Maternal Attachment Impedes Effectiveness of Interventions for Teen Mothers

A R T I C L E

MATERNAL UNRESOLVED ATTACHMENT STATUS
IMPEDES THE EFFECTIVENESS OF INTERVENTIONS
WITH ADOLESCENT MOTHERS

GREG MORAN, DAVID R. PEDERSON, AND ANNE KRUPKA
The University of Western Ontario

ABSTRACT: Children of adolescent mothers are at risk for a variety of developmental difficulties. In the
present study, the effectiveness of a brief intervention program designed to support adolescent mothers’
sensitivity to their infants’ attachment signals was evaluated. Participants were adolescent mothers and
their infants who were observed at 6, 12, and 24 months of age. The intervention conducted by clinically
trained home visitors consisted of eight home visits between 6 and 12 months in which mothers were
provided feedback during the replay of videotaped play interactions. At 12 months, 57% of the mother–
infant dyads in the intervention group and 38% of the comparison group dyads were classified as secure
in the Strange Situation. Seventy-six percent of the mothers in the intervention group maintained sensi-
tivity from 6 to 24 months compared with 54% of the comparison mothers. Further analyses indicated
that the intervention was effective primarily for mothers who were not classified as Unresolved on the
Adult Attachment Interview.

RESUMEN: Los ninos de madres adolescentes se encuentran bajo riesgo debido a una variedad de difi-
˜
cultades de desarrollo. En el presente estudio, se evaluo la efectividad de un breve programa de inter-
´
vencion disenado para apoyar la sensibilidad de las madres adolescentes hacia las senales de afectividad
´ ˜ ˜
de los infantes. Participaron madres adolescentes y sus infantes, a quienes se les observo a los 6, 12 y
´
24 meses de edad de estos. La intervencion, llevada a cabo for individuops clınicamente entrenados para
´ ´ ´
hacer visitas a casa, consistio en ocho visitas entre 6 y 12 meses, en las cuales se les proveyo a las madres
´ ´
importante informacion durante la presentacion de un vıdeo previamente realizado sobre las interacciones
´ ´ ´
de juego. A los 12 meses, 57% de las dıadas de madres e infantes que participaban en el grupo de
´
intervencion, y 38% de las dıadas del grupo comparativo fueron clasificadas com “seguras,” dentro de
´ ´
las clasificaciones de la Situacion Extrana. Setenta y seis por ciento de las madres en el grupo de inter-
´ ˜
vencion mantuvo la sensibilidad de los 6 a los 24 meses, comparadas con el 54% de las madres del grupo
´
de comparacion. Analisis posteriores indicaron que la intervencion fue efectiva principalmente para las
´ ´ ´
madres que no estaban clasificadas como “No-dispuestas” en la escala de la Entrevista de la Afectividad
en Adultos.

This research was supported by research grants from the Social Sciences and Humanities Research Council and Health
Canada. The authors gratefully acknowledge the mothers and infants who contributed their time and energy to partic-
ipate in their study. They would also like to thank Deanne Pederson for her work as a home visitor and Sandi Bento
for Strange Situation and Adult Attachment Interview coding. Direct correspondence to: Greg Moran, Office of the
Provost and Vice-President (Academic), University of Western Ontario, London, Ontario, N6A 5B8, Canada; e-mail:
gmoran2@uwo.ca.

INFANT MENTAL HEALTH JOURNAL, Vol. 26(3), 231– 249 (2005)
2005 Michigan Association for Infant Mental Health
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/imhj.20045

231

232 ● G. Moran et al.

´ ´
RESUME: Les enfants de meres adolescentes sont a risque pour une quantite de difficultes en matiere de
` ` ´ ´ `
developpement. Dans cette etude, l’efficacite d’un bref programme d’intervention concu pour soutenir la
´ ´ ´ ¸
sensibilite des meres adolescentes aux signaux d’attachement de leurs bebes a ete evaluee. Les participants
´ ` ´ ´ ´´´ ´
etaient des meres adolescentes et leurs bebes, qui ont ete observes a l’age de 6, 12 et 24 mois.
´ ` ´ ´ ´´ ´ ` ˆ
L’intervention a ete faite par des visiteurs a domicile formes cliniquement et a consiste en huit visites a
´´ ` ´ ´ `
domicile entre l’age de 6 et 12 mois, durant lesquelles s’est esquisse un dialogue durant le visionage
ˆ ´
` ´ ` ˆ
d’interactions de jeu prises a la video. A l’age de 12 mois, 57% des dyades mere-bebe du groupe
` ´ ´
d’intervention et 38% des dyades du groupe de comparaison ont ete classees comme etant secures dans
´´ ´ ´ ´
la Situation Etrange. Soixante-dix pourcent des meres du groupe d’intervention ont maintenu leur sen-
`
sibilite de l’age de 6 mois a 24 mois, compare a 54% des meres de comparaison. Des analyses supple-
´ ˆ ` ´ ` ` ´
mentaires indiquent que l’intervention a ete efficace avant tout pour les meres qui n’etaient pas classees
´´ ` ´ ´
comme etant Irresolues a l’Entrevue d’Attachement Adulte.
´ ´ `

ZUSAMMENFASSUNG: Kinder jugendlicher Mutter tragen ein erhohtes Risiko fur eine Vielzahl an Entwick-
¨ ¨ ¨
lungsproblemen. In dieser Studie wurde die Effektivitat einer Kurzintervention evaluiert, die darauf aus-
¨
gerichtet war, die Feinfuhligkeit der Mutter gegenuber den Signalen des Kindes zu erhohen. Die Teil-
¨ ¨ ¨ ¨
nehmerinnen waren jugendliche Mutter und deren Kinder, die mit 6, 12 und 24 Monaten beobachtet
¨
wurden. Die Intervention, die von einem in der Klinik ausgebildeten Hausbesucher gemacht wurde,
bestand aus acht Hausbesuchen zwischen dem 6. und dem 12. Monat bei denen den Muttern Ruckmel-
¨ ¨
dungen zu ihrem Verhalten an Hand von Spielszenen, die mit Video aufgezeichnet worden waren, gegeben
wurden. Im Alter von 12 Monaten wurden 57% der Interventionsgruppe und 38% der Kontrollgruppe als
sicher gebunden Mittels des Tests: Fremde Situation klassifiziert. 66% der Mutter in der Interventions-
¨
gruppe blieben feinfuhlig zwischen dem 6. und dem 24. Monat im Unterschied zu 54% der Kontroll-
¨
gruppenmutter. Weiter Analysen zeigten, dass die Intervention vor allem fur jene Mutter effektiv war,
¨ ¨ ¨
die nicht als ungelost mittels des Erwachsenen – Bindungsinterviews klassifiziert worden waren.
¨

