Child Development; March, 2003; Tampa, Fla.
14. Boris NW, Zeanah CH, Larrieu JA, Scheeringa MS, Heller SS. Attachment
disorders in infancy and early childhood: A preliminary investigation of
diagnostic criteria. American Journal of Psychiatry 1998;155(2):295-297.
15. Boris NW, Hinshaw-Fuselier SS, Smyke AT, Scheeringa MS, Heller SS, Zeanah
CH. Comparing criteria for attachment disorders: Establishing reliability and

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validity in high-risk samples. Journal of the American Academy of Child and

Adolescent Psychiatry 2004;43(5):568-577.
16. Zeanah CH, Scheeringa M, Boris NW, Heller SS, Smyke AT, Trapani J. Reactive
attachment disorder in maltreated toddlers. Child Abuse and Neglect
2004;28(8):877-888.
17. Chisholm K. A three year follow-up of attachment and indiscriminate friendliness
in children adopted from Romanian orphanages. Child Development
1998;69(4):1092-1106.
18. Tizard B, Rees J. The effect of early institutional rearing on the behaviour
problems and affectional relationships of four-year-old children. Journal of Child
19. Hodges J, Tizard B. Social and family relationships of ex-institutional
adolescents. Journal of Child Psychology and Psychiatry and Allied Disciplines
1989;30(1):77-97.
20. Tizard B, Hodges J. The effect of institutional rearing on the development of
eight-year-old children. Journal of Child Psychology and Psychiatry
1978;19(2):99-118.
21. Boris NW, Zeanah CH. Disturbances and disorders of attachment in infancy: An
overview. Infant Mental Health Journal 1999;20(1):1-9.
22. van IJzendoorn MH, Bakersmans-Kranenburg MJ. Disorganized attachment and
the dysregulation of negative emotions. In: Zuckerman B, Lieberman A, Fox N,
eds. Socioemotional regulation: Dimensions, developmental trends and
influences. New York, NY: Johnson & Johnson Pediatric Institute; 2002:159-180.
23. Bakersmans-Kranenburg MJ, van IJzendoorn MH, Juffer F. Less is more : Meta-
Zeanah CH Jr., Shah P. Attachment and its impact on child development: Comments on van IJzendoorn,
Grossmann and Grossmann, and Hennighausen and Lyons-Ruth. In: Tremblay RE, Barr RG, Peters
RDeV, eds. Encyclopedia on Early Childhood Development [online]. Montreal, Quebec: Centre of
encyclopedia.com/documents/Zeanah-ShahANGxp.pdf. Accessed [insert date].
Copyright © 2005

Attachment Security and Disorganization in Maltreating
Families and Orphanages
MARINUS H. VAN IJZENDOORN, PhD
MARIAN J. BAKERMANS-KRANENBURG. PhD
Centre for Child and Family Studies,
Leiden University, NETHERLANDS
(Published online November 11, 2009)
Topic
Attachment
Prevention of child maltreatment (abuse/neglect)
Introduction
Extremely insensitive and maltreating caregiving behaviors may be among the most
important precursors involved in the development of attachment insecurity and
disorganization. Egeland and Sroufe1 pointed out the dramatically negative impact of
neglecting or abusive maternal behavior for attachment and personality development, for
which they accumulated unique prospective evidence in later phases of the Minnesota
study.2 What do we know about the association between child maltreatment and
attachment, what are the mechanisms linking maltreatment with attachment insecurity
and disorganization, and what type of attachment-based interventions might be most
effective?
Subject
Following Cicchetti and Valentino,3 we include in our definition of child maltreatment
sexual abuse, physical abuse, neglect and emotional maltreatment. Besides these “family-
context” types of maltreatment, we also draw attention to structural neglect from which
world-wide millions of orphans and abandoned children suffer. Structural neglect points
to the inherent features of institutional care that preclude continuous, stable and sensitive
caregiving for individual children: caregiver shifts, high staff-turnover rates, large groups,
strict regimes, and sometimes physical and social chaos.4
Attachment disorganization has been suggested to be caused by frightening and

extremely insensitive or neglectful caregiving.5 Studies on non-maltreated samples have
demonstrated that anomalous parenting, involving (often only brief episodes of) parental
dissociative behavior, rough handling, or withdrawn behavior, is related to the
development of attachment disorganization (see Madigan, Bakermans-Kranenburg et al.,6
for a meta-analytic review). Parental maltreatment is probably one of the most frightening
behaviors a child may be exposed to. Abusive mothers show aversive, intrusive and
controlling behavior toward their child, in contrast to neglecting mothers who may display

van IJzendoorn MH, Bakermans-Kranenburg MJ
ATTACHMENT
inconsistent care. Maltreating insensitive parents do not regulate or buffer their child’s
experience of distress, but they also activate their child’s fear and attachment systems at
the same time. The resulting experience of fright without solution is characteristic of
maltreated children. According to Hesse and Main,5 disorganized children are caught in
an unsolvable paradox: their attachment figure is a potential source of comfort and at the
same time a source of unpredictable fright.
Problems
We speculate that multiple pathways to attachment disorganization exist involving either
child maltreatment by abusive parents or neglect in chaotic multiple-risk families or
institutions.
The pathway of abuse is based on the idea of (physically or sexually) maltreating parents
creating fright without solution for the child who cannot handle the paradox of a
potentially protective and, at the same time, abusive attachment figure, and thus becomes
disorganized.
A second pathway is associated with the chaotic environment of multiple-risk families or

institutional care leading to neglect of the attachment needs of the children. Caregivers’
withdrawal from interacting with the children because of urgent problems and hassles in
other domains of functioning (securing an income, housing problems, too many children
to care for) creates a chronic hyper-aroused attachment system in a child who does not
know to whom to turn for consolation in times of stress. This may in the end lead to a
breakdown of organized attachment strategies or impede children’s capacity to even
develop an organized insecure attachment strategy.
Third, marital discord and domestic violence may lead to elevated levels of
disorganization as the child is witnessing an attachment figure unable to protect herself in
her struggle with a partner. Zeanah et al.7 documented a dose-response relation between
mothers’ exposure to partner violence and infant disorganization. Witnessing parental
violence may elicit fear in a young child about the mother’s well-being and her ability to
protect herself and the child against violence.
Research context
Collecting data on maltreatment samples is difficult. Maltreated children are often
victims of multiple forms of abuse, making it difficult to compare the different types of
maltreatment. Conjoint work with the child welfare system may raise legal and ethical
issues involving sharing information with clinical workers or being asked to provide a
statement in court.
Remarkable and rigorous but scarce work has been conducted by research groups
pioneering this challenging area. Seven studies on attachment security/disorganization
and child maltreatment in families have been reported, and six studies on attachment in
institution-reared children using the (modified) Strange Situation procedure to assess
attachment.8 In order to examine the impact of child maltreatment on attachment we
compare the studies’ combined distribution of attachment patterns to the normative low-

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risk distribution of attachment (N=2104, derived from the meta-analysis of Van

IJzendoorn, Schuengel, & Bakermans-Kranenburg8): insecure-avoidant (A): 15%, secure
(B): 62%, insecure-resistant (C): 9%, and disorganized (D): 15%.
Key research questions

Three issues are central: first, does child maltreatment lead to more insecure-organized
(avoidant and resistant) attachments? Second, is maltreatment related to attachment
disorganization? Third, what are effective (preventive) interventions for child
maltreatment?
Recent research results

Studies of children maltreated in families show very few securely-attached children
(14%), a majority of disorganized children (51%), and some insecure-avoidant (23%) and
insecure-resistant (12%) attachments. This distribution differs strongly from the
normative distribution, in particular in terms of disorganization10,11,1,12,13,14 (for a meta-
analysis see Cyr, Euser, Bakermans-Kranenburg, & Van Ijzendoorn15).
Six recent studies addressed the effects of institutional care on attachment16,17,18,19,20,21

Overall, the distribution of institution-reared children was strongly deviating from the
norm distribution, with 17% secure, 5% avoidant, 5% resistant, and 73% disorganized
attachments to the favorite caregiver.
The percentage of secure attachments is similar in maltreated children and institution-

reared children, but the percentage of disorganized attachments in institution-reared
children is considerably larger (Figure 1).
B B
A
C D A
D
C
D
institutions C maltreatment
B
A
B= secure
A= avoidant
C= ambivalent
D= disorganized
typical families
Figure 1: Attachment Distributions (Proportions) in Maltreatment
Samples, Institutions and Typical Families

ATTACHMENT
Research gaps
How do some institution-reared and maltreated children develop secure attachment, and
what characterizes these children? Does attachment security constitute a protective factor
in high-risk contexts? Does it interact with other protective factors such as the child’s
biological constitution or the caregivers’ psychosocial resources? Little is know about the
differential effects of the various types of abuse and neglect – co-morbidity may hamper
a clear distinction of differential effects. Lastly, long-term effects of child maltreatment
should be studied more closely.
Implications for parents, services and policy

Several randomized control trials have started to provide data on the effectiveness of
attachment-based interventions with high-risk populations (see Bakermans-Kranenburg,
Van IJzendoorn, & Juffer22, Juffer, Bakermans-Kranenburg, Van Ijzendoorn4, and Berlin,
Ziv, Amaya-Jackson, & Greenberg23 for reviews). However, very few of these
intervention studies were conducted with maltreated children and their parents, or with
children in orphanages.
The lack of evidence-based interventions for maltreatment may have led some clinicians
to rely on so-called holding therapies, in which children are forced to make physical
contact with their caregiver although they strongly resist these attempts. Holding therapy
has not been proven to be effective,24,25 and in some cases has been harmful for children
to the level of casualties.26 Holding therapy is not implied at all by attachment theory. In
fact, therapists force the caregiver to be extremely insensitive and to ignore clear child
signals.
A major randomized control study by Cicchetti, Rogosch, and Toth27 has demonstrated
the effectiveness of an attachment-based intervention for maltreating families with child-
parent psychotherapy, enhancing maternal sensitivity through reinterpretation of past
attachment experiences. The intervention resulted in a substantial reduction in infant
disorganized attachment, and an increase in attachment security.
Maltreatment prevalence data show a large impact of risk factors associated with a very
low education and unemployment of parents (e.g., Euser et al.28). A practical implication
of this observation is the recommendation to pursue a socio-economic policy with a
strong emphasis on education and employment. Since unemployed and school dropped-
out parents are the most frequent perpetrators of child maltreatment, policies enhancing
education and employment rates are expected to effectively decrease child maltreatment
rates.

