Maternal unresolved attachment status impedes the effectiveness of interventions with adolescent 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 OntarioABSTRACT: Children of adolescent mothers are at risk for a variety of developmental difﬁculties. In thepresent 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 andtheir infants who were observed at 6, 12, and 24 months of age. The intervention conducted by clinicallytrained home visitors consisted of eight home visits between 6 and 12 months in which mothers wereprovided 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 securein 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 indicatedthat the intervention was effective primarily for mothers who were not classiﬁed as Unresolved on theAdult 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 Afectividaden Adultos.This research was supported by research grants from the Social Sciences and Humanities Research Council and HealthCanada. 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 Bentofor Strange Situation and Adult Attachment Interview coding. Direct correspondence to: Greg Moran, Ofﬁce of theProvost and Vice-President (Academic), University of Western Ontario, London, Ontario, N6A 5B8, Canada; e-mail:email@example.com.INFANT MENTAL HEALTH JOURNAL, Vol. 26(3), 231– 249 (2005) 2005 Michigan Association for Infant Mental HealthPublished 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.´ ` ´ ´ ´´ ´ ` ˆL’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 ´ ` ´ ` ˆd’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, gegebenwurden. Im Alter von 12 Monaten wurden 57% der Interventionsgruppe und 38% der Kontrollgruppe alssicher 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 placeboth the mother and child at risk for a range of negative psychosocial outcomes. Furstenbergand colleagues (Furstenberg, Brooks-Gunn, & Chase-Lansdale, 1989; Furstenberg, Brooks-Gunn, & Morgan, 1987) have shown that the social and economic futures of these youngwomen are substantially compromised. Even prior to the pregnancy, teenage mothers oftencome from a background of poverty, have had conﬂicts with the law, have dropped out ofschool, 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 economicmaladjustment may well be the precursor of developmental difﬁculties in the children of thesemothers. Support for an intergenerational pattern of transmission comes from ﬁndings thatchildren of adolescent mothers, relative to those born to older mothers, display markedly lowerlevels 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, anda 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 consequencesof early childbearing. They called this source “social inﬂuence.” Here, the consequences ofadolescent parenthood contribute to a maladaptive developmental environment, increasing thelikelihood of poor outcomes for the children. Second, adverse outcomes could be a product ofpreexisting maladaptive characteristics of the mother. For example, the same social – emotionaldifﬁculties that might have led to a mother’s early pregnancy could predispose her to poorparenting. They called this source “social selection.” Using this model as a framework, Jaffeet al. (2001) analyzed data from a New Zealand cohort born during two months of 1972. Theyfound that the children of adolescent mothers were two to three times more likely to experienceadverse academic and employment outcomes in adulthood, to commit violent offences, and tobecome 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 socialinﬂuence and social selection mechanisms of transmission. Family circumstances (social inﬂu-ence) and maternal characteristics (social selection) together accounted for 39% of the variancein outcome, with family circumstances and maternal characteristics independently accountingfor 18% and 21% of the variance, respectively. The Jaffe et al. (2001) conclusion that the personal characteristics of adolescent motherscontribute to adverse outcomes for their children, even when the negative social consequencesof early childbirth are taken into account, takes on special importance in light of the fact thatadolescent mothers are more likely than their peers to have experienced maladaptive parentingin their own childhood, including physical and sexual abuse (Osofsky, 1990; Osofsky, Osofsky,& Diamond, 1988). Gershenson, Musick, Ruch-Ross, and Magee (1989), for example, foundthat 61% of a large sample of adolescent mothers had suffered coercive sexual experiences; inalmost one-third of the cases, the perpetrator was a family member. Such ﬁndings emphasizethe need for new approaches to supporting adolescent mothers that address those aspects ofthe mother’s behavior that are likely to contribute to adverse developmental outcomes for herchild. Based on attachment theory, a good starting point would be the style and quality of herinteractions with her infant. Adolescent mothers have been shown to be less responsive to their infants’ signals, touse more intrusive and physical interventions, and to provide less verbal stimulation thanhave 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 lesslikely to form Secure attachment relationships than are infants of older mothers. In theirmeta-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 adultmiddle-class samples had Secure attachment relationships. Furthermore, infants of adolescent