* * *
In industrialized western societies, pregnancy and motherhood during adolescence place
both the mother and child at risk for a range of negative psychosocial outcomes. Furstenberg
and colleagues (Furstenberg, Brooks-Gunn, & Chase-Lansdale, 1989; Furstenberg, Brooks-
Gunn, & Morgan, 1987) have shown that the social and economic futures of these young
women are substantially compromised. Even prior to the pregnancy, teenage mothers often
come from a background of poverty, have had conflicts with the law, have dropped out of
school, rely on public financial assistance, and display other types of social maladjustment

Teen Mother Attachment and Intervention Stress ● 233

(Furstenberg et al., 1989; Lamb, 1988). This pattern of social, educational, and economic
maladjustment may well be the precursor of developmental difficulties in the children of these
mothers. Support for an intergenerational pattern of transmission comes from findings that
children of adolescent mothers, relative to those born to older mothers, display markedly lower
levels of academic achievement and perform less well on assessments of cognitive ability
(Coley & Chase-Lansdale, 1998; Corcoran, 1998; Hoforth, 1987). By adolescence, these chil-
dren show a range of maladaptive outcomes, including academic failure, early pregnancy, and
a variety of antisocial behavior (Brooks-Gunn & Furstenberg, 1986; Fergusson & Woodward,
1999; Furstenberg et al., 1987; Grogger, 1997; Hardy et al., 1997).
Jaffee, Caspi, Moffitt, Belsky, and Silva (2001) proposed that the developmental difficul-
ties shown by children of adolescent mothers could arise from at least two sources. First,
adverse outcomes could be a product of the direct social, economic, and familial consequences
of early childbearing. They called this source “social influence.” Here, the consequences of
adolescent parenthood contribute to a maladaptive developmental environment, increasing the
likelihood of poor outcomes for the children. Second, adverse outcomes could be a product of
preexisting maladaptive characteristics of the mother. For example, the same social – emotional
difficulties that might have led to a mother’s early pregnancy could predispose her to poor
parenting. They called this source “social selection.” Using this model as a framework, Jaffe
et al. (2001) analyzed data from a New Zealand cohort born during two months of 1972. They
found that the children of adolescent mothers were two to three times more likely to experience
adverse academic and employment outcomes in adulthood, to commit violent offences, and to
become adolescent parents themselves. Jaffee et al. also found compelling evidence that neg-
ative outcomes for the children of adolescent mothers were associated with both the social
influence and social selection mechanisms of transmission. Family circumstances (social influ-
ence) and maternal characteristics (social selection) together accounted for 39% of the variance
in outcome, with family circumstances and maternal characteristics independently accounting
for 18% and 21% of the variance, respectively.
The Jaffe et al. (2001) conclusion that the personal characteristics of adolescent mothers
contribute to adverse outcomes for their children, even when the negative social consequences
of early childbirth are taken into account, takes on special importance in light of the fact that
adolescent mothers are more likely than their peers to have experienced maladaptive parenting
in their own childhood, including physical and sexual abuse (Osofsky, 1990; Osofsky, Osofsky,
& Diamond, 1988). Gershenson, Musick, Ruch-Ross, and Magee (1989), for example, found
that 61% of a large sample of adolescent mothers had suffered coercive sexual experiences; in
almost one-third of the cases, the perpetrator was a family member. Such findings emphasize
the need for new approaches to supporting adolescent mothers that address those aspects of
the mother’s behavior that are likely to contribute to adverse developmental outcomes for her
child. Based on attachment theory, a good starting point would be the style and quality of her
interactions with her infant.
Adolescent mothers have been shown to be less responsive to their infants’ signals, to
use more intrusive and physical interventions, and to provide less verbal stimulation than
have adult mothers (Culp, Culp, Osofsky, & Osofsky, 1991; Culp, Osofsky & O’Brien, 1996;
Garcia Coll, Hoffman, & Van Houten, 1987; Garcia Coll, Vohr, Hoffman, & Oh, 1986).
They also attempt to promote independence in their infants prematurely (Osofsky, 1990).
Not surprisingly, given such patterns of interaction, infants of adolescent mothers are less
likely to form Secure attachment relationships than are infants of older mothers. In their
meta-analytic review, Van IJzendoorn, Schuengel, and Bakermans-Kranenburg (1999) re-
ported that only 40% of the infants in adolescent-mother samples compared to 62% in adult
middle-class samples had Secure attachment relationships. Furthermore, infants of adolescent


mothers displayed more Avoidant (33% versus 15%) and Disorganized (23% versus 15%)
attachment relationships.
To summarize, the existing literature suggests that both the personal social and emotional
histories of adolescent mothers and the quality of their interactions with their infants puts the
infants at increased risk of developing non-Secure attachment relationships. Moreover, the
developmental difficulties displayed by children of adolescent mothers are consistent with those
associated with non-Secure attachment relationships in general (see Greenberg, 1999, for a
review). It seems reasonable, then, that intervention efforts with this population focus on fa-
cilitating patterns of mother – infant interaction that are likely to increase the probability of a
Secure infant – mother attachment relationship.