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REFERENCES
1. Egeland B, Sroufe AL. Attachment and early maltreatment. Child Development

1981;52(1):44-52.
2. Sroufe LA, Egeland B, Carlson EA, Collins WA. The Development of the Person.
The Minnesota Study of Risk and Adaptation from Birth to Adulthood. New York,
NY: Guilford Press, 2005.
3. Cicchetti D, Valentino K. An ecological-transactional perspective on child
maltreatment: Failure of the average expectable environment and its influence on
child development. In: Cicchetti D, Cohen DJ, eds. Developmental
Psychopathology. 2nd Ed. Hoboken, N.J.: John Wiley & Sons; 2006:129-201.
4. Bakermans-Kranenburg MJ, Van IJzendoorn MH, Juffer F. Earlier is better: A
meta-analysis of 70 years of intervention improving cognitive development in
institutionalized children. Monographs of the Society for Research of Child
Development 2008;73(3):279-293.
5. Hesse E, Main M. Frightened, threatening, and dissociative parental behavior in
low-risk samples: Description, discussion, and interpretations. Development and
6. Madigan S, Bakermans-Kranenburg MJ, Van IJzendoorn MH, Moran G, Pederson
DR, Benoit D. Unresolved states of mind, anomalous parental behavior, and
Attachment and Human Development 2006;8(2):89-111.
7. Zeanah CH, Danis B, Hirshberg L, Benoit D, Miller D, Heller SS. Disorganized
attachment associated with partner violence: A research note. Infant Mental
Health Journal 1999;20(1):77-86.
8. Ainsworth MDS, Blehar MC, Waters E, Wall S. Patterns of Attachment: A
Psychological Study of the Strange Situation. Hillsdale, N.J.: Lawrence Erlbaum
Associates; 1978.
9. Van IJzendoorn MH, Schuengel C, Bakermans-Kranenburg MJ. Disorganized
attachment in early childhood: Meta-analysis of precursors, concomitants, and
sequelae. Development and Psychopathology 1999;11(2):225-249.
10. Barnett D, Ganiban J, Cicchetti D. Maltreatment, negative expressivity, and the
development of type D attachments from 12 to 24 months of age. Monographs of
the Society for Research in Child Development 1999;64(3):97-118.
11. Crittenden PM. Relationships at risk. In: Belsky J, Nezworski T, eds. Clinical
Implications of Attachment. Hillsdale, NJ, England: Lawrence Erlbaum
Associates, Inc;1988:136-174.
12. Lamb ME, Gaensbauer TJ, Malkin CM, Schultz LA. The effects of child
maltreatment on security of infant-adult attachment. Infant Behavior and
Development 1985;8(1):35-45.
13. Lyons-Ruth K, Connell DB, Grunebaum HU, Botein, S. Infants at social risk:
Maternal depression and family support services as mediators of infant
development and security of attachment. Child Development 1990:61(1):85-98.
14. Valenzuela M. Attachment in chronically underweight young children. Child
Development 1990;61(6):1984-1996.

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15. Cyr C, Euser EM, Bakermans-Kranenburg M.J, Van IJzendoorn MH. Attachment
security and disorganization in maltreating and high-risk families: A series of
meta-analyses. Development & Psychopathology 2010;22(1):87-108.
16. The St. Petersburg – USA Orphanage Research Team. The effects of early social-
emotional and relationship experience on the development of young orphanage
children. Monographs of the Society for Research in Child Development
2008;73(3):1-262.
17. Vorria P, Papaligoura Z, Dunn J, van IJzendoorn MH, Steele H, Kontopoulou A,
Sarafidou J. Early experiences and attachment relationships of Greek infants
raised in residential group care. Journal of Child Psychology and Psychiatry
2003;44(8):1208-1220.
18. Zeanah CH, Smyke AT, Koga SF, Carlson E, Bucharest Early Internvention
Project Core Group. Attachment in institutionalized and community children in
Romania. Child Development 2005;76(5):1015-1028.
19. Steele M, Steele H, Jin X, Archer M, Herreros F. Effects of lessening the level of
deprivation in Chinese orphanage settings: Decreasing disorganization and
increasing security. Paper presented at: The Biennial Meeting of the Society for
Research in Child Development. April 2-4, 2009; Denver, CO.
20. Herreros F. Attachment security of infants living in a Chilean orphanage. Poster
session presented at: The Biennial Meeting of the Society for Research in Child
Development. April 2-4, 2009; Denver, CO.
21. Dobrova-Krol NA, Bakermans-Kranenburg MH, van Ijzendoorn MH, Juffer J.
The importance of quality of care: Effects of perinatal HIV infection and early
institutional rearing on preschoolers’ attachment and indiscriminate friendliness.
In: Dobrova-Krol NA, eds. Vulnerable children in Ukraine impact of institutional
care and HIV on the development of preschoolers. Leiden, the Netherland:
Mostert en van Onderen; 2009.
22. Bakermans-Kranenburg MJ, Van IJzendoorn MH, Juffer F. Less is more: Meta-
23. Berlin LJ, Ziv Y, Amaya-Jackson L, Greenberg MT, eds. Enhancing Early
Attachments: Theory, Research, Intervention, and Policy. New York, NY:
Guilford Press; 2005.
24. O’Connor MJ, Zeanah CH. Introduction to the special issue: Current perspectives
on assessment and treatment of attachment disorders. Attachment & Human
Development 2003;5(3):221-222.
25. Sroufe A, Erickson MF, Friedrich WN. Attachment theory and “attachment
therapy.” APSAC Advisor 2002;14:4-6.
26. Chaffin M, Hanson R, Saunders B, Barnett D, Zeanah C, Berliner L, Egeland B,
Lyon T, Letourneau E, Miller-Perrin C. Report of the APSAC Task Force on
attachment therapy, reactive attachment disorder, and attachment problems. Child
Maltreatment 2006;11(1):76-89.
27. Cicchetti D, Rogosch FA, Toth SL. Fostering secure attachment in infants in
maltreating families through prevention interventions. Development and
Psychopathology 2006;18:623-649.

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28. Euser EM, Van IJzendoorn MH, Prinzie P, Bakermans-Kranenburg MJ. The
prevalence of child maltreatment in Netherlands. Child Maltreatment
2010;15(1):5-17.
van IJzendoorn MH, Bakermans-Kranenburg MJ. Attachment security and disorganization in maltreating
families and orphanages. In: Tremblay RE, Barr RG, Peters RDeV, Boivin M, eds. Encyclopedia on Early
Childhood Development [online]. Montreal, Quebec: Centre of Excellence for Early Childhood
Development; 2009:1-7. Available at: http://www.child-encyclopedia.com/documents/van_IJzendoorn-
Bakermans-KranenburgANGxp-Attachment.pdf. Accessed [insert date].
Copyright © 2009

The Impact of Attachment-Based Interventions
on the Quality of Attachment Among
Infants and Young Children
MARY DOZIER, PhD
KRISTIN BERNARD, MA
University of Delaware, USA
(Published online December 15, 2004)
(Revised August 25, 2009)
Topic
Attachment
Introduction
A key biologically-based task for infants and toddlers is developing attachment
relationships with caregivers. The quality of attachment that children develop appears
largely dependent on caregivers’ availability.1 When caregivers are responsive, children
tend to develop secure attachments, seeking out caregivers directly when distressed.
When caregivers reject children’s bids for reassurance, children tend to develop avoidant
attachments, turning away from caregivers when distressed. When caregivers are
inconsistent in their availability, children tend to develop resistant attachments, showing a
mixture of proximity-seeking and resistance. Although it may be optimal for children in
our society to develop secure attachments,2-6 each of these three attachment types can be
seen as well-suited to caregivers’ availability. When caregivers are frightening to
children, though, children have difficulty developing organized attachments and instead
often develop disorganized attachments, which leave children without a consistent
strategy for dealing with their distress. Attachment quality has been linked with later
problem behaviours, with disorganized attachment especially predictive of dissociative
symptoms (e.g. seeming spacey, “in a fog” etc.),7 and internalizing and externalizing
problems.6,8-10 A number of prevention and intervention programs have been developed
that aim to improve infant attachment quality.
Subject
The strongest predictor of infant attachment is parental state of mind with regard to
attachment.11 State of mind refers to the manner in which adults process attachment-
related thoughts, feelings and memories. When parents are coherent in discussing their
own attachment experiences, they are said to have “autonomous states of mind” with
regard to attachment. When parents are not coherent in discussing their own attachment
experiences, they are said to have “non-autonomous states of mind” with regard to
attachment. Parents with autonomous states of mind are most likely to have babies with

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secure attachments, whereas parents with “non-autonomous” states of mind are most
likely to have babies with insecure attachments. Given this association between parental
state of mind and infant attachment, some interventions12-15 target parent state of mind as
a means of changing infant attachment.
Other interventions16-18 attempt to change parental behaviours without targeting

parental state of mind. In particular, a number of interventions have attempted to enhance
caregiver sensitivity. Caregiver sensitivity has not been linked as strongly with
attachment quality as has state of mind,11 but sensitivity has seemed the most likely
mechanism by which caregiving qualities are transmitted to children.
Problems
Programs that share the goal of enhancing attachment may differ in their focus, in their
intervention strategy, and in the populations targeted. Whereas an overall objective may
be to enhance attachment quality, other goals of improving quality of life, increasing life
skills and reducing symptomatology may differ, depending on the intervention and the
population served, as well as the level of fidelity to the treatment model. There is
disagreement among experts in the area regarding the nature of what is needed. For
example, some13 suggest that intensive interventions that start prenatally are essential,
whereas others19 suggest that targeted, short-term interventions are needed. Assessment
of treatment process and treatment fidelity is crucial to knowing what is being provided
in an intervention. For example, Korfmacher et al.20 found that their intervention,
intended to modify parental state of mind, rarely engaged parents in insight-oriented
work.
Research Context
In 2003, a meta-analysis reported by Bakermans-Kranenburg, van IJzendoorn and
Juffer19 found 29 studies that included attachment security as an outcome. Of these, 23
were randomized clinical trials, with a total of 1,255 participants. The nature of the
interventions, and the populations served, differed widely from one study to another.
Nonetheless, meta-analytic results allow assessment of the importance of factors such as
intervention intensity and population. Attachment quality was assessed in the Strange
Situation in most studies, although the Attachment Q-set was used in some investigations.

Key research questions include:
• Do intervention or prevention programs enhance the quality of children’s
attachments to their caregivers?
• What are the characteristics of successful interventions?
• For whom are interventions most successful?
• What is the process by which intervention programs work?

Interventions that have targeted sensitivity have been found to be more effective in
enhancing attachment security than interventions targeting other issues (such as parental
state of mind).19 It makes sense to target parental behaviours directly, rather than

Dozier M, Bernard K
ATTACHMENT
underlying characteristics, for several reasons. First, state of mind and other parent
characteristics are not as amenable to change as are parental behaviours. Second,
presumably, it is parental behaviours that directly affect children’s expectations of
parental availability.
Interventions that started after the child was at least six months old have been more
effective than those starting earlier.19 Although it is speculative, interventions may be
most efficient and effective when children have begun to show attachments to specific
caregivers.
For the most part, intervention effects have not proven to be significantly different for
different types of study populations. For example, intervention effects have been
generally comparable across risk status and socioeconomic status. Nonetheless, samples
with higher levels of insecurity have shown the largest effect sizes.
Conclusions
1. Interventions are effective in enhancing children’s attachment quality.
2. Interventions that target specific issues, most especially parental sensitivity,
appear more effective than interventions with more global goals.
3. Interventions that are brief are at least as effective as those that are of longer
duration.
4. Interventions that begin when attachment quality has begun to emerge (after about
six months of age) appear more effective than those begun earlier.
Implications
Currently, the research evidence favours brief, highly targeted interventions to enhance
attachment quality among infants. Given that the current evidence base is relatively
small, it makes sense to continue to examine associations between intervention
characteristics and outcome. Nonetheless, at this point, time-limited interventions
beginning in the second half of the first year of life appear most promising.