234 ● G. Moran et al.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 emotionalhistories of adolescent mothers and the quality of their interactions with their infants puts theinfants at increased risk of developing non-Secure attachment relationships. Moreover, thedevelopmental difﬁculties displayed by children of adolescent mothers are consistent with thoseassociated with non-Secure attachment relationships in general (see Greenberg, 1999, for areview). 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 aSecure infant – mother attachment relationship. ATTACHMENT-BASED INTERVENTION PROGRAMSAll 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 theresponsiveness 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 empiricalassociation between sensitive maternal interaction and Secure attachment than anticipatedfrom 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 homeobservations have conﬁrmed a strong association between the two factors (Pederson, Gleason,Moran, & Bento, 1998; Pederson & Moran, 1996). Attachment theory also holds that themother’s ability to interact effectively with her infant is a function of her own cognitiverepresentations 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 belimited by the nature of her own representational status, and that intervention, at least forsome mothers, might need to focus on the cognitive intrapsychic level, as well as on thebehavioral – interactive. In their meta-analysis of interventions aimed at promoting Secure attachment relationships,Van IJzendoorn, Juffer, and Duyvesteyn (1995) compared the effectiveness of behavioral andrepresentational approaches and found that longer-term interventions aimed at modifying themother’s representational structures were less effective than shorter-term interventions thatfocused directly on enhancing the quality of the mother’s interaction with her infant. The resultsof interventions were signiﬁcant, but highly variable: the combined effect size on maternalsensitivity was d 0.58, with effect sizes for individual studies ranging from a high of 2.62to a low of 0.0; effect sizes measuring the impact of the intervention on the security of theattachment 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 littleor no commonality across studies. A more recent meta-analytic review (Bakermans-Kranen-burg, Van IJzendoorn, & Juffer, 2003) largely replicated the earlier review, conﬁrming thatinterventions with a clear behavioral focus were the most effective, but added the unexpectedconclusion that behavioral intervention programs using only a moderate number of sessionswere more effective than were more extensive programs. Although both these reviews provideencouragement that successful intervention is possible, understanding the actual mechanismsof success remains a challenge. A comprehensive study involving the behavioral approach was carried out in the Nether-
Teen Mother Attachment and Intervention Stress ● 235lands by van den Boom (1994). The effect sizes for intervention in this study were dramaticallyhigher than were those of any other study reported in both meta-analyses. Van den Boomworked with 100 low-income adult mothers and their highly irritable infants. One-half of themothers received a brief intervention involving three home visits when the infants were between6 and 9 months of age. The intervention aimed at increasing the mother’s attentiveness to herinfant’s signals and at improving her responsiveness in interactions, initially by imitation ofthe infant’s signals. The results were striking. When infants were 9 months of age, mothers inthe 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 theintervention group were more sociable, better able to self-soothe, and showed more functionalplay than were their counterparts in the control group. In the Strange Situation when infantswere 12 months, 78% of the intervention group dyads were in Secure attachment relationshipscompared 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 attachmentrelationships were sustained in observations carried out when the infants were 18, 24, and 42months of age. The van den Boom studies provide compelling evidence that a brief interaction-focusedintervention in the ﬁrst year of an infant’s life can effectively change maternal interactivebehavior and facilitate the development of a secure infant – mother attachment relationship.Although these ﬁndings hold promise for work with adolescent mothers, the adult mothers inthe Dutch sample were very different from most adolescent mothers in North America: Almost100% lived in a nuclear family and their average age was 25 years. In addition, their childrenappear to be different from children of adolescent mothers. Only 10% of the dyads in the Dutchsample had Disorganized attachment relationships, a ﬁnding consistent with the conclusion thatmost of the children were not at high risk for serious developmental difﬁculties. Within ourresearch 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 patternsof 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 parentingstress and depression. In Strange Situation assessments, 39% of the dyads were classiﬁed asAvoidant and only 37% were classiﬁed as securely attached in contrast with the 66% typicallyreported 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 and23 to a Comparison group. Mothers and infants in the Intervention group received 12 to 16home visits when the infants were between 6 and 13 months of age. The intervention includeda discussion of the mother’s current life experiences, especially around parenting, videotapingthe mother and infant at play, and reviewing the tape with the mother. The home visitor afﬁrmedthe mother’s parenting skills and encouraged her to reﬂect on her infant’s thoughts and feelingsand to note her own strengths. Mothers and infants in the Comparison group were visited onceat 9 months to videotape mother – infant interactions. Maternal sensitivity was assessed in homevisits (by independent observers) at 6 and 13 months. The sensitivity scores were comparablefor both groups at 6 months. At 13 months, mothers in the Comparison group demonstratedthe drop in sensitivity seen in the ﬁrst study. In contrast, mothers in the Intervention groupincreased in sensitivity, although levels remained lower than those reported for older mothersin 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 thedyads in the Comparison group were secure. The purpose of the present study was to extend