ATTACHMENT-BASED INTERVENTION PROGRAMS
All attachment-based early intervention programs are guided by the central claim of attach-
ment theory that the quality of the attachment relationship is in large part determined by the
responsiveness and sensitivity of the mother’s interactions with her infant (Ainsworth, Blehar,
Waters, & Wall, 1978). Although it has proven more difficult to establish a robust empirical
association between sensitive maternal interaction and Secure attachment than anticipated
from the theory [see meta-analyses by Atkinson et al. (2000) and DeWolff amd van IJzen-
doorn (1997)], individual studies employing well-established assessments in extended home
observations have confirmed a strong association between the two factors (Pederson, Gleason,
Moran, & Bento, 1998; Pederson & Moran, 1996). Attachment theory also holds that the
mother’s ability to interact effectively with her infant is a function of her own cognitive
representations of attachment and intimate relationships (Main, Kaplan, & Cassidy, 1985).
It can be argued then that any attempts to modify a mother’s interactive behavior might be
limited by the nature of her own representational status, and that intervention, at least for
some mothers, might need to focus on the cognitive intrapsychic level, as well as on the
behavioral – interactive.
In their meta-analysis of interventions aimed at promoting Secure attachment relationships,
Van IJzendoorn, Juffer, and Duyvesteyn (1995) compared the effectiveness of behavioral and
representational approaches and found that longer-term interventions aimed at modifying the
mother’s representational structures were less effective than shorter-term interventions that
focused directly on enhancing the quality of the mother’s interaction with her infant. The results
of interventions were significant, but highly variable: the combined effect size on maternal
sensitivity was d 0.58, with effect sizes for individual studies ranging from a high of 2.62
to a low of 0.0; effect sizes measuring the impact of the intervention on the security of the
attachment relationship were much smaller (combined effect size, d .0.17), again with con-
siderable variability across studies, d 0.42 to 0.65. In fact, three studies showed a neg-
ative impact of intervention on attachment security, all three involving longer-term, represen-
tational approaches. Even within those studies evaluating shorter-term behavioral approaches,
the effects were highly variable and the actual interventions were very diverse, showing little
or no commonality across studies. A more recent meta-analytic review (Bakermans-Kranen-
burg, Van IJzendoorn, & Juffer, 2003) largely replicated the earlier review, confirming that
interventions with a clear behavioral focus were the most effective, but added the unexpected
conclusion that behavioral intervention programs using only a moderate number of sessions
were more effective than were more extensive programs. Although both these reviews provide
encouragement that successful intervention is possible, understanding the actual mechanisms
of success remains a challenge.
A comprehensive study involving the behavioral approach was carried out in the Nether-


lands by van den Boom (1994). The effect sizes for intervention in this study were dramatically
higher than were those of any other study reported in both meta-analyses. Van den Boom
worked with 100 low-income adult mothers and their highly irritable infants. One-half of the
mothers received a brief intervention involving three home visits when the infants were between
6 and 9 months of age. The intervention aimed at increasing the mother’s attentiveness to her
infant’s signals and at improving her responsiveness in interactions, initially by imitation of
the infant’s signals. The results were striking. When infants were 9 months of age, mothers in
the intervention group were significantly more stimulating, responsive, attentive, and control-
ling in interactions with their infants than were mothers in the control group. Infants in the
intervention group were more sociable, better able to self-soothe, and showed more functional
play than were their counterparts in the control group. In the Strange Situation when infants
were 12 months, 78% of the intervention group dyads were in Secure attachment relationships
compared to only 38% of those in the control group. In a follow-up study, van den Boom
(1995) found that the effects of the intervention on maternal interactions and on the attachment
relationships were sustained in observations carried out when the infants were 18, 24, and 42
months of age.
The van den Boom studies provide compelling evidence that a brief interaction-focused
intervention in the first year of an infant’s life can effectively change maternal interactive
behavior and facilitate the development of a secure infant – mother attachment relationship.
Although these findings hold promise for work with adolescent mothers, the adult mothers in
the Dutch sample were very different from most adolescent mothers in North America: Almost
100% lived in a nuclear family and their average age was 25 years. In addition, their children
appear to be different from children of adolescent mothers. Only 10% of the dyads in the Dutch
sample had Disorganized attachment relationships, a finding consistent with the conclusion that
most of the children were not at high risk for serious developmental difficulties. Within our
research group, Krupka (1995) conducted two studies of young, socio-economically disadvan-
taged mothers for her doctoral thesis. In the first study, developmental changes in the patterns
of interaction between the young mothers and their infants were examined. Significant de-
creases were found in maternal sensitivity over the first year, as well as increases in parenting
stress and depression. In Strange Situation assessments, 39% of the dyads were classified as
Avoidant and only 37% were classified as securely attached in contrast with the 66% typically
reported in samples of middle-class older mothers. Based on her review of studies of mother –
infant psychotherapy and early intervention programs, Krupka developed a home-based inter-
vention program designed to attenuate the decline in maternal sensitivity that had been ob-
served. In the second study, 23 mothers were randomly assigned to an Intervention group and
23 to a Comparison group. Mothers and infants in the Intervention group received 12 to 16
home visits when the infants were between 6 and 13 months of age. The intervention included
a discussion of the mother’s current life experiences, especially around parenting, videotaping
the mother and infant at play, and reviewing the tape with the mother. The home visitor affirmed
the mother’s parenting skills and encouraged her to reflect on her infant’s thoughts and feelings
and to note her own strengths. Mothers and infants in the Comparison group were visited once
at 9 months to videotape mother – infant interactions. Maternal sensitivity was assessed in home
visits (by independent observers) at 6 and 13 months. The sensitivity scores were comparable
for both groups at 6 months. At 13 months, mothers in the Comparison group demonstrated
the drop in sensitivity seen in the first study. In contrast, mothers in the Intervention group
increased in sensitivity, although levels remained lower than those reported for older mothers
in middle-class samples. Correspondingly, 68% of dyads in the Intervention group were clas-
sified as secure in the Strange Situation assessment of attachment, whereas only 35% of the
dyads in the Comparison group were secure. The purpose of the present study was to extend


Krupka’s (1995) intervention study using a larger sample and including assessments of the
mother’s attachment representational system.