Dozier M, Bernard K
ATTACHMENT
REFERENCES
1. Ainsworth MD. The development of infant-mother attachment. In: Caldwell BM,

Ricciutti HN, eds. Child development and social policy. Chicago, Ill: University
of Chicago Press; 1973:1-94. Review of child development research; vol. 3.
2. Elicker J, Englund M, Sroufe LA. Predicting peer competence and peer
relationships in childhood from early parent-child relationships. In: Parke RD,
Ladd GW, eds. Family-peer relationships: Modes of linkage. Hillsdale, NJ:
Lawrence Erlbaum Associates; 1992:77-106.
3. Erickson MF, Sroufe LA, Egeland B. The relationship between quality of
attachment and behavior problems in preschool in a high-risk sample.
Monographs of the Society for Research in Child Development 1985;50(1-2):147-
166.
4. Matas L, Arend RA, Sroufe LA. Continuity of adaptation in the second year: The
relationship between quality of attachment and later competence. Child
Development 1978;49(3):547-556.
5. Sroufe LA. Infant-caregiver attachment and patterns of adaptation in preschool:
The roots of maladaption and competence. Minnesota Symposia on Child
Psychology 1983;16:41-83.
6. Kobak R, Cassidy J, Lyons-Ruth K, Ziv Y. Attachment, stress, and
psychopathology: A developmental pathways model. In: Cicchetti D, Cohen DJ,
eds. Developmental psychopathology. 2nd Ed.. New York, NY: Wiley-
Interscience; 2006:333-369. Theory and method; vol 1.
7. Carlson EA. A prospective longitudinal study of attachment disorganization/
disorientation. Child Development 1998;69(4):1107-1128.
8. Lyons-Ruth K, Alpern L, Repacholi B. Disorganized infant attachment
classification and maternal psychosocial problems as predictors of hostile-
aggressive behavior in the preschool classroom. Child Development
1993;64(2):572-585.
9. Lyons-Ruth K. Attachment relationships among children with aggressive behavior
problems: The role of disorganized early attachment patterns. Journal of
Consulting and Clinical Psychology 1996;64(1):64-73.
10. Lyons-Ruth K. Contributions of the mother-infant relationship to dissociative,
borderline, and conduct symptoms in young adulthood. Infant Mental Health
Journal. 2008;29(special issue):203-218.
11. van Ijzendoorn MH. Adult attachment representations, parental responsiveness,
and infant attachment: A meta-analysis on the predictive validity of the adult
attachment interview. Psychological Bulletin 1995;117(3):387-403.
12. Lieberman AF, Weston DR, Pawl JH. Preventive intervention and outcome with
anxiously attached dyads. Child Development 1991;62(1):199-209.
13. Egeland B, Weinfield NS, Bosquet M, Cheng BK. Remembering, repeating, and
working through: Lessons from attachment-based interventions. In: Osofsky JD,
Fitzgerald HE, eds. Infant mental heath groups at high risk. New York, NY:
Wiley; 2000:35-89. Handbook of infant mental health; vol. 4.

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ATTACHMENT
14. Heinicke CM, Fineman NR, Ruth G, Recchia SL, Guthrie D, Rodning C.
Relationship-based intervention with at-risk mothers: Outcome in the first year of
life. Infant Mental Health Journal 1999;20(4):349-374.
15. Baradon T, Steele M. Integrating the AAI in the clinical process of psychoanalytic
parent-infant psychotherapy in a case of relational trauma. In: Steele H, Steele M,
eds. Clinical applications of the Adult Attachment Interview. New York, NY:
Guilford Press; 2008;195-212.
16. van den Boom DC. The influence of temperament and mothering on attachment
1994;65(5):1457-1477.
17. van den Boom DC. Do first-year intervention effects endure? Follow-up during
toddlerhood of a sample of Dutch irritable infants. Child Development
1995;66(6):1798-1816.
18. Juffer F, Hoksbergen RAC, Riksen-Walraven JM, Kohnstamm GA. Early
intervention in adoptive families: Supporting maternal sensitive responsiveness,
infant-mother attachment, and infant competence. Journal of Child Psychology
and Psychiatry and Allied Disciplines 1997;38(8):1039-1050.
20. Korfmacher J, Adam E, Ogawa J, Egeland B. Adult attachment: Implications for
the therapeutic process in a home visitation intervention. Applied Developmental
Science 1997;1(1):43-52.
Dozier M, Bernard K. The impact of attachment-based interventions on the quality of attachment among
infants and young children. Rev ed. In: Tremblay RE, Barr RG, Peters RDeV, Boivi M, eds. Encyclopedia
on Early Childhood Development [online]. Montreal, Quebec: Centre of Excellence for Early Childhood
Development; 2009:1-5. Available at: http://www.child-encyclopedia.com/documents/Dozier-
BernardANGxp_rev.pdf. Accessed [insert date].

Dozier M, Bernard K
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Dozier M, Bernard K
Attachment-Based Intervention and
Prevention Programs for Young Children
BYRON EGELAND, PhD
Institute of Child Development, University of Minnesota, USA
(Published online December 15, 2004)
(Revised November 13, 2009)
Topic
Attachment
Introduction
Bowlby’s attachment theory is a theory of both psychopathology and normal socio-
emotional development. It is based on the idea that the early relationship that develops
between the infant and caregiver provides the foundation for later development.
Bowlby’s theory attempts to explain how the early relationship contributes to
psychological well-being or later psychopathology. The term attachment is used to
describe the affective bond that develops between an infant and caregiver.1,2 Attachment
is not a characteristic of the infant, nor is it a characteristic of the caregiver. Rather, it is a
pattern of emotional and behavioural interaction that develops over time as the infant and
caregiver interact, particularly in the context of the infant’s needs and bids for attention
and comfort.
Through repeated interactions with the same adults, an infant begins to recognize
caregivers and to anticipate the behaviour of the primary caregiver, usually the mother.
Bowlby described the infant as biologically predisposed to use the caregiver as a haven of
safety, or a secure base, while exploring the environment.1 So an infant who feels
threatened will turn to the caregiver for protection and comfort. The caregiver’s responses
to such bids help mould the attachment relationship into a pattern of interaction that
develops over time. By the end of the first year of life, the history of the relationship
between infant and caregiver allows the infant to begin to anticipate the caregiver’s
response to her bids for comfort, and to act in accordance with those expectations.
Another tenet of attachment theory is that from these first relationships, infants form
mental representations of the self, others and the relationship between self and other.
Bowlby called these representations inner working models.1 As the infant develops and
encounters the world beyond that first relationship, the inner working model guides her
behaviour and expectations in subsequent relationships as well.
Mothers who are sensitive and comforting when the infant makes bids for comfort will
have infants who continue to seek out the mother when distressed, and will be calmed by
contact with the mother. The infant’s inner working model will lead her to see others as

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reliable and compassionate, and herself as worthy of this kind of attention. This pattern
has been labelled secure.1,2
In contrast, if the caregiver has been unavailable or only erratically available or

insensitive or rejecting when the infant has sought contact, the infant will learn not to
seek contact when distressed or to seek comfort only in an ambivalent manner, as strong
bids might alienate an already unreliable caregiver. The inner working model of this
infant will lead her to see others as untrustworthy and potentially rejecting, and herself as
not deserving reliable, sensitive care. These patterns have been labelled insecure.1,2
Insecure attachment patterns have been further specified into two patterns: avoidant
attachment and resistant (or ambivalent) attachment. In addition, some infants are
classified as disorganized/disoriented with regard to attachment because they do not seem
able to resort to a single, organized attachment pattern in the face of threat or stress.
Instead, they become disoriented or resort to conflicting behaviour strategies.
Subject
Research has demonstrated that security of attachment during infancy predicts aspects of
social development during childhood and adolescence, such as empathy,3,4,5 social
competence5,6,7,8,9 and behaviour problems,10,11,12 with secure attachment predicting more
optimal developmental outcomes and insecure attachment predicting behaviour and
relationship difficulties. We have also found a secure attachment to be a major protective
factor for children who function in a competent fashion even in the face of adversity.13 In
addition, attachment relationships may have long-term effects on functioning by
influencing the course of biological development, including brain development. 14
Inner working models are carried forward from infancy throughout the life course and, as
noted above, they influence the individual’s expectations and behaviour in relationships,
including parenting in the next generation. Using the Adult Attachment Interview
(AAI),15 a number of studies have demonstrated that parent attachment organization is
related to infant attachment patterns. Parents with secure organizations are likely to have
infants who are securely attached with them, and parents with insecure organizations are
likely to have infants who are insecurely attached with them.16,17
Because of the many positive outcomes associated with a secure attachment, the
implications are clear. Design (and evaluate) prevention and intervention programs to
promote a secure parent-infant attachment relationship in order to improve developmental
outcomes of infants and children who are at risk for poor developmental outcomes and
prevent behaviour problems and psychopathology.
Problems
Attachment relationships, like all other aspects of development, do not exist in isolation
from their context. As noted above, caregivers who respond to their infant’s needs and
cues in a sensitive fashion are likely to develop a secure attachment relationship with
their infant. There are many personal (e.g. mother’s depression) and interpersonal (e.g.
violent relationship with spouse) factors that may make it more difficult for the caregiver
to respond to the infant in a sensitive and emotionally responsive fashion. In addition, a

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host of environmental factors, such as chaotic living conditions, may interfere with the
developing attachment relationship, particularly when intervening with families from
high-risk populations who face multiple personal and environmental challenges. Many
programs were not equipped to deal with the problems of high-risk families.
Research Context
In 1995, van Ijzendoorn et al.18 conducted a review of 12 attachment interventions, and in
2000, Egeland and colleagues19 found a few more programs that had been implemented
and evaluated. In 2003, the Dutch investigators conducted another meta-analysis that
included 29 investigations designed to enhance attachment security. More recently, there
has been an increase of attachment-based prevention and intervention programs20.
There are basically two broad types of intervention programs designed to enhance the
quality of mother-infant attachment: (1) those that endeavour to help the parents become
more sensitive to infant cues; and (2) those that attempt to change parents’
representations of how they were cared for by their own parents. Many of the attachment
interventions fall into one of these two categories, while others combine the two
approaches and still others, such as Beckwith’s21 program emphasizing social support.
Key Research Question

Since a secure parent-infant attachment relationship is associated with positive
developmental outcomes and has been found to be a protective factor in the face of
adversity, it behooves us to develop, implement and evaluate attachment-based
intervention/prevention programs. There are many research questions that remain to be
answered, particularly having to do with the long-term cost-benefits associated with
attachment-based prevention programs. In addition, researchers need to determine who is
most likely to benefit from particular program approaches and strategies.

Several interventions conducted in the Netherlands have been successful in their attempts
to improve mother’s sensitivity to infant’s cues. Van den Boom22 randomly assigned 100
irritable infants and their mothers to treatment and control and found that those in the
treatment group were more sensitive and had more securely attached mother-infant pairs
compared to control dyads. The aim of this home-based intervention was to enhance
parental sensitivity. The intervention consisted of only three sessions and positive
outcomes were found at 24- and 42-month follow-ups. Using a similar approach with
adopted infants and their adoptive parents, Juffer et al.23,24 also obtained positive findings.
In a more recent investigation, van Zeijl and colleagues25 used the video feedback
procedure with a group of 1- to 3-year-old children who had high levels of externalizing
behaviour. The intervention was effective in decreasing overactive, oppositional, and
aggressive behaviour compared to the control group. Later analyses of these data by
Bakermans-Kranenburg and colleagues26 indicated that genetic differences moderated the
effects of intervention. Children with a certain genotype on the dopamine receptor gene
showed the largest decrease of externalizing behaviour in the cases where parents showed
the largest increase in the use of positive discipline. Findings that children’s susceptibility
to changes in their environment depends in part on genetic differences are very

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provocative and hopefully will lead to more gene by environment studies in the area of
prevention and intervention in the early years.
The results of evaluations of programs designed to alter parents’ cognitive representations

have yielded many positive findings, but few have obtained significant differences
between treatment and control on attachment classifications. Lieberman et al.27 identified
a group of anxiously attached infants from high-risk families. They, like most
investigators attempting to alter inner working models, used an infant-parent
psychotherapy approach. The focus of the once-a-week home visits was on responding to
the affective experience of the mother and child, both as reported by the mother and as
observed through mother-child interactions. The intervenor attempted to clarify the
mother’s affective experiences and feelings toward her toddler and toward the intervenor.
They found significant differences between intervention and control groups in maternal
empathy, goal-corrected partnership behaviour, child avoidance and child anger towards
mother, with the intervention group showing optimal behaviours on each of these
variables. Using a similar approach, Toth and colleagues28 found a higher rate of secure
attachment for children of depressed mothers who were in the toddler-parent
psychotherapy group compared to those in the randomly-assigned control group.
Project STEEP (Steps Toward Effective Enjoyable Parenting) is a comprehensive

program designed to change inner working models and enhance maternal sensitivity.29
The approach involved home visits and group sessions beginning prenatally and
continuing for two years (the original program was designed for one year). The program
resulted in many positive outcomes. For example, mothers in the STEEP program were
more sensitive, had a better understanding of infant development and lower depression
and anxiety scores, were more competent in managing their family affairs and had a
larger social support network compared to control mothers.
Conclusions
The positive long-term developmental outcome associated with a secure parent-infant
attachment relationship provides an excellent rationale for implementing attachment-
based prevention programs early in life. Recognizing the significance of this early
relationship, however, has not resulted in a large number of attachment-based
interventions. A variety of early parent education and home visitation programs exist, but
very few have as their primary goal facilitating the development of a secure attachment
relationship. The results of the evaluation of existing attachment-based interventions are
encouraging, particularly the Dutch studies involving relatively low-risk samples. Based
on the findings of the Dutch studies, it appears that attachment-based interventions that
focus on enhancing sensitivity are likely to be successful with parents who are motivated
to learn ways of responding with their difficult infants. For more high-risk families, it
appears that more comprehensive, long-term interventions are necessary.
Implications
Based on attachment theory and research, as well as results from evaluations of existing
attachment-based interventions, it would be recommended to incorporate attachment-
based intervention/prevention programs into existing home visitation and parent

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ATTACHMENT
education programs for high-risk families of young children, as well as investigate new
approaches for changing parents’ cognitive representation of their attachment with their
parents. Much is known about parent-child interaction, parental characteristics and
beliefs, and contextual factors that are antecedents of a secure attachment relationship.
This knowledge needs to be applied in the development of the next generation of
attachment interventions. The needs and strengths of high-risk families are highly varied.
Intervention programs must be designed to meet the unique needs of each family as well
as to take advantage of their strengths.