236 ● G. Moran et al.Krupka’s (1995) intervention study using a larger sample and including assessments of themother’s attachment representational system. METHODParticipantsParticipants in the present study were adolescent mothers and their infants recruited into alongitudinal intervention study conducted by the Child Development Centre at the Universityof Western Ontario. Mothers who met the following criteria were initially approached duringtheir postpartum stay in a London, Ontario hospital: less than 20 years of age, uneventfuldelivery, and infants born at full term with no medical complications. Those who lived inLondon and had expressed an interest in participating in the study were contacted again whenthe infant was 5 months of age. Initial assessment visits were conducted when the infants wereapproximately 6 months of age. By the end of the recruitment process, 100 dyads were involvedin the study and, of these, 99 dyads (50 girls and 49 boys) completed the assessments at 12months 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 commonlaw, and 15% were married. Mean age at the time of the infant’s birth was 18.42 (SD1.01), with a range from 15.97 to 19.98 years. Annual personal and family incomes wererecorded 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 ProcedureResearchers trained in home observations assessed each mother – infant dyad in their homewhen 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-monthbaseline visit, mothers were randomly assigned to an Intervention or Comparison group. Dyadsin the Intervention group received eight home visits between 7 and 12 months; dyads in theComparison group received one visit at 9 months. When the infant was approximately 12months of age, each dyad took part in the Strange Situation procedure.The Intervention ProgramRationale. The intervention program was based on the assumption that the development of asecure attachment relationship is a major developmental task in the last half of the infant’s ﬁrstyear of life. The goal of intervening was to support the mother’s sensitivity to her infant. We
Teen Mother Attachment and Intervention Stress ● 237focused 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 experientialdeterminant of attachment security. Second, Krupka (1995) observed a decline in sensitivityover the ﬁrst year in young mothers. This decline was particularly noticeable in the latter halfof the infant’s ﬁrst year. Finally, the observation and assessment of maternal sensitivity hasbeen 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 decidedto 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 governmentsocial-support agencies judge them negatively. Transportation and other logistic problems alsoprovide 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 interventiongroup (1 out of 50 mothers) indicates that adolescent mothers may be more willing to participatein such programs, resulting in future beneﬁts for the children, the mothers, and society ingeneral. The word “intervention” was not used to describe our study as it may have had a negativeimpact on our adolescent mothers. Instead, participants were told that we were interested inseeing how young mothers and babies played together and in trying new ways of playing thatwould be fun for both mother and baby, with the ultimate goal of developing support programsfor adolescent parents. The visits were designed to provide experiences of mutually beneﬁcialplay interactions and to support the mother’s enjoyment of her infant. Four general goals servedas guides to the home visitors. The ﬁrst goal was to afﬁrm parenting strengths already presentin the mother. A second goal was to increase the mother’s awareness of how her behaviorinﬂuenced her infant’s behavior. The visitors also looked for ways to augment the mother’sawareness of her infant’s signals and for ways to establish positive experiences for both themother and the infant.Intervention procedures. Home visits lasted approximately one hour and were carried out bytwo mature women who had raised their own families and who were knowledgeable aboutinfant development and attachment theory and research. One visitor had a PhD in child clinicalpsychology 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 familieswere 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 theintervention procedures. In the initial part of each visit, the home visitor focused on building rapport with themother because a trusting relationship plays an important role in any support system. Themother and infant were videotaped for about ﬁve minutes while playing with age-appropriatetoys 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 askedfor the mother’s interpretation of her infant’s behavior. The discussion focused on identifyingpositive features of the interactions and on providing the mother with opportunities to ponderher infant’s motivational states. For example, if the mother’s intrusiveness stimulated the infant