METHOD

Participants
Participants in the present study were adolescent mothers and their infants recruited into a
longitudinal intervention study conducted by the Child Development Centre at the University
of Western Ontario. Mothers who met the following criteria were initially approached during
their postpartum stay in a London, Ontario hospital: less than 20 years of age, uneventful
delivery, and infants born at full term with no medical complications. Those who lived in
London and had expressed an interest in participating in the study were contacted again when
the infant was 5 months of age. Initial assessment visits were conducted when the infants were
approximately 6 months of age. By the end of the recruitment process, 100 dyads were involved
in the study and, of these, 99 dyads (50 girls and 49 boys) completed the assessments at 12
months and 90 dyads (46 girls, 43 boys) remained in the study through the 24-month assess-
ments.
Demographic information was obtained during the ﬁrst home visit. Approximately 81%
of the sample were Caucasian; the remaining mothers were of Native American (n 5),
Middle Eastern (n 5), Latin American (n 4), Caribbean (n 1), and Asian (n 1)
ethnic backgrounds. Fifty-seven percent were single/never married, 28% were living common
law, and 15% were married. Mean age at the time of the infant’s birth was 18.42 (SD
1.01), with a range from 15.97 to 19.98 years. Annual personal and family incomes were
recorded on a scale from 1 to 8, with 1 as “less than $5,000” and 8 as “more than $60,000”
(Canadian dollars). The average personal income corresponded to approximately 2 — “be-
tween $5,000 and $9,999.” Average household income was only slightly higher, correspond-
ing to approximately 3 — “between $10,000 and $19,999.” The majority of the sample (80%)
reported being unemployed or a full-time student. According to Statistics Canada, the low-
income cutoff for a two-person family living in a city the size of London per year was $18,367
(Paquet, 2001).

Overview of the Procedure
Researchers trained in home observations assessed each mother – infant dyad in their home
when the infants were 6, 12, and 24 months of age. The Adult Attachment Interview (AAI,
George, Kaplan, & Main, 1985) was also administered at 6 months of age. After the 6-month
baseline visit, mothers were randomly assigned to an Intervention or Comparison group. Dyads
in the Intervention group received eight home visits between 7 and 12 months; dyads in the
Comparison group received one visit at 9 months. When the infant was approximately 12
months of age, each dyad took part in the Strange Situation procedure.

The Intervention Program
Rationale. The intervention program was based on the assumption that the development of a
secure attachment relationship is a major developmental task in the last half of the infant’s ﬁrst
year of life. The goal of intervening was to support the mother’s sensitivity to her infant. We


focused on maternal sensitivity for three reasons. First, sensitivity is theoretically (Ainsworth,
Bell, & Stayton, 1971; Ainsworth, et al., 1978; Bowlby, 1969) and empirically (DeWolff &
van IJzendoorn, 1997; Pederson & Moran, 1996; van den Boom, 1994) the primary experiential
determinant of attachment security. Second, Krupka (1995) observed a decline in sensitivity
over the first year in young mothers. This decline was particularly noticeable in the latter half
of the infant’s first year. Finally, the observation and assessment of maternal sensitivity has
been the focus of our research group over the past decade (Moran, Pederson, Pettit, & Krupka,
1992; Moran, Pederson, & Tarabulsy, 1996; Pederson & Moran, 1995, 1996; Pederson et al.,
1990). It seemed prudent to target behaviors that we had worked hard to understand.
Although inviting mothers to participate in center-based parenting groups may have af-
forded several practical advantages, given the characteristics of adolescent mothers, we decided
to use a home-visiting program. In our experience, adolescent mothers are wary of institutions,
perhaps because of their perception that service providers in hospitals, schools, and government
social-support agencies judge them negatively. Transportation and other logistic problems also
provide practical impediments for mothers on limited income. For these and other reasons,
adolescent mothers are seldom enthusiastic participants in center-based parenting programs.
Home visits are labor intensive and initially costly, but the low attrition rate in our intervention
group (1 out of 50 mothers) indicates that adolescent mothers may be more willing to participate
in such programs, resulting in future benefits for the children, the mothers, and society in
general.
The word “intervention” was not used to describe our study as it may have had a negative
impact on our adolescent mothers. Instead, participants were told that we were interested in
seeing how young mothers and babies played together and in trying new ways of playing that
would be fun for both mother and baby, with the ultimate goal of developing support programs
for adolescent parents. The visits were designed to provide experiences of mutually beneficial
play interactions and to support the mother’s enjoyment of her infant. Four general goals served
as guides to the home visitors. The first goal was to affirm parenting strengths already present
in the mother. A second goal was to increase the mother’s awareness of how her behavior
influenced her infant’s behavior. The visitors also looked for ways to augment the mother’s
awareness of her infant’s signals and for ways to establish positive experiences for both the
mother and the infant.

Intervention procedures. Home visits lasted approximately one hour and were carried out by
two mature women who had raised their own families and who were knowledgeable about
infant development and attachment theory and research. One visitor had a PhD in child clinical
psychology and the second visitor was an early childhood educator with over 10 years’ ex-
perience in working with children and families in preschool settings. The first four families
were seen by both visitors to be sure that similar approaches were used in conducting the visits.
The visitors also met biweekly to review their cases as a check on the uniformity of the
intervention procedures.
In the initial part of each visit, the home visitor focused on building rapport with the
mother because a trusting relationship plays an important role in any support system. The
mother and infant were videotaped for about five minutes while playing with age-appropriate
toys and the tape was played back for the mother to observe and discuss. During the review,
the home visitor commented on maternal behavior that the infant appeared to enjoy and asked
for the mother’s interpretation of her infant’s behavior. The discussion focused on identifying
positive features of the interactions and on providing the mother with opportunities to ponder
her infant’s motivational states. For example, if the mother’s intrusiveness stimulated the infant


to turn away, the visitor might note that the infant seemed to be looking away and ask the
mother for her interpretation of what the infant might have been thinking or feeling at that
time.
A seven-level hierarchy of interaction, adapted by Krupka (1995) from Clark and Seifer
(1983), served as a framework for the home visitors. At the low levels of this hierarchy (least-
sensitive interactional behavior), mothers were under-involved or intrusive. Maternal behavior
at the middle levels consisted of monitoring and acknowledging infant behavior. Maternal
imitation and elaboration of infant-initiated play constituted the top levels of the hierarchy
(most-sensitive interactional behavior). Home visitors used descriptions of these ordered levels
in planning the goals for a particular home visit and as a framework for providing feedback to
the mother. The goal of the eight home visits was to facilitate the mother’s progression along
this hierarchy. Funding constraints limited the number of intervention visits in the present study
to eight in contrast with the 12 to 16 intervention visits in the Krupka (1995) study. The first
three visits were carried out within one week of each other in order to establish rapport with
the mothers. The subsequent five visits were spaced about three to four weeks apart. Each
visitor made two or three visits per week and had a caseload of six or seven families at any
one time. Completing the eight home visits was time consuming and often challenging. Phone
calls were always made within 24 hours of a scheduled visit to confirm that the time did not
conflict with the baby’s current naptime. Despite this reconfirmation, some mothers would not
be at home when the visitor arrived, necessitating a rescheduling of about 20% of the visits.
Explanations, when offered, were typical of adolescents — for example, a friend had come by
unexpectedly and they had gone to the mall. It took about two years to complete the Intervention
program for the 49 mothers. Mothers in the Comparison group received one home visit when
their infants were 9 months old. They were interviewed about their current relationships and a
videotape was made of infant – mother play, feeding, and other activities of the mother’s choice.