Egeland B
ATTACHMENT
REFERENCES
1. Bowlby J. Attachment. 2nd ed. New York, NY: Basic Books; 1982. Attachment
and loss; vol 1.
2. Ainsworth MDS, Blehar M, Waters E, Wall S. Patterns of attachment: A
Psychological study of the strange situation. Hillsdale, NJ: Lawrence Erlbaum
Associates; 1978.
3. Kestenbaum R, Farber E, Ellen A, Sroufe LA. Individual differences in empathy
among preschoolers: Relation to attachment history. New Directions for Child
Development 1989;44:51-64.
4. Oppenheim D, Sagi A, Lamb ME. Infant-adult attachments on the kibbutz and
their relation to socioemotional development four years later. In: Chess S, Hertzig
ME, eds. Annual progress in child psychiatry and child development, 1989.
Philadelphia, Pa: Brunner/Mazel Inc.; 1990:92-106.
The roots of maladaptation and competence. Minnesota Symposia on Child
Psychology 1983;16:41-83.
Ladd GW, eds. Family-Peer Relationships: Modes of Linkage. Hillsdale, NJ:
Lawrence Erlbaum Associates; 1992:77-106.
7. Sroufe LA, Egeland B, Carlson EA, Collins WA. The development of the person:
The Minnesota study of risk and adaptation from birth to adulthood. New York,
NY: Guilford Press; 2005.
8. Sroufe LA, Egeland B, Carlson EA. One social world: The integrated
development of parent-child and peer relationships. In: Collins WA, Laursen B,
eds. Relationships as developmental contexts. Mahwah, NJ: Lawrence Erlbaum
Associates; 1999: 241-262. Minnesota symposium on child psychology; vol 30.
9. Thompson RA. Early attachment and later development: Familiar questions, new
answers. In: Cassidy J, Shaver PR, eds. Handbook of attachment: Theory,
research, and clinical applications. 2nd Ed. New York: Guilford Press; 2008: 348-
365.
10. Egeland B, Carlson B. Attachment and psychopathology. In: Atkinson L,
Goldberg S, eds. Attachment issues in psychopathology and intervention.
Mahwah, NJ: Lawrence Erlbaum; 2004:27-48.
11. Erickson MF, Sroufe LA, Egeland B. The relationship between quality of
attachment and behavior problems in preschool in a high-risk sample.
Monographs of the Society for Research in Child Development 1985;50(1-2):147-
166.
12. Lyons-Ruth K, Easterbrooks MA, Cibelli CD. Infant attachment strategies, infant
mental lag, and maternal depressive symptoms: Predictors of internalizing and
externalizing problems at age 7. Developmental Psychology 1997;33(4):681-692.
13. Yates TM, Egeland B, Sroufe LA. Rethinking resilience: A developmental
process perspective. In: Luthar SS, eds. Resilience and vulnerability: Adaptation
in the context of childhood Adversities. Cambridge, UK: Cambridge University
Press; 2003: 243-266.

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ATTACHMENT
14. Schore AN. The experience-dependent maturation of a regulatory system in the

orbital prefrontal cortex and the origin of developmental psychopathology.
Development and Psychopathology 1996;8(1):59-87.
15. Main M, Goldwyn R. Adult attachment scoring and classification system.
Berkeley, Calif: Department of Psychology, University of California at Berkeley;
1985. Unpublished manuscript.
16. Benoit D, Parker KCH. Stability and transmission of attachment across three
generations. Child Development 1994;65(5):1444-1456.
17. Zeanah CH, Benoit D, Barton M, Regan C, Hirshberg L, Lipsitt L.
Representations of attachment in mothers and their one-year-old infants. Journal
of the American Academy of Child and Adolescent Psychiatry 1993;32(2):278-
286.
18. Van IJzendoorn MH, Juffer F, Duyvesteyn MGC. Breaking the intergenerational
cycle of insecure attachment: A review of the effects of attachment-based
interventions on maternal sensitivity and infant security. Journal of Child
Psychology and Psychiatry and Allied Disciplines 1995;36(2):225-248.
19. Egeland B, Weinfield NS, Bosquet M, Cheng VK. Remembering, repeating, and
working through: Lessons from attachment-based interventions. In: Osofsky JD,
Fitzgerald HE, eds. WAIMH handbook of infant mental health. New York, NY:
Wiley; 2000: 35-89. Infant mental health groups at high risk; vol 4.
20. Bakermans-Kranenburg M.J, van IJzendoorn MH, Juffer F. Less is more: Meta-
21. Beckwith L. Intervention with disadvantaged parents of sick preterm infants.
Psychiatry: Journal for the Study of Interpersonal Processes 1988;51(3):242-247.
22. Van den Boom DC. The influence of temperament and mothering on attachment
1994;65(5):1457-1477.
23. Juffer F, Hoksbergen RAC, Riksen-Walraven JM, Kohnstamm GA. Early
intervention in adoptive families: Supporting maternal sensitive responsiveness,
infant-mother attachment, and infant competence. Journal of Child Psychology
and Psychiatry and Allied Disciplines 1997;38(8):1039-1050.
24. Juffer F, Rosenboom LG, Hoksbergen RAC, Riksen-Walraven JMA, Kohnstamm
GA. Attachment and intervention in adoptive families with and without biological
children. In: Koops W, Hoeksma JB, van den Boom DC, eds. Development of
interaction and attachment: Traditional and non-traditional approaches.
Amsterdam, Netherlands: North Holland; 1997:93-108.
25. Van Zeijl J, Mesman J, Van IJzendoorn MH, Bakermans-Kranenburg MJ, Juffer
F, Stolk MN, Koot HM, Alink LRA. Attachment-based intervention for
enhancing sensitive discipline in mothers of 1- to 3-year-old children at risk for
externalizing behavior problems: A randomized controlled trial. Journal of
Consulting and Clinical Psychology 2006;74(6):994-1005.
26. Bakermans-Kranenburg MJ, Van IJzendoorn MH, Pijlman FTA, Mesman J, Juffer
F. Experimental evidence for differential susceptibility: Dopamine D4 receptor
polymorphism (DRD4 VNTR) moderates intervention effects on toddlers'

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externalizing behavior in a randomized controlled trial. Developmental

Psychology 2008;44(1):293-300.
27. Lieberman AF, Weston DR, Pawl JH. Preventive intervention and outcome with
anxiously attached dyads. Child Development 1991;62(1):199-209.
28. Toth SL, Rogosch FA, Manly JT, Cicchetti D. The efficacy of toddler-parent
psychotherapy to reorganize attachment in the young offspring of mothers with
major depressive disorder: A randomized preventive trial. Journal of Consulting
and Clinical Psychology 2006;74(6):1006-1016.
29. Egeland B, Erickson M. Lessons from STEEPTM: Linking theory, research, and
practice for the well-being of infants and parents. In: Sameroff A, McDonough S,
Rosenblum K, eds. Treating parent-nfant relationship problems. New York, NY:
Guilford Press; 2004: 213-242.
Egeland B. Attachment-based intervention and prevention programs for young children. Rev ed. In:
Tremblay RE, Barr RG, Peters RDeV, Boivin M, eds. Encyclopedia on Early Childhood Development
[online]. Montreal, Quebec: Centre of Excellence for Early Childhood Development; 2009:1-8. Available
at: http://www.child-encyclopedia.com/documents/EgelandANGxp_rev.pdf. Accessed [insert date].

Egeland B
Efficacy of Attachment-Based Interventions
DIANE BENOIT, MD, FRCPC
University of Toronto, The Hospital for Sick Children, CANADA
(Revised October 5, 2009)
Topic
Attachment
Introduction
There is growing prospective and retrospective evidence linking the quality of early
infant-caregiver attachment relationships with later social and emotional outcomes.1,2
Four types of infant attachment have been described. Secure infant-caregiver attachment
is believed to develop when the caregiver responds to the child’s distress in a sensitive
manner. Insecure-avoidant infant-caregiver attachment presumably results from the
caregiver consistently responding to the child’s distress in ways that are rejecting.
Insecure-resistant infant-caregiver attachment is thought to occur when the caregiver
responds to the child’s distress in ways that are inconsistent and unpredictable. Insecure-
disorganized infant-caregiver attachment evidently develops when the caregiver displays
unusual and ultimately frightening behaviours in the presence of the child. Of the four
patterns of infant-caregiver attachment (secure, avoidant, resistant, disorganized), the
disorganized classification has been identified as a powerful childhood risk for later
socio-emotional maladjustment and psychopathology.2,3
Subject
Children who have disorganized attachment with their primary attachment figure have
been shown to be vulnerable to stress, have problems with regulation and control of
negative emotions, and display oppositional, hostile-aggressive behaviours, and coercive
styles of interaction.2,3 They may exhibit low self-esteem, internalizing and externalizing
problems in the early school years, poor peer interactions, unusual or bizarre behaviour in
the classroom, high teacher ratings of dissociative behaviour and internalizing symptoms
in middle childhood, high levels of teacher-rated social and behavioural difficulties in
class, low mathematics attainment, and impaired formal operational skills.3 They may
show high levels of overall psychopathology at 17 years.3 Disorganized attachment with
a primary attachment figure is over-represented in groups of children with clinical
problems and those who are victims of maltreatment.1,2,3 A majority of children with
early disorganized attachment with their primary attachment figure during infancy go on
to develop significant social and emotional maladjustment and psychopathology.3,4 Thus,
an attachment-based intervention should focus on preventing and/or reducing

Benoit D
ATTACHMENT
Problems and Research Context

Historically, most attachment-based interventions have focused on improving caregiver
sensitivity (which could be defined as the capacity to read cues and signals accurately and
respond promptly and appropriately), with the assumption that this would promote secure
child-caregiver attachment, which in turn would be linked to positive social and
emotional outcomes. Attempts at improving caregiver sensitivity have been largely
through targeting caregiver representations and/or caregiver behaviour during interactions
with their children.5 However, while caregiver sensitivity is linked to the organized types
of attachment (secure, avoidant, resistant), it may not be as robustly linked to
disorganized attachment.6 Thus, attachment-based interventions that target child-
caregiver interactions to date may not have focused on the most clinically significant
caregiver behaviours to prevent or reduce disorganized attachment. This might reflect the
fact that, in addition to the still fresh discovery that disorganized attachment is often
associated with markedly negative outcomes, it is only recently that researchers have
uncovered one possible child-caregiver interactional pathway to disorganized attachment.
This pathway includes children’s exposure to specific forms of aberrant caregiving
behaviours that are referred to as “atypical” or frightening, dissociated, disoriented
(arguably qualitatively distinct from sensitivity or extreme forms of insensitivity),7 and
may account for some of the poorest outcomes for children. Examples of atypical
caregiver behaviours include failing to keep a child safe, failing to comfort a distressed
child, laughing while the child is distressed, mocking or teasing a distressed child, asking
for affection and reassurance from the child, stilling or freezing (i.e., absence of
movements and facial expressions for extended periods, as seen in some dissociated
states), or threatening to harm. Thus, given current knowledge, one could argue that an
attachment-based intervention that targets caregiver behaviour should focus both on
improving caregiver sensitivity (to promote secure attachment and the associated positive
socio-emotional outcomes) and on reducing and/or eliminating atypical caregiver
behaviours, a known precursor of disorganized attachment7 (to prevent or reduce
disorganized attachment and associated negative outcomes).
Key Research Questions and Recent Research Results

There is good evidence for how to improve caregiver sensitivity and promote secure
child-caregiver attachment. In a meta-analysis of 70 published studies (including 9,957
children and parents, and a core set of 51 randomized controlled trials with 6,282 mothers
and children), Bakermans-Kranenburg, van IJzendoorn & Juffer8 demonstrated that the
most effective attachment-based interventions to improve parent sensitivity (d = 0.33, p
<.001) and promote secure infant-caregiver attachment (d = 0.20, p <.001) included the
following characteristics: (1) a clear and exclusive focus on behavioural training for
parent sensitivity rather than a focus on sensitivity plus support, or a focus on sensitivity
plus support plus internal representations (e.g. individual therapy); (2) the use of video
feedback; (3) fewer than five sessions (fewer than five sessions were as effective as five
to 16 sessions, and 16 sessions or more were least effective); (4) a later start, i.e. after the
infant is six months or older (rather than during pregnancy or before age six months); and
(5) conducted by non-professionals. In addition, the intervention site (home versus office)
and the presence of multiple risk factors did not affect efficacy, but interventions
conducted with clinically referred patients/clients and those that included fathers were

Benoit D
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more effective than interventions without such characteristics. One shortcoming of the
Bakermans-Kranenburg et al.8 meta-analysis is that it did not address the question of
whether attachment-based interventions focusing on caregiver sensitivity have a
significant impact on preventing disorganized attachment.
To address this question, Bakermans-Kranenburg, van IJzendoorn & Juffer6 examined 15

studies (n= 842) from the original 2003 meta-analysis that provided information on the
impact of the attachment-based intervention on preventing the emergence of disorganized
attachment. Overall, attachment-based interventions that focus on improving caregiver
sensitivity have limited effectiveness (d = 0.05, not significant) in preventing or reducing
disorganized attachment. However, a few sensitivity-focused interventions seemed to
have some impact, suggesting that disorganized attachment might change as a side effect
of some sensitivity-focused attachment interventions. The sensitivity-focused attachment
interventions that changed disorganized attachment started after infant age six months
(rather than during pregnancy and before infant age six months), focused on children at
risk (rather than parents at risk), and were conducted by professionals rather than non-
professionals. The authors concluded that attachment interventions that focus on
preventing or reducing disorganized attachment might need to focus specifically on
caregiver behaviours associated with disorganized attachment, such as atypical caregiver
behaviours. In two recent studies, Benoit et al.9,10 demonstrated that a brief, focused,
behavioural parent training intervention could reduce atypical caregiver behaviours.
Conclusions
In summary, attachment-based interventions to date have focused mainly on precursors of
organized types of attachment rather than on precursors of disorganized attachment,
reflecting the fact that the extent of negative sequelae of disorganized child-caregiver
attachment has only recently been identified, as have precursors of disorganized
attachment. Given the high base rate of organized but insecure (avoidant or resistant)
attachment in the general population, it might not be realistic or even necessary to focus
interventions on preventing or eliminating avoidant or resistant attachment, unless the
infant is symptomatic. On the other hand, a large proportion of infants who develop
insecure-disorganized attachment with their primary caregiver go on to develop
significant social and emotional maladjustment and psychopathology. Thus, clinically,
insecure-disorganized child-caregiver attachment appears to be the most significant type
of attachment that requires intervention. The direct focus on antecedents of disorganized
attachment, such as atypical caregiver behaviours, represents a promising direction for
future research.
Implications
Research findings suggest that an attachment-based intervention should focus on
improving caregiver sensitivity to promote secure child-caregiver attachment and the
positive social and emotional outcomes associated with secure attachment. However, an
exclusive focus on improving caregiver sensitivity may be neither sufficient nor effective
in preventing or reducing the most clinically relevant type of insecure attachment, i.e.
disorganized attachment. Recent research findings suggest that a focus on reducing
atypical caregiver behaviours might be a promising direction to reduce disorganized

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child-caregiver attachment. More research is needed to determine whether a reduction in

factors linked to disorganized attachment, such as atypical caregiver behaviours, is in fact
linked to a reduction in disorganized attachment and the associated poor social and
emotional outcomes for children. More research is also needed to determine what
intervention techniques are most effective in reducing atypical caregiver behaviours (or
other precursors of disorganized child-caregiver attachment) and disorganized child-
caregiver attachment. It is important to appreciate that when dealing with problems in the
child-caregiver attachment relationship, recent meta-analyses5,8 show that the best
interventions to date are brief, use video feedback, start after infant age six months, and
have a clear and exclusive focus on behavioural training of the parent rather than a focus
on sensitivity plus support, or a focus on sensitivity plus support plus internal
representations. However, other researchers emphasize the need for home-based,
intensive, and long-term interventions for some of the most disturbed and dysfunctional
families.4 There is obviously a need for more research to identify what characteristics of
attachment-based interventions best meet the needs of specific families. There is also a
need to train service providers in the use of proven attachment-based techniques and in
recognizing disorganized attachment and its precursors.

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REFERENCES
1. Benoit D. Infant-parent attachment: Definition, types, antecedents, measurement

and outcome. Paediatrics & Child Health 2004;9(8):541-545.
2. van IJzendoorn MH, Schuengel C, Bakermans-Kranenburg MJ. Disorganized
attachment in early childhood: Meta-analysis of precursors, concomitants, and
sequelae. Development and Psychopathology 1999;11(2):225-249.
3. Green J, Goldwyn R. Annotation: Attachment disorganisation and
psychopathology: new findings in attachment research and their potential
implications for developmental psychopathology in childhood. Journal of Child
Psychology & Psychiatry & Allied Disciplines 2002;43(7):835-846.
4. Hennighausen K, Lyons-Ruth K. Disorganization of attachment strategies in
infancy and childhood. Rev ed. In: Tremblay RE, Barr RG, Peters RDeV, eds.
Encyclopedia on Early Childhood Development [online]. Montreal, Quebec:
Centre of Excellence for Early Childhood Development; 2007:1-7. Available at:
http://www.child-encyclopedia.com/documents/Hennighausen-
LyonsRuthANGxp_rev.pdf . Accessed October 1st 2009.
5. Egeland B. Attachment-based intervention and prevention programs for young
children. In: Tremblay RE, Barr RG, Peters RDeV, eds. Encyclopedia on Early
Childhood Development [online]. Montreal, Quebec: Centre of Excellence for
Early Childhood Development; 2004:1-7. Available at: http://www.child-
encyclopedia.com/documents/EgelandANGxp.pdf. Accessed October 1st 2009.
6. Bakermans-Kranenburg MJ, van IJzendoorn MH, Juffer F. Disorganized infant
attachment and preventive interventions: A review and meta-analysis. Infant
Mental Health Journal 2005;26(3):191-216.
7. Madigan S, Bakermans-Kranenburg MJ, van IJzendoorn MH, Moran G, Pederson
DR, Benoit D. Unresolved states of mind, anomalous parental behavior and
Attachment & Human Development 2006;8(2):89-111.
analysis of sensitivity and attachment interventions in early childhood.
9. Benoit D, Madigan S, Lecce S, Shea B, Goldberg S. Atypical maternal behavior
toward feeding-disordered infants before and after intervention. Infant Mental
Health Journal 2001;22(6):611-626.
10. Madigan S, Hawkins E, Goldberg S, Benoit, D. Reduction of disrupted caregiver
behavior using Modified Interaction Guidance. Infant Mental Health Journal
2006;27(5): 509-527.
Benoit D. Efficacy of attachment-based interventions. Rev ed. In: Tremblay RE, Barr RG, Peters RDeV,
eds. Encyclopedia on Early Childhood Development [online]. Montreal, Quebec: Centre of Excellence for
encyclopedia.com/documents/BenoitANGxp_rev-Attachment.pdf. Accessed [insert date].

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Benoit D
Attachment-Based Interventions:
Comments on Dozier 1 , Egeland2 , and Benoit 3
SHEREE L. TOTH, PhD
Mt. Hope Family Center, University of Rochester, USA
Topic
Attachment
Introduction
Attachment theory provides a powerful perspective for investigating the nature of the
relationship between experiences of caregiving and developmental outcome.1,2,3
Attachment organization in infants and toddlers has been linked with future adaptation.4,3
Therefore, it is important to promote secure attachment relationships between caregivers
and their offspring. In the last decade, investigators have increasingly directed their
efforts toward understanding and modifying attachment relationships in high-risk and
psychiatric populations.5,6,7 Dozier, Egeland, and Benoit have been at the forefront of
theoretical and research initiatives designed to prevent insecure relationships and
promote secure attachment relationships in young children. In these articles, the authors
review the literature on attachment-based interventions and highlight key empirical
findings regarding the efficacy of prevention and intervention initiatives.

Dozier begins by reviewing how the type of caregiving provided affects the quality of
children’s attachment. She goes on to explain that the strongest predictor of infant
attachment is parental state of mind regarding attachment. Dozier also discusses the
variations among intervention strategies utilized to enhance attachment security. She
draws upon a 2003 meta-analysis conducted by Bakermans-Kranenburg, van Ijzendoorn
and Juffer, in which they concluded that interventions that target parental sensitivity and
are initiated after approximately six months of age are more effective than interventions
with more global goals that begin during the early months.8 Moreover, she concludes that
brief interventions are at least as effective as those that are longer in duration.
1
Comments on original paper published by Mary Dozier in 2004. To have access to this article, contact us
at [email protected].
2
Comments on original paper published by Byron Egeland in 2004. To have access to this article, contact
us at [email protected].
3
Comments on original paper published by Diane Benoit in 2005. To have access to this article, contact us

Toth SL
ATTACHMENT
Egeland emphasizes that security of attachment during infancy has been consistently
shown to predict aspects of social development during childhood, with secure attachment
relating to more optimal developmental outcomes and insecure attachment predicting
socioemotional maladaptation. Egeland further states that attachment relationships may
have long-term effects on the course of biological development. Consistent with Dozier,
Egeland therefore concludes that it is critical to design and evaluate programs to promote
a secure parent-infant attachment relationship. Like Dozier, Egeland also discusses two
broad types of intervention strategies designed to foster secure attachment relationships:
1) strategies that target parental sensitivity; and 2) strategies that strive to alter parental
representation with respect to their own histories of caregiving. A central tenet of
attachment theory is that the early relationships between infants and their caregivers lead
to the formation of mental representations of the self, others, and of the self in relation to
others. Therefore, the focus of interventions on modifying these mental representations or
targeting caregiver behaviour assumes importance. Egeland proffers an important caveat
to findings that support the utilization of short-term interventions that target modifying
parental sensitivity. Specifically, Egeland cautions that although these programs are
successful with relatively low-risk samples, more comprehensive and long-term
interventions are likely to be necessary with high-risk families.
Benoit’s article is focused on a particular pattern of insecure attachment, the disorganized

classification. Unlike organized attachments, in which coherent strategies for relating to
the caregiver in times of stress are present, disorganized attachment is not characterized
by any consistent strategy of relating to the caregiver. Disorganized attachment has been
identified as particularly significant in putting youngsters at risk for socioemotional
maladjustment and psychopathology. Benoit emphasizes that although caregiver
sensitivity has been linked with organized patterns of attachment, it has not been shown
to relate to disorganized attachment. Benoit discusses the fact that, in an analysis of 15
studies from their 2003 meta-analysis, Bakermans-Kranenburg and colleagues concluded
that attachment interventions that focus on preventing or reducing disorganized
attachment may need to target the reduction of atypical caregiver behaviours.8
Specifically, frightened or frightening caregiver behaviour has been implicated in the
etiology of disorganized attachment.
Implications for Development and Policy