Measures
Strange Situation procedure. At 12 months of age, the infant – mother dyads visited the uni-
versity and participated in Ainsworth’s Strange Situation procedure (Ainsworth et al., 1978).
This laboratory procedure, consisting of a succession of separation and reunion episodes be-
tween the mother and her infant, was designed to heighten infant attachment behavior. The
infant’s behavior at reunion with the mother is of particular interest. Infant – mother relation-
ships were assigned to one of four attachment relationship classifications — Secure, Avoidant,
Resistant, and Disorganized/Disoriented — based on the infant’s behavior during the Strange
Situation (Ainsworth et al., 1978; Main & Solomon, 1990). Secure infants responded to the
mother’s return in the reunion episodes by showing a desire for proximity or contact or a wish
for interaction. These infants were effective in obtaining comfort from the mother and were
then able to resume exploration of the environment. Avoidant infants showed little or no desire
for proximity, contact, or interaction with their mothers. In fact, they tended to ignore or avoid
their mothers during the reunion episodes. Resistant infants typically fussed during separations
and had difficulty resuming play during reunions. They displayed angry behaviors that appeared
to interfere with receiving comfort from their mothers and thus failed to use their mothers as
a source of security in order to resume exploration. Disorganized/Disoriented infants exhibited
inexplicable and/or odd behaviors in the presence of their caregivers in the Strange Situation.
They did not appear to have an organized strategy for coping with the stress of the situation.
These behaviors included sequences of strong attachment behavior followed by strong avoid-
ance in reunion, lengthy bouts of freezing or stilling, or signs of fear of the mother such as
crouching on approach. Infants classified as Disorganized were also assigned to the best-fitting


Secure, Avoidant, or Resistant classification. The Strange Situations were coded by individuals
who had passed the Sroufe and Carlson reliability test for Secure, Avoidant, Resistant, and
Disorganized classifications. For reliability purposes, 25 Strange Situations were independently
coded with 88% reliability for the four classifications ( 0.78, p 0.001).

Adult Attachment Interview. The Adult Attachment Interview (AAI) (George et al., 1985) was
conducted with the mothers when infants were 6 months of age. The AAI includes questions
addressing the mother’s experiences with attachment figures; early childhood and perceptions
of her parents at that time; experiences of early emotional and physical upsets; physical and
sexual abuse; and deaths of loved ones. Mothers also were asked to reflect on how these past
experiences may have affected their present personalities. In accordance with the AAI coding
system (Main & Goldwyn, 1998), each transcript was classified for state of mind with respect
to attachment. Autonomous individuals responded to questions about their childhood in a con-
sistent, relevant, and coherent manner. Dismissing adults often idealized their childhood ex-
periences, had difficulty providing explicit examples to support their overall positive charac-
terizations of childhood relationships, and sometimes appeared oblivious to clear contradictions
in their stories. Preoccupied adults, on the other hand, typically expressed confusion, passivity,
anger, and distress when speaking about their attachment figures; interviews often were inco-
herent and difficult to follow. Unresolved/disoriented (U/d) individuals exhibited lapses in
monitoring of reasoning or discourse during discussions of abuse or loss. Thirty-five interviews
were classified independently by coders who had passed the Main and Hesse reliability test
procedures with 86% agreement ( 0.782, p 0.001). Differences were resolved by con-
ferencing.

Maternal Behavior Q-Sort. Dyads were observed in their homes when infants were 6, 12, and
24 months of age. Following each two-hour semi-structured home visit, trained observers
completed the Maternal Behavior Q-sort (MBQS, 3rd edition; Pederson, Moran, & Bento,
1998). The MBQS consists of 90 behavioral items that correspond to different aspects of the
mother’s interactive behavior. Observers progressively sort these cards into nine equal piles
from 1 (most unlike the mother’s behavior) to 9 (most like the mother’s behavior). The mother’s
sensitivity score is the correlation between the Q-sort description of her behavior and a de-
scription of a prototype of a sensitive mother. Inter-observer correlations of the Q-sort sensi-
tivity scores were 0.89 at 6 months (n 70), 0.91 at 12 months (n 78), and 0.87 at 24
months (n 26).

RESULTS

Intervention and the Quality of the Attachment Relationship
Fifty-seven (58%) of the 99 dyads were classified as Disorganized in the Strange Situation at
12 months, reflecting the high-risk nature of this sample. Twenty-eight (54%) of the infants in
the Intervention group and 29 (58%) in the Comparison group were classified as Disorganized.
The intervention procedure was designed to promote sensitivity, a behavior that is theoretically
unrelated to Disorganization; therefore, the similar rates of Disorganization in the two groups
had been anticipated. Subsequent analyses of the quality of the attachment relationship used
the original Ainsworth Secure, Avoidant, and Resistant classifications using the best fitting of
these classifications for the Disorganized infants.
Using these three categories, mothers participating in the intervention program were more


likely than mothers in the Comparison group to be in Secure attachment relationships with
their infants at 12 months. Twenty-eight of the 49 dyads in the Intervention group were Secure
(57%), 9 were Avoidant, and 12 were Resistant. In contrast, 19 of the 50 (38%) dyads in the
Comparison group were Secure, 21 (42%) were Avoidant, and 10 (20%) were Resistant. Al-
though 2 analysis showed this difference in attachment security to be significant [ 2(2)
6.70, p 0.05, a medium effect size, w 0.25 (see Cohen, 1987)], the overall effect was
modest. None of the individual cell residuals achieved significance, nor did a 2 analysis using
a simple Secure/non-Secure comparison rather than the three-way classification [ 2 (1) 3.64,
p 0.06, ns].