Taken in tandem, all three of these papers support the importance of preventing insecure
relationships and promoting secure attachment relationships between young children and
their caregivers. Over the last several decades, evidence has mounted regarding the
importance of establishing secure attachment for future adaptive development.
Increasingly, prevention and intervention programs have targeted security of attachment
as an outcome goal. Although there has been some evidence suggesting that short-term
interventions that target parental sensitivity are efficacious and perhaps superior to long-
term approaches that strive to modify parental state of mind regarding attachment, this
controversy is far from resolved. In fact, it would be extremely premature to conclude
that one approach is preferable to the other. As Egeland cautions, short-term behavioural
approaches may be effective with lower-risk groups of infants and mothers, but we still

Toth SL
ATTACHMENT
do not have evidence that they would be as effective, or effective at all, with higher-risk
populations.
In fact, studies recently conducted at Mt. Hope Family Center have offered compelling
evidence that preventive interventions that target maternal representations of relationships
are very effective in promoting attachment security. In the first investigation, toddler
offspring of mothers who had experienced a major depressive disorder since the birth of
the child were randomly assigned to an attachment-theory informed intervention or to a
community standard condition. A group of non-depressed mothers served as a normative
comparison group. Although at baseline toddlers with depressed mothers evidenced
higher rates of insecurity than did toddlers with non-depressed mothers, at the completion
of the intervention the group that received the attachment-theory informed intervention
had significantly higher rates of security than did participants who received the
community standard intervention. Importantly, rates of security in the mother-child dyads
that received the attachment-theory informed intervention did not differ from those
present in the dyads where mothers were not depressed.5 For toddlers who participated in
the attachment intervention, there was also a greater maintenance of secure attachment
organization among those who were initially secure, as well as a greater shift from
insecure to secure attachment groupings. Similarly compelling results have been obtained
with maltreated infants, where baseline rates of insecurity were over 90% and where
post-intervention attachment security did not differ from that of non-maltreated infants.
Maltreated infants randomized to the community standard condition continued to
evidence extremely high rates of insecure attachment consistent with that present at
baseline.9 Interestingly, in the latter preventive intervention, a didactic and more
behaviourally focused intervention was just as effective as one dealing with maternal
representations in promoting secure attachment. Conversely, in the evaluation of a
preventive intervention for maltreated preschool-aged children, only an intervention that
targeted maternal representations resulted in improvement in child representations of
caregivers and of self.10 Thus, the issue of preferred intervention strategy appears to be
far from resolved and caution must be exercised in bringing premature closure to this
issue.
A number of other important issues need to be considered before definitive conclusions

can be reached on how best to promote secure attachment organization. First, it is unclear
how durable the effects of the interventions are and whether durability might vary as a
function of the length and intensity of the intervention being provided. Second, few if any
investigations have sought to elucidate mediators of the intervention outcome. That is,
while we may know that a given intervention has been efficacious, we know considerably
less about the mechanisms that may be contributing to its efficacy. Such knowledge could
be extremely helpful in identifying critical aspects of an intervention and eliminating
those that may be costly but do not add to the overall value of the intervention. Finally,
the bulk of evaluations have involved well-controlled efficacy trials that utilize clear
inclusion/exclusion criteria and well-trained and supervised clinicians, and also monitor
the fidelity of the intervention being provided. Although such randomized clinical trials
are necessary in order to establish a knowledge base, we must also work toward exporting
these clinical methods into real-world arenas and then continue to evaluate their

Toth SL
ATTACHMENT
effectiveness. Only then will we truly know how best to promote secure attachment and
what approaches may be most effective for a given population.

Toth SL
ATTACHMENT
REFERENCES
1. Ainsworth MDS, Blehar MC, Waters E, Wall S. Patterns of attachment: A

Associates; 1978.
2. Main M, Kaplan N, Cassidy JC. Security in infancy, childhood and adulthood: A
move to the level of representation. Monographs of the Society for Research in
Child Development 1985;50(1-2):66-104.
The roots of maladaptation and competence. Minnesota symposia on child
psychology 1983;16:41-83.
Ladd GW, eds. Family-peer relationships: Modes of linkage. Hillsdale, NJ:
Lawrence Earlbaum Associates; 1992:77-106.
5. Cicchetti D, Toth SL, Rogosch FA. The efficacy of toddler-parent psychotherapy
to increase attachment security in offspring of depressed mothers. Attachment and
Human Development 1999;1(1):34-66.
6. Lieberman AF, Pawl JH. Disorders of attachment and secure base behavior in the
second year of life: Conceptual issues and clinical intervention. In: Greenberg
397.
7. van Ijzendoorn MH, Juffer F, Duyvesteyn MGC. Breaking the intergenerational
Psychology and Psychiatry and Allied Disciplines 1995;36(2):225-248.
8. Bakermans-Kranenburg MJ, van Ijzendoorn MH, Juffer F. Less is more: Meta-
9. Cicchetti D, Toth SL, Rogosch FA. The efficacy of interventions for maltreated
infants in fostering secure attachment. In preparation.
10. Toth SL, Maughan A, Manly JT, Spagnola M, Cicchetti D. The relative efficacy
of two interventions in altering maltreated preschool children's representational
models: Implications for attachment theory. Development and Psychopathology
2002;14(4):877-908.
Toth SL. Attachment-based interventions: Comments on Dozier, Egeland, and Benoit. In: Tremblay RE,
Barr RG, Peters RDeV, eds. Encyclopedia on Early Childhood Development [online]. Montreal, Quebec:
Centre of Excellence for Early Childhood Development; 2005:1-4. Available at: http://www.child-
encyclopedia.com/documents/TothANGxp.pdf. Accessed [insert date].
Copyright © 2005

Toth SL
Supporting Families to Build Secure Attachment
Relationships:
Comments on Benoit1 , Dozier 2 , and Egeland 3
FEMMIE JUFFER, PhD, MARIAN J. BAKERMANS-KRANENBURG, PhD,
& MARINUS H. VAN IJZENDOORN, PhD
Centre for Child & Family Studies, Leiden University, NETHERLANDS
(Published online June 30, 2005)
Topic
Attachment
Introduction
Since Bowlby and Ainsworth formulated attachment theory,1,2 many early intervention
programs have been launched that aim to promote secure child-parent attachment
relationships. Usually, these intervention programs are designed to enhance parental
sensitivity, the ability to accurately perceive children’s attachment signals, and the ability
to respond to these signals in a prompt and appropriate manner.2 The ultimate goal of
these interventions is to turn insecure-avoidant (A) and insecure-resistant (C) attachment
relationships into secure (B) child-parent attachment relationships.2 In a few programs,
the intervention is not only directed at sensitive parental behaviour but also at maternal
mental attachment representations, as in the STEEP (Steps Toward Effective Enjoyable
Parenting) program described by Egeland. According to Benoit, with the discovery of a
new insecure attachment category, disorganized attachment (D),3 new challenges arose
for attachment-based interventions. Because of the negative impact of, in particular,
disorganized attachment on child outcomes, attachment-based interventions should not,
or not only, focus on the empirically derived determinants of organized (A, B, and C)
attachment, such as parental (in)secure mental attachment representations and sensitive
behaviour (see Dozier), but also on the determinants of disorganized (D) attachment.
Empirical studies have found evidence for Main and Hesse’s4 model that parents’
unresolved loss or trauma is linked to children’s insecure-disorganized attachment
through frightening or frightened parental behaviour. However, there are as yet no
reported outcomes from interventions that have directly targeted frightening behaviours.
As a first step, it is important to evaluate the effects of attachment-based interventions
that include infant attachment disorganization as an outcome measure (see below), but in
1
Comments on original paper published by Diane Benoit in 2005. To have access to this article, contact us
2
Comments on original paper published by Mary Dozier in 2004. To have access to this article, contact us
3
Comments on original paper published by Byron Egeland in 2004. To have access to this article, contact
us at [email protected].

Juffer F, Bakermans-Kranenburg MJ, van IJzendoorn MH
ATTACHMENT
the next step interventions that are specifically designed to prevent insecure disorganized
attachment should be tested.

Egeland elegantly summarizes the main tenets of attachment theory. According to
Bowlby,1 infants are biologically predisposed to use their parent as a haven of safety to
provide comfort and protection when they are distressed, and as a secure base from which
they can explore the environment. As children develop, they form mental representations
or inner working models on the basis of their experiences with their caregivers. If
children have had positive experiences with sensitive parents, they will continue to rely
on them by showing their distress and being calmed by contact with the parent (defined
by Ainsworth2 as secure patterns of attachment). In contrast, insensitive parents reject
their children’s bids for comfort, and other parents are inconsistently available. Children
of these parents develop insecure attachment relationships, either avoiding, or angrily or
passively resisting the parent. Secure attachments during early childhood predict more
optimal developmental outcomes in later childhood (e.g. social competence), whereas
insecure attachments predict less optimal child outcomes. Drawing on the many positive
outcomes of secure attachment found in empirical studies, Egeland comes to a crystal-
clear conclusion that programs should be designed and evaluated to promote secure
attachment relationships in order to improve developmental outcomes of children who are
at risk for poor developmental outcomes. Egeland reviews several attachment-based
interventions (e.g. the comprehensive STEEP project). As well, a first meta-analysis in
this field5 is described. This meta-analysis of the effects of 12 attachment-based
interventions on maternal sensitivity and infant security showed that these interventions
were more effective in changing parental insensitivity than in changing children’s
attachment security.5
Egeland does not address the follow-up of this first meta-analysis on parental sensitivity
and attachment, nor does he cover the question of how insecure disorganized attachments
might be prevented. Recently, 88 interventions on maternal sensitivity and infant security
in 70 studies were included in a thoroughly extended and updated quantitative meta-
analysis.6 This meta-analysis showed that interventions that specifically focused on
promoting sensitive parental behaviour appeared to be rather effective in changing
insensitive parenting as well as infant attachment insecurity. One of the conclusions of
this series of meta-analyses, also illustrated in the title of the paper “Less is more,” was
that interventions with a modest number of intervention sessions (up to 16) appeared to
be more effective than interventions with larger numbers of sessions, and this was true for
clinical as well as for non-clinical groups.6 This diverges from Egeland’s conclusion that
more comprehensive, long-term interventions are necessary for high-risk families.
Although this might be true for other intervention goals, such as helping high-risk
mothers to cope with adversity or the daily hassles surrounding the birth of a child, the
recent meta-analysis shows that for sensitivity and attachment, the most effective way is
to provide attachment-based interventions in a modest number of sensitivity-focused
sessions.