Intervention and the Quality of Mother–Infant Interaction
Maternal sensitivity scores, assessed with the Maternal Behavior Q-set in observations in the
home at 6, 12, and 24 months, fell for mothers in the Comparison group from 0.38 to 0.12
between 6 and 12 months; at 24 months, sensitivity in this group had recovered somewhat to
an average value of 0.24. Changes in the maternal sensitivity of mothers involved in the
intervention followed a different pattern. Mothers in the Intervention group displayed similar
levels of maternal sensitivity to those in the Comparison group at 6 months (0.34), dropped
less in sensitivity at 12 months (0.20), and recovered to a substantially higher level at the
follow-up observations at 24 months (0.49). A repeated-measures analysis of variance (AN-
OVA) revealed a significant Age by Group interaction (F(2,87) 3.12, p 0.05); however,
none of the t-tests comparing the Intervention and Comparison group means at each age were
significant.
A goal of the intervention program was to ameliorate the decline in sensitivity observed
by Krupka (1995); therefore, a second analysis was performed using a categorical assessment
of change in sensitivity. Two groups were formed based on a rational distinction between the
pattern of changes in sensitivity scores between 6 and 24 months. Fifty-nine mothers (66%)
were included in a Positive Outcome Group, consisting of those who increased or maintained
sensitive levels of interaction. This group included 48 mothers for whom sensitivity scores
increased and whose 24-month sensitivity score was at least 0, plus 11 additional mothers who
displayed some decrease in sensitivity, but retained a 24-month sensitivity score of greater than
0.40. Thirty-one mothers (34%) were placed in the Negative Outcome Group, consisting of
those who decreased sensitivity or maintained low sensitivity. This group was composed of 27
mothers who declined in sensitivity to a 24-month sensitivity of less than 0.4, plus four mothers
whose sensitivity increased somewhat, but remained below 0 at 24 months. A significantly
greater number of mothers in the Intervention group (76%) was found to be in the Positive
Outcome Group than mothers in the Comparison group (54%) [ 2(1) 4.62, p 0.05,
w 0.21].
The results of the above analyses indicate that the brief intervention had a positive impact
on the quality of mother – infant interactions. However, examining the data in terms of Positive
and Negative Outcome groups, it became apparent that approximately one-quarter of the moth-
ers participating in the intervention did not appear to benefit; therefore, further analyses were
carried out to identify factors that might account for the variation in the effectiveness of the
intervention across individuals. Based on attachment theory and on our understanding of the
characteristics of adolescent mothers, two factors were examined more closely: the mother’s
state of mind with regard to attachment and the mother’s experience of trauma, as determined
by her responses in the Adult Attachment Interview (AAI) when the baby was 6 months old.


FIGURE 1. Maternal sensitivity related to intervention and unresolved adult attachment interview clas-
sification.

The moderating effect of Unresolved/disoriented state of mind on the effectiveness of interven-
tion. Thirty-seven mothers (37%) were classified as Unresolved/disoriented [18 (or 37%) in
the Intervention and 19 (or 38%) in the Comparison Group]. To examine the effectiveness of
the intervention in relation to Unresolved/disoriented state of mind on the AAI, 2 analyses
were performed on the frequencies of Secure attachment in dyads in which the mothers were
or were not classified as Unresolved/disoriented. For dyads in which the mother was Unre-
solved/disoriented, six of the 18 dyads in the Intervention group and six of the 19 dyads in the
Comparison group were classified as Secure (33% and 32%, respectively, 2 (1) 0.01, ns) in
the Strange Situation at 12 months. For the mothers who were not classified as Unresolved/
disoriented, 22 of the 31 dyads in the Intervention group and 13 of the 31 dyads in the Com-
parison group were classified as Secure (71% and 42%, respectively, 2 (1) 5.31, p 0.05,
w 0.23). These data indicate that the intervention was effective in promoting a Secure infant –
mother attachment relationship only when the mother was not classified as Unresolved/diso-
riented on the AAI.
A second set of analyses suggested that the differential effectiveness of the intervention
on the quality of the attachment relationship could be traced to the impact of the intervention
on the sensitivity of the mothers. Maternal sensitivity scores for Intervention and Comparison
groups are presented in Figure 1. Between 6 and 12 months, the period of the intervention,
sensitivity dropped for Unresolved/disoriented mothers in both the Intervention and Compar-
ison groups. For mothers who were not-Unresolved/disoriented, there also was a drop in sen-
sitivity for those in the Comparison Group but not for those in the Intervention group. Between
12 and 24 months, the sensitivity of mothers in the Intervention group who were not-Unre-
solved/disoriented increased markedly to over 0.60. Although the sensitivity of mothers who
were Unresolved/disoriented and involved in intervention also increased, scores remained be-
low the levels displayed at 6 months and were considerably less than those of the not Unre-
solved mothers in the same group. Mothers who were Unresolved/disoriented and in the Com-
parison group displayed the lowest average level of sensitivity at 12 and 24 months. A repeated
measures ANOVA of maternal sensitivity at infant ages 6, 12, and 24 months, with Intervention


and Unresolved/disoriented status as between-subject factors, revealed a main effect for infant
age [F(2,85) 6.74, p 0.01] and an effect for Unresolved/disoriented status [F(1,86)
7.12, p 0.01], but no significant interaction between the impact of intervention and the
mother’s state of mind regarding attachment [F(2,85) 2.42, p 0.095].
This general pattern of results, however, received statistical substantiation by way of an
alternative analysis using the same metric of change in sensitivity described above. Mothers
participating in the intervention were more likely to be in the Positive Outcome Group (de-
scribed above) only if they were not classified as Unresolved/Disoriented. More specifically,
24 of the 29 mothers in the Intervention Group and 17 of the 30 mothers in the Comparison
Group who were not Unresolved/disoriented were in the Positive Outcome Group (83% and
57%, respectively, 2(1) 4.74, p 0.05, w 0.22). In contrast, for mothers who were
Unresolved/disoriented, the number of mothers in the Positive Outcome Group did not differ
significantly between Intervention (11 of 17 dyads) and Control Groups (7 of 14 dyads (65%
and 50%, respectively, 2(1) 0.68, ns].