ATTACHMENT
Dozier elaborates on parental state of mind as one of the strongest predictors of infant
attachment. Parents who are able to reflect on their own childhood experiences in a
coherent way are said to have autonomous states of mind. When parents are not coherent
in discussing their own attachment experiences, they are said to have non-autonomous
states of mind. Here, the work of Main comes to the fore: the Adult Attachment
Interview7 enables coders to distinguish reliably between parents with insecure
(dismissing, preoccupied or unresolved) states of mind and parents with secure
(autonomous) attachment representations. Several empirical studies and a meta-analysis8
have found that insecure parents usually have insecurely attached infants and secure
parents tend to have secure children. Dozier remarks that some attachment-based
interventions are designed to target parent state of mind as a means of changing infant
attachment, although many other interventions try to change parental sensitivity alone.
Citing the recent meta-analysis of attachment-based interventions by Bakermans-

Kranenburg and colleagues,6 Dozier summarizes the main outcomes: brief sensitivity-
focused interventions that start after the child is at least six months old are most
successful, irrespective of parental risk status or socioeconomic status. Dozier does not
explicitly address disorganized attachment and the implications of disorganized
attachment for intervention research.
In contrast to the first two authors, Benoit explicitly describes the challenge of the
discovery of insecure-disorganized attachment for the field of attachment-based
interventions. At the beginning of her paper, she notices that of the four patterns of infant
attachment (secure, avoidant, resistant, disorganized), the disorganized classification has
been identified as a powerful childhood risk for later psychopathology. She continues
with the observation that for disorganized attachment the focus of the intervention should
not be parental sensitivity, as she notes that sensitivity is not linked to disorganized
attachment. Nevertheless, a meta-analysis showed that interventions with a focus on
sensitivity were successful in reducing or preventing attachment disorganization9 (see
below), and we noted that the explanation for this finding might be that parents become
more focused in the interaction with their child, and thereby less prone to dissociative
processes in the presence of the child. According to Benoit, one recently identified
pathway to disorganized attachment is children’s exposure to specific forms of aberrant
caregiving behaviours that are referred to as “atypical.” Therefore, Benoit concludes that
attachment-based interventions should focus both on improving parental sensitivity (to
promote secure attachment) and on reducing or eliminating atypical parental behaviours
(to prevent or reduce disorganized attachment). Benoit’s own study, which demonstrated
the effects of a brief, focused, behavioural parent training intervention in reducing
atypical caregiver behaviours, is a first example of much needed studies designed to
reduce frightening/frightened or atypical parental behaviours. It would be exciting to
learn whether this type of intervention was indeed successful in preventing or reducing
Implications for Clinical Practice and Services

What can we conclude about attachment-based interventions and the state of the art of
intervention research? Based on the two meta-analyses5,6 conducted in 1995 and 2003,

ATTACHMENT
several conclusions for clinical practice and services can be drawn. It has been
empirically proven that interventions can successfully enhance parental sensitivity and
promote secure attachment in children, in particular when the intervention is relatively
brief (up to 16 sessions), behaviourally oriented, focuses on sensitivity only (instead of
broader interventions including social support, etc.), and starts after the infant’s age of six
months. However, long-term and broadly-focused support of multi-problem families in
coping with their daily hassles may be needed in order to enable them to focus on
sensitivity subsequently.6 The 2003 meta-analysis also found an important dose-response
relation between the success of the intervention on parental sensitivity and its impact on
children’s attachment security: only interventions that brought about substantial effects
on sensitivity succeeded in changing attachment insecurity.6
Both meta-analyses included interventions designed to change children’s insecure,

organized attachment relationships: insecure-avoidant and insecure-resistant
relationships, and not the clinically important category of insecure-disorganized
attachment. Today, few interventions have been specifically designed to prevent
attachment disorganization. In the same vein, most attachment-based interventions do not
report effects on disorganized attachment. This is a serious gap in our knowledge for two
reasons: (1) Recent research has shown that disorganized attachment is a predictor of
psychopathology, whereas insecure-avoidant and resistant attachment lead to less optimal
but not pathological child adjustment.10 Therefore, it is imperative to evaluate
attachment-based interventions on their potential value to prevent attachment
disorganization. (2) Because even secure children are considered insecure when their
attachment behaviour shows serious signs of disorganization, it is of great relevance for
interventions to report not only effects on secure attachment but also effects on
Recently, a narrative review and quantitative meta-analysis has been completed including
15 preventive interventions that included infant disorganized attachment as an outcome
measure.9 Although the overall effect of all interventions combined was not significant,
some interventions did succeed in preventing disorganized attachment in children. These
interventions shared the following characteristics: They started after six months of the
infant’s age rather than before six months; they were sensitivity-focused; and they
involved samples with children at risk rather than at-risk parents.9
As an example, a preventive intervention in families with internationally adopted infants

significantly enhanced maternal sensitivity and also significantly reduced disorganized
attachment: in the intervention group there were only 6% disorganized-attached children
compared with 22% in the control group.11 This study used a brief intervention of three
home-based sessions of video feedback focusing on parental sensitivity, with the
intervention starting when the child was six months old. Based on the positive outcomes
of this study, adoption practice in the Netherlands has changed. New adoptive parents can
apply for a new adoption after-care service: up to four sessions of video feedback,
implemented by a central adoption service organization financed by the government. An
increasing number of adoptive parents make use of this new service. The video-feedback
intervention used in adoptive families11 was extended and adapted into the Leiden VIPP

ATTACHMENT
(Video-feedback Intervention to Promote Positive Parenting).12, 13 The VIPP program and

several adaptations and extensions have been used in different cultures and contexts, for
example with insecure or eating-disordered mothers, in families with premature and sick
infants or externalizing toddlers, and in a daycare setting.14
Future studies should also focus on evaluating interventions that are explicitly directed at
parental frightening or frightened behaviour as the empirically derived determinant of
infant disorganized attachment. As the meta-analyses on organized and disorganized
attachment all indicate an important role for parental sensitivity, it may be wise to
include the enhancement of parental sensitivity in all attachment-based interventions.

ATTACHMENT
REFERENCES
1. Bowlby J. Attachment. New York, NY: Basic Books; 1982. Attachment and loss.
2nd ed; vol 1.
2. Ainsworth MDS, Blehar MC, Waters E, Wall S. Patterns of attachment: a
Associates; 1978.
160.
4. Main M, Hesse E. Parents’ unresolved traumatic experiences are related to infant
disorganized attachment status: Is frightened and/or frightening parental behavior
the linking mechanism? In: Greenberg MT, Cichetti D, Cummings E, eds.
Attachment in the preschool years: Theory, research, and intervention. Chicago,
Ill: University of Chicago Press; 1990:161-182.
5. Van IJzendoorn MH, Juffer F, Duyvesteyn MGC. Breaking the intergenerational
6. Bakermans-Kranenburg MJ, Van IJzendoorn MH, Juffer F. Less is more: Meta-
7. Main M, Goldwyn R. Adult attachment rating and classification system.
Berkeley, Calif: University of California. Unpublished manuscript.
8. Van IJzendoorn MH. Adult attachment representations, parental responsiveness,
and infant attachment: A meta-analysis on the predictive validity of the Adult
Attachment Interview. Psychological Bulletin 1995;117(3):387-403.
9. Bakermans-Kranenburg MJ, Van IJzendoorn MH, Juffer F. Disorganized infant
attachment and preventive interventions: A review and meta-analysis. Infant
Mental Health Journal. In press.
10. Solomon J, George C. The place of disorganization in attachment theory: Linking
classic observations with contemporary findings. In: Solomon J, George C, eds.
Attachment disorganization. New York, NY: Guilford Press; 1999:3-32.
11. Juffer F, Bakermans-Kranenburg MJ, Van IJzendoorn MH. The importance of
parenting in the development of disorganized attachment: evidence from a
preventive intervention study in adoptive families. Journal of Child Psychology
and Psychiatry 2005;46(3):263-274.
12. Juffer F, Bakermans-Kranenburg MJ, Van IJzendoorn MH. Enhancing children’s
socioemotional development: A review of intervention studies. In: Teti DM, ed.
Handbook of Research Methods in Developmental Science. Oxford, United
Kingdom: Blackwell Publishers; 2004:213-232.
13. Juffer F, Bakermans-Kranenburg MJ, Van IJzendoorn MH. Introduction and
outline of the VIPP and VIPP-R program. In: Juffer F, Bakermans-Kranenburg
MJ, van IJzendoorn MH, eds. Attachment-based intervention with video-feedback

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and biographical discussion: The Leiden VIPP and VIPP-R program. Mahwah,
NJ: Lawrence Erlbaum. In press.
14. Juffer F, Bakermans-Kranenburg MJ, Van IJzendoorn MH, eds. Attachment-
based intervention with video-feedback and biographical discussion: The Leiden
VIPP and VIPP-R program. Mahwah, NJ: Lawrence Erlbaum. In press.
Juffer F, Bakermans-Kranenburg MJ, van IJzendoorn MH. Supporting families to build secure attachment
relationships: Comments on Benoit, Dozier, and Egeland. In: Tremblay RE, Barr RG, Peters RDeV, eds.
Encyclopedia on Early Childhood Development [online]. Montreal, Quebec: Centre of Excellence for
encyclopedia.com/documents/JufferANGxp.pdf. Accessed [insert date].
Copyright © 2005

Early Day Care and Infant-Mother Attachment Security
JAY BELSKY, PhD
Institute for the Study of Children, Families and Social Issues,
Birkbeck University of London, UK
(Published online October 20, 2009)
Topic
Attachment
Child care (0-5 years)
Introduction
Whether and how non-maternal child-care experience affects children’s development
have been of long-standing interest to parents, policymakers and developmental scholars.
Ever since Bowlby1 promulgated attachment theory, thinking derived from it has led
some to expect day care, especially when initiated in the earliest years of life, to
undermine the security of infant-parent attachment relationships. To some, this was
because day care involved the infant’s separation from mother (or other principle
caregiver), as separation from the attachment figure was inherently stressful. Separation
could also undermine the mother’s own capacity to provide sensitive care, the primary
determinant of security, thereby fostering insecurity indirectly (i.e.,
separationÆinsensitivityÆinsecurity). A final reason for anticipating a link between day
care and attachment security was because security reflected general emotional well-being,
so adverse effects of day care in infancy would manifest themselves as insecure
attachment.
Background
Early research on the link between day care and attachment, often carried out on children
3-5 years of age, provided no compelling evidence to support the claim that day care
undermined security.2 But by the mid-1980s, studies carried out on much younger
children began to chronicle links between day care and insecurity as measured in the
Strange Situation Procedure (SSP) (e.g., Barglow, Vaughn & Molitar3). This led
Belsky4,5,6 to conclude that infant day care, especially that initiated on a full- or near full-
time basis beginning in the first year of life,7 was a “risk factor” in the development of
insecure attachment in infancy (and of aggression and disobedience in 3-8 year olds).
This conclusion did not go unchallenged. One criticism was that the apparent influence of
early and extensive day care on insecurity was the result of other explanatory factors
(e.g., family income) not adequately accounted for in existing research.8 Another was that
(unmeasured) poor quality care and not timing and quantity of care was the influential
factor.9 And a third was that independent behavior displayed by day care children not