The moderating effect of maternal childhood abuse on the effectiveness of intervention. During
the Adult Attachment Interview, 52 mothers reported sexual or physical abuse during childhood
(26 in the Intervention and 26 in the Comparison Group) and 47 did not report abuse. There
were no significant differences in the frequency of security between Intervention and Com-
parison Groups when examined separately for mothers who did or did not report abuse. Sim-
ilarly, a repeated measures ANOVA revealed a main effect for infant age [F(2,83) 5.48,
p 0.01], but only non-significant trends for intervention and childhood abuse and an inter-
action between these two factors. However, mothers participating in the intervention were more
likely to be in the Positive Outcome Group only if they had not reported childhood abuse.
Eighty-six percent of mothers in the Intervention group with no history of abuse were in the
Positive Outcome group, in contrast to 58% of mothers in the Comparison group [ 2(1)
4.09, p 0.05, w 0.30]. For mothers who reported childhood sexual or physical abuse, the
intervention had no significant impact on sensitivity change groups (Intervention 68% and
Comparison Group 50% in the Positive Outcome Group [ 2(1) 1.50, ns]).

DISCUSSION
This study was prompted by a set of inter-related observations and conjectures: the children
of adolescent mothers have been shown to be at risk for later social and emotional problems;
there is some indication that the patterns of dysfunctional interaction between adolescent moth-
ers and their infants may contribute to these developmental difficulties; adolescent mothers are
likely to have had a history of physical and sexual abuse in their own childhoods that may
well underlie their dysfunctional interactions with their infants; and finally, attachment-based
interventions in the first year of life have been shown to enhance mother – infant interactions
and to promote Secure attachment relationships. This study explored the impact of a brief early
intervention on the sensitivity of maternal interactions over the first two years of an infant’s
life and on the quality of the attachment relationship in a group of adolescent mothers and their
infants. Particular attention was paid to the moderating effect on the intervention of a maternal
history of childhood trauma associated with an Unresolved/disoriented state of mind regarding
attachment.
The results confirmed that interaction-focused intervention in the first year of life can
improve the quality of the relationship between adolescent mothers and their infants and that
the improvement in interactions persists into at least the second year of the child’s life. These
results parallel and extend published studies of mothers who were not drawn from a high-risk


population (van den Boom, 1994, 1995; Van IJzendoorn et al., 1995). The study also provides
another example of the success of relatively brief behavior-focused interventions, supple-
menting those reviewed in the meta-analysis by Bakermans-Kranenburg et al. (2003).
A basic tenet of attachment theory is that early mother – infant interaction is the overriding
determinant of the quality of the relationship. Theory and much supporting empirical evidence
indicate that this relationship forms a critical foundation for the future social and emotional
development of the child, and that a failure to develop an organized attachment relationship is
associated with developmental risk. Our intervention was directed at the quality of this early
interaction and it succeeded in enhancing sensitivity in most adolescent mothers, thus making
it more likely that their infants will develop secure attachment relationships. Relatively non-
invasive and low-cost programs similar to the one described in this study can provide effective
support for infants who might otherwise be at risk for serious developmental difficulties that
are likely to be much more resistant to modification later in childhood and adolescence.
Consistent with attachment theory, the increased likelihood of Secure attachment relation-
ships in the Intervention group was associated with a parallel increase in the sensitivity of
observed interactions between the adolescent mother and her infant. Unexpectedly, however,
a statistically significant difference in sensitivity between those mothers who participated in
the intervention program and those who did not was not observed in interactions in the home
until the children were 24 months of age. This finding is inconsistent with the fact that the
positive impact of the intervention was seen in a relatively higher frequency of Secure attach-
ment relationships in the Strange Situation at 12 months. It seems likely that these apparently
puzzling results are a function of a number of inter-related factors, some reflecting the socio-
behavioral processes and others the power of our analyses. As we reported in the introduction,
previous work in our research group (Krupka, 1995) suggested that maternal sensitivity in
adolescent mothers declines substantially between 6 and 12 months of the infants’ age. This
trend would tend to mask any positive impact of intervention, perhaps simply eliminating or
reducing such a decline rather than producing an increase in sensitivity at 12 months. Perhaps
more importantly, as discussed in detail below, the results of this study indicate that some
mothers, those with a history of trauma associated with an Unresolved/disoriented state of mind
regarding attachment, are resistant to the positive effects of intervention, at least for the inter-
vention mode used in this study. Indeed, only a subset of adolescent mothers involved in the
intervention displayed a clear positive impact. Those who were not classified as Unresolved/
disoriented maintained their average level of sensitivity from 6 to 12 months sharply increased
in sensitivity between 12 and 24 months and displayed a substantially higher level of sensitivity
at the end of the study. The fact that this complex but distinct pattern of change in sensitivity
was not revealed in a statistically unambiguous manner in our ANOVA may be more a function
of a loss of power resulting from the division of the sample into relatively small groups than
a reflection of lack of robustness of the intervention effect.
The observed variability in the effectiveness of the intervention raises a number of inter-
esting conceptual issues worthy of investigation in future research. The pattern of changes in
maternal sensitivity in mothers who did not receive intervention in this study was consistent
with that observed in earlier work in our research group. Adolescent mothers displayed a
reasonably positive style of interaction with their infants until about 6 months of age, but in
the absence of support, the average level of sensitivity drops dramatically by the time their
infants are one year of age (Krupka, 1995). For the majority of mothers receiving intervention
in this study, this pattern of decline between 6 and 12 months was not significant and inter-
actions appeared substantially more sensitive at 24 months of age. This overall result was
paralleled by a relatively higher percentage of Secure attachment relationships assessed in the
Strange Situation at 12 months when compared to the Comparison group of mothers and infants.


However, approximately 25% of mothers involved in the intervention failed to show increased
sensitivity in their interactions when their infants were two years of age and their interactions
remained very dissimilar to those of mothers expected to develop and sustain a secure attach-
ment relationship with their child. Additional analyses revealed that these mothers were more
likely to have been classified on the AAI as having an Unresolved/disoriented state of mind
associated with childhood experiences of loss or abuse than those who benefited from the
intervention. For these mothers, a brief behavior-focused program of intervention failed to
prevent the decline in the quality of the interactions that were critical to the formation of a
Secure relationship with their infants. Why might this be so? Within attachment theory, trauma
is seen as a necessary but not sufficient condition for the development of an Unresolved/
disoriented state of mind, a mental representational state that interferes with a coherent approach
to intimate interaction, which is essential for an organized relationship. That is, although the
trauma of loss or abuse often interferes with the development of an organized state of mind
regarding intimate relationships, this maladaptive Unresolved/disoriented representational state
is not seen in those who manage to integrate and resolve these experiences. It is the absence
of an organized representational state rather than the direct effects of loss or trauma that creates
relational and emotional difficulties. Developing this theme, Hesse and Main (Hesse & Main,
1999; Main & Hesse, 1990) and others (Jacobvitz, Hazen, & Riggs, 1997; Lyons-Ruth, Bronf-
man, & Atwood, 1999; Lyons-Ruth & Jacobvitz, 1999; Schuengel, Van IJzendoorn, Baker-
mans-Kranenburg, & Blom, 1999) have argued that trauma, when associated with an Unre-
solved state of mind in the mother, gives rise to fear and anxiety. These states, in turn, are
likely to be associated with behaviors that interfere with effective interactions with the infant.
Such manifestations include fearful and frightening behavior, an inability to repair or correct
interactions that might be distorted by such behavior, and a pervasive disruption of the essential
elements of a framework for adaptive mother – infant interaction. Our finding that a maternal
Unresolved/disoriented state of mind was associated with the persistence of insensitive inter-
action between mothers and infants is consistent with this model. The finding that the Unre-
solved/disoriented status was also associated with a failure to benefit from Intervention supports
the conclusion that the absence of an organized state of mind regarding attachment is a sub-
stantial threat to the mother – infant relationship.
A related emerging body of theory and research provides some clues to the pervasive and
persistent impact of maternal Unresolved/disoriented attachment status on early interaction.
Lyons-Ruth and Block (1996) have pointed to the possibility that the inability of these mothers
to integrate their own childhood trauma within an organized state of mind regarding attachment
is likely to be manifest by symptoms of Post Traumatic Stress Disorder (PTSD). They proposed
a link between the established psycho-emotional characteristics of PTSD and the maladaptive
interactions of Unresolved/disoriented mothers and their infants. DeOlivera, Bailey, Moran
and Pederson (2004) have elaborated on this suggestion, outlining a model in which the
symptoms associated with chronic childhood trauma are reflected in particular deficits in those
key aspects of early mother – infant interaction that support the normal development of affect
regulation. They argue that the acquisition of organized patterns of affect regulation, a process
that is dependent on these early interactions, is critical for the establishment of an organized
attachment relationship. Their model, then, posits a complex developmental chain across gen-
erations: childhood trauma leading to an Unresolved/disoriented state of mind in the mother,
the established psycho-emotional symptoms of PTSD, interference with early mother – infant
interactions that are particularly critical to the development of effective affect-regulation strat-
egies in the infant, and, ultimately, the development of a Disorganized attachment relationship.
The early stage in this development of Disorganized attachment is a pattern of early interaction


that is ultimately highly dysfunctional, but, at the time, may be an unavoidable outcome of the
mother’s Unresolved/disoriented state of mind.
In addition to the relative ineffectiveness of the intervention with mothers who were clas-
sified as Unresolved/disoriented or who had experienced trauma as children, it was notable
that the intervention had no effect on the likelihood of observing Disorganized patterns of
attachment. It appears that the intervention procedures aimed at enhancing maternal sensitivity
had little impact on those dyads who were destined to develop Disorganized relationships, the
category of relationship most often linked to substantial developmental problems for the child.
This result constitutes another challenge in conducting research and designing programs of
intervention for high-risk populations. As noted by Bakermans-Kranenburg et al. (2003), be-
havior-focused intervention programs, including the one presented here, have been designed
to increase maternal sensitivity and, in turn, the likelihood of Secure attachment relationships.
However, the antecedents of a Disorganized attachment relationship may lie in other features
of the mother’s behavior and, as a result, may need to be addressed by a distinct intervention
program. Several other approaches to intervention with at-risk mother – infant dyads have util-
ized techniques that move beyond a traditional sensitivity-based focus and may hold promise
for dyads like those who did not appear to benefit in this study. The details of such interventions,
however, vary widely, invoking both behavioral and intra-psychic therapeutic techniques. For
example, Benoit, Madigan, Lecce, Shea, and Goldberg (2001), in their work with a clinical
sample of mothers and infants referred with a range of serious developmental problems, utilize
video records of interactions to provide the mother with unusually directive feedback regarding
the most atypical aspects of her interactions with her child. Heinicke et al.’s (1999) intervention
program for mothers and infants identified as being at substantial developmental risk, in con-
trast, used well-qualified social workers in a program that focused on relationship formation
and the development of a therapeutic atmosphere of trust in which the mother’s personal
psychological issues could be addressed. In a final example of a program aimed at assisting
at-risk mothers and their infants, Marvin, Cooper, Hoffman, and Powell’s (2002) “Circle of
Security” involves an innovative application of basic attachment principles in a group inter-
vention model. Although each of these approaches resulted in positive outcomes, the diversity
of the participants and their contrasting techniques provide no clear insight into the psycho-
logical mechanisms underlying their success.
A next step towards understanding why an Unresolved/disoriented state of mind poses
such an impediment to both sensitive, effective mother – infant interactions, and to the success
of interventions aimed at increasing maternal sensitivity, is to explore the specific nature of
the emotional and psychological symptoms associated with the trauma the mothers have ex-
perienced. Identification of these symptoms is a prerequisite to understanding their relation to
mother – infant interactions and to designing effective approaches to removing the impediment
to mutually beneficial interactions and the formation of an organized attachment relationship.
These issues will be addressed in a follow-up to this intervention study, providing initial results
of a more-detailed study of the childhood experiences of these same adolescent mothers and
their reports of trauma-related symptoms.

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