Belsky J
ATTACHMENT
particularly stressed by the SSP ̶ due to their familiarity with separation ̶ was
misconstrued as avoidant behavior, leading to erroneous assessments of children as
insecure-avoidant.10
Research Questions
All agreed, however, that more research was needed to illuminate the conditions under
which early day care did and did not undermine ̶ or enhance ̶ attachment security.
Considered especially important was (a) taking into account confounding child, parent
and family background factors that could be responsible for any putative child care
effects; (a) distinguishing and disentangling potential effects of distinctive features of the
child-care experience, particularly quality, quantity and type of care (e.g., center-based
vs. home-based); and (b) determining whether day care was associated with less
separation distress in the SSP or independent behavior was mischaracterized as avoidant
behavior.
Recent Research
The NICHD Study of Early Child Care and Youth Development (SECCYD), launched in
1991 in the US, sought to address these issues and many others.11 It followed more than
1300 children from birth through the primary-school years12 and into adolescence,13
while administering SSP assessments at 15 and 36 months.
After taking into account a host of potentially confounding background factors, results
proved strikingly consistent with the risk-factor conclusion14 ̶ even though the opposite is
implied by many writers.15,16 Typically emphasized is that no single feature of the day
care experience in and of itself ̶ quantity, type or quality of care ̶ predicted attachment
security, seeming to suggest no effect of day care on attachment security. Yet what the
findings actually revealed was a “dual-risk” phenomenon.17 Although the strongest
predictor of insecurity at 15 months of age was, as expected, insensitive mothering
(observed at ages 6 and 15 months), this effect was amplified if any one of three distinct
child-care conditions characterized the child’s experience across the first 15 months of
life: (a) averaging more than 10 hours per week in any type of care, irrespective of
quality; (b) enrolment in more than a single child-care arrangement; and (c) exposure to
low quality care. The first two amplifying conditions applied to most children being
studied. But only the first, quantity of care, also contributed to the prediction of
attachment insecurity at 36 months,18 again in interaction with insensitive mothering. Just
as important was evidence that infants with extensive day care experience (a) were not
less stressed in the SSP than other infants (see also19) and that (b) putatively independent
behavior was not misconstrued as avoidant behavior.14
Two other reasonably large-sample studies yield results that are at odds with those of the
US study. In one investigation of more than 700 Israeli infants, Sagi and associates20
found that “center-care, in and of itself, adversely increased the likelihood of infants
developing insecure attachment to their mothers as compared with infants who were
either in maternal care, individual nonparental care with a relative, individual nonparental
care with a paid caregiver, or family day-care.” Additional results suggested it was “the
poor quality of center-care and the high infant-caregiver ratio that accounted for this

Belsky J
ATTACHMENT
increased level of attachment insecurity among center-care infants” (see also16). In a

second study of 145 first-born Australian infants, Harrison and Unger21 focused on
maternal employment more than features of day care. Return to employment before five
months postpartum ̶ and thus earlier use of child care ̶ predicted decreased rates of
insecurity at 12 months of age relative to returning to work later in the first year or not at
all. The Australian mothers were more likely than their American and Israeli counterparts
to be employed part-time rather than full-time.
Research Gaps
It remains unclear why results from different locales produce variable findings. It could
well involve the broader, national child care systems in which day care is embedded.
Cross-national research seems called for.
Characteristics of children themselves, perhaps especially their genetic make up, also
merits further consideration. After all, ever more evidence indicates that children vary
substantially in their susceptibility to environmental influences,22 including day care23
with some proving more developmentally malleable than others.
Conclusions
After decades of debate and study, findings from the largest studies of day care and
attachment compellingly discredit any claim that “no relation exists between day care and
attachment.” Also disconfirmed are assertions that the SSP is methodologically unsuited
for evaluating effects of day care or that, at least in the US, adverse effects of day care are
simply a function of poor quality care. Nevertheless, the fact that results of three large-
scale studies carried out in different locales vary substantially should make it clear that
there are probably no inevitable effects of day care on attachment. Effects appear
contingent on the societal context in which day care is experienced.
Implications
The fact that detected effects of day care on attachment security vary substantially by
national context means that it is precarious to draw strong inferences from attachment
theory as to what the effect of day care will be. Ultimately, day care is a multi-
dimensional phenomenon, so questions such as “is day care good for infants (or young
children)?” are too simplistic. Quality, type, timing and quantity of care must be
distinguished and effects of these features of the child care may vary as a function of the
larger familial, community, societal and cultural context in which child care occurs. Not
to be forgotten in any evaluation of the effects of day care are humanitarian
considerations: What, not only, do mothers, fathers, policymakers and society more
generally want, but what do children want?

Belsky J
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REFERENCES
1. Bowlby J. Attachment and Loss. New York, NY: Basic Books; 1969. Attachment.
Vol 1.
2. Belsky J, Steinberg L. The effects of day care: A critical review. Child
Development 1978;49(4):929-949.
3. Barglow P, Vaughn B, Molitor N. Effects of maternal absence due to employment
on the quality of infant-mother attachment in a low risk sample. Child
Development 1987;58(4):945-954.
4. Belsky J. Infant day care: A cause for concern? Zero to Three 1986;6(4):1-7.
5. Belsky J. The “effects” of infant day care reconsidered. Early Childhood
Research Quarterly 1988;3(3):235-272.
6. Belsky J. Emanuel Miller Lecture: Developmental risks (still) associated with
early child care. Journal of Child Psychology and Psychiatry 2001;42(7):845-859.
7. Belsky J, Rovine M. Nonmaternal care in the first year of life and the security of
infant-parent attachment. Child Development 1988;59(1):157-167.
8. Scarr S, Phillips D, McCartney K. Facts, fantasies, and the future of child care in
the United States. Psychological Science 1990;1(1):26-35.
9. Phillips D, McCartney K, Scarr S, Howes C. Selective review of infant day care
research: A cause for concern. Zero to Three 1987;7:18-21.
10. Clarke-Stewart KA. Infant day care: Maligned or malignant? American
Psychologist 1989;44(2):266-273.
11. NICHD Early Child Care Research Network, ed. Child Care and Child
Development: Results of the NICHD Study of Early Child Care and Youth
Development. New York, NY: Guilford Press; 2005.
12. Belsky J, Vandell D, Burchinal M, Clarke-Stewart KA, McCartney K, Owen MT
and The NICHD Early Child Care Research Network. Are There Long-term
Effects of Early Child Care? Child Development 2007;78(2):681-701.
13. Vandell DL, Belsky J, Burchinal M, Steinberg L, Vandergrift N, the NICHD
Early Child Care Research Network. Do Effects of Early Child Care Extend to
Age 15 Years? Child Development. In press.
14. NICHD Early Child Care Research Network The effects of infant child care on
infant-mother attachment security: Results of the NICHD Study of Early Child
Care. Child Development 1997;68(5):860-879.
15. Allhusen VD, Clarke-Stewart KA, Miner JL. Childcare in the United States:
Characteristics and consequences. In: Melhuish E, Petrogiannis K, eds. Early
Childhood Care and Education: International Perspectives. London, UK:
Routledge; 2008:7-26.
16. Love M, Harrison L, Sagi-Schwartz A, van Ijzendoorn MH, Ross C, Ungerer JA,
Raikes H, Brady-Smith C, Boller K, Brooks-Gun JC, Jill K, Ellen E, Paulsell D,
Chazen-Cohen R. Child Care Quality Matters: How Conclusions May Vary with
Context. Child Development 2003;74(4):1021-1033.
17. NICHD Early Child Care Research Network The effects of infant child care on
infant-mother attachment security: Results of the NICHD Study of Early Child
Care. Child Development 1997;68(5):876.

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18. NICHD Early Child Care Research Network. Child care and family predictors of
preschool attachment and stability from infancy. Developmental Psychology
2001;37(6):847-862.
19. Belsky J, Braungart J. Are insecure-avoidant infants with extensive day-care
experience less stressed by and more independent in the strange situation? Child
Development 1991;62(3):567-571.
20. Sagi A, Koren-Karie N, Gini M, Ziv Y, Joels T. (2002). Shedding further light on
the effects of various types and quality of early child care on infant-mother
attachment relationship: The Haifa Study of Early Child Care. Child Development
2002;73(4):1166.
21. Harrison LJ, Ungerer JA. Maternal employment and infant-mother attachment
security at 12 months postpartum. Developmental Psychology 2002;38(5):758-
773.
22. Belsky J, Bakermans-Kranenburg M, van Ijzendoorn M. For Better and for worse:
Differential susceptibility to environmental influences. Current Directions in
Psychological Science 2007;16(6):305-309.
23. Pluess M, Belsky J. Differential susceptibility to rearing experience: the case of
childcare. Journal of Child Psychology and Psychiatry 2009:50(4):396-404.
Belsky J. Early day care and infant-mother attachment security. In: Tremblay RE, Barr RG, Peters RDeV,
Boivin M, eds. Encyclopedia on Early Childhood Development [online]. Montreal, Quebec: Centre of
encyclopedia.com/documents/BelskyANGxp-Attachment.pdf. Accessed [insert date].
Copyright © 2009

Belsky J
ATTACHMENT

Belsky J

Attachment

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Attachment

Synthesis on attachment .........................................................................................................i

How important is it?

To assess the quality of attachment in infancy, researchers often use a standardized

Encyclopedia on Early Childhood Development i

Secure attachment is considered a protective factor as it has been associated with

What can be done?

To improve long-term developmental outcomes of infants and children, prevention

A few sensitivity-focused interventions have had some impact on disorganized

Encyclopedia on Early Childhood Development - ii –

However, more comprehensive, long-term interventions or other types of

Nonetheless, it is clear that service providers should be trained in the use of

1. van IJzendoorn MH, Schuengel C, Bakermans-Kranenburg MJ. Disorganized

Encyclopedia on Early Childhood Development - iii –

Encyclopedia on Early Childhood Development 1

Encyclopedia on Early Childhood Development 2

Key Research Questions

1. Security in attachment and partnership representation at the age of 22 was significantly

2. Mothers’ as well as fathers’ sensitive supportiveness, acceptance of the child and

4. In contrast to some other longitudinal studies of attachment development, patterns of

5. Project 1 is an example of the complexity of developmental pathways beyond infancy.

Encyclopedia on Early Childhood Development 3

6. In Project 1, an insecure pattern of attachment in infancy was predictive of less optimal

8. The socio-emotional development of the not-at-risk children in both projects was

The child’s subjective experiences can best be assessed by open-minded, reliable

Encyclopedia on Early Childhood Development 4

competencies. Appropriate emotional responses to real events and attempted appropriate

Implications for the Policy and Services Perspective

Encyclopedia on Early Childhood Development 5

1. Ainsworth MDS, Bowlby J. An ethological approach to personality development.

Encyclopedia on Early Childhood Development 6

relationship: Fathers’ sensitive and challenging play as a pivotal variable in a 16-

Encyclopedia on Early Childhood Development 7

28. Larose S, Bernier A, Tarabulsy GM. Attachment state of mind, learning

To cite this document:

Encyclopedia on Early Childhood Development 8

Disorganized attachment behaviours in infancy

Encyclopedia on Early Childhood Development 1

Controlling attachment patterns in childhood

Parental behaviours related to disorganized/controlling attachment strategies

Intervening with disorganized/controlling families

Encyclopedia on Early Childhood Development 2

a warm and responsive therapeutic relationship to provide a corrective attachment

Implications for Policy and Services

Encyclopedia on Early Childhood Development 3

Indices of Infant Disorganization and Disorientation in the Presence of the Parent

1. Sequential display of contradictory behaviour patterns, such as strong attachment

2. Simultaneous display of contradictory behaviour patterns, such as strong avoidance

3. Undirected, misdirected, incomplete and interrupted movements and expressions;

4. Stereotypes, asymmetrical movements, mistimed movements and anomalous postures;

5. Freezing, stilling or “slow-motion” movements and expressions;

6. Direct indices of apprehension regarding the parent;

7. Direct indices of disorganization or disorientation in the presence of the parent, such as

Note: See Main & Solomon3 for complete descriptions.

1. Spangler G, Grossmann K. Individual and physiological correlates of attachment

Encyclopedia on Early Childhood Development 4

5. Lyons-Ruth K, Jacobvitz D. Attachment disorganization: Genetic factors,

Encyclopedia on Early Childhood Development 5

Encyclopedia on Early Childhood Development 6

To cite this document:

Hennighausen K, Lyons-Ruth K. Disorganization of attachment strategies in infancy and childhood. Rev

Encyclopedia on Early Childhood Development 7

Explaining individual differences in attachment

Encyclopedia on Early Childhood Development 1

Key Research Questions

Recent Research Results

the quality of attachment in twin pairs with an adapted separation-reunion procedure

Is sensitive parenting the core ingredient of the shared environment? Twenty-one

Implications for Social Policy

Encyclopedia on Early Childhood Development 3

Encyclopedia on Early Childhood Development 4

To cite this document:

Encyclopedia on Early Childhood Development 5

Encyclopedia on Early Childhood Development 1

Research and Conclusions

Neither author comments at length on research on the developmental consequences of