238 ● G. Moran et al.to turn away, the visitor might note that the infant seemed to be looking away and ask themother for her interpretation of what the infant might have been thinking or feeling at thattime. 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 behaviorat the middle levels consisted of monitoring and acknowledging infant behavior. Maternalimitation and elaboration of infant-initiated play constituted the top levels of the hierarchy(most-sensitive interactional behavior). Home visitors used descriptions of these ordered levelsin planning the goals for a particular home visit and as a framework for providing feedback tothe mother. The goal of the eight home visits was to facilitate the mother’s progression alongthis hierarchy. Funding constraints limited the number of intervention visits in the present studyto eight in contrast with the 12 to 16 intervention visits in the Krupka (1995) study. The ﬁrstthree visits were carried out within one week of each other in order to establish rapport withthe mothers. The subsequent ﬁve visits were spaced about three to four weeks apart. Eachvisitor made two or three visits per week and had a caseload of six or seven families at anyone time. Completing the eight home visits was time consuming and often challenging. Phonecalls were always made within 24 hours of a scheduled visit to conﬁrm that the time did notconﬂict with the baby’s current naptime. Despite this reconﬁrmation, some mothers would notbe 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 byunexpectedly and they had gone to the mall. It took about two years to complete the Interventionprogram for the 49 mothers. Mothers in the Comparison group received one home visit whentheir infants were 9 months old. They were interviewed about their current relationships and avideotape was made of infant – mother play, feeding, and other activities of the mother’s choice.MeasuresStrange 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. Theinfant’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 StrangeSituation (Ainsworth et al., 1978; Main & Solomon, 1990). Secure infants responded to themother’s return in the reunion episodes by showing a desire for proximity or contact or a wishfor interaction. These infants were effective in obtaining comfort from the mother and werethen able to resume exploration of the environment. Avoidant infants showed little or no desirefor proximity, contact, or interaction with their mothers. In fact, they tended to ignore or avoidtheir mothers during the reunion episodes. Resistant infants typically fussed during separationsand had difﬁculty resuming play during reunions. They displayed angry behaviors that appearedto interfere with receiving comfort from their mothers and thus failed to use their mothers asa source of security in order to resume exploration. Disorganized/Disoriented infants exhibitedinexplicable 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 ascrouching on approach. Infants classiﬁed as Disorganized were also assigned to the best-ﬁtting
Teen Mother Attachment and Intervention Stress ● 239Secure, Avoidant, or Resistant classiﬁcation. The Strange Situations were coded by individualswho had passed the Sroufe and Carlson reliability test for Secure, Avoidant, Resistant, andDisorganized classiﬁcations. For reliability purposes, 25 Strange Situations were independentlycoded with 88% reliability for the four classiﬁcations ( 0.78, p 0.001).Adult Attachment Interview. The Adult Attachment Interview (AAI) (George et al., 1985) wasconducted with the mothers when infants were 6 months of age. The AAI includes questionsaddressing the mother’s experiences with attachment ﬁgures; early childhood and perceptionsof her parents at that time; experiences of early emotional and physical upsets; physical andsexual abuse; and deaths of loved ones. Mothers also were asked to reﬂect on how these pastexperiences may have affected their present personalities. In accordance with the AAI codingsystem (Main & Goldwyn, 1998), each transcript was classiﬁed for state of mind with respectto 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 contradictionsin 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 inmonitoring of reasoning or discourse during discussions of abuse or loss. Thirty-ﬁve interviewswere classiﬁed independently by coders who had passed the Main and Hesse reliability testprocedures 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, and24 months of age. Following each two-hour semi-structured home visit, trained observerscompleted 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 themother’s interactive behavior. Observers progressively sort these cards into nine equal pilesfrom 1 (most unlike the mother’s behavior) to 9 (most like the mother’s behavior). The mother’ssensitivity 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 24months (n 26). RESULTSIntervention and the Quality of the Attachment RelationshipFifty-seven (58%) of the 99 dyads were classiﬁed as Disorganized in the Strange Situation at12 months, reﬂecting the high-risk nature of this sample. Twenty-eight (54%) of the infants inthe 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 theoreticallyunrelated to Disorganization; therefore, the similar rates of Disorganization in the two groupshad been anticipated. Subsequent analyses of the quality of the attachment relationship usedthe original Ainsworth Secure, Avoidant, and Resistant classiﬁcations using the best ﬁtting ofthese classiﬁcations for the Disorganized infants. Using these three categories, mothers participating in the intervention program were more
240 ● G. Moran et al.likely than mothers in the Comparison group to be in Secure attachment relationships withtheir 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 theComparison 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 wasmodest. None of the individual cell residuals achieved signiﬁcance, nor did a 2 analysis usinga 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 InteractionMaternal sensitivity scores, assessed with the Maternal Behavior Q-set in observations in thehome at 6, 12, and 24 months, fell for mothers in the Comparison group from 0.38 to 0.12between 6 and 12 months; at 24 months, sensitivity in this group had recovered somewhat toan average value of 0.24. Changes in the maternal sensitivity of mothers involved in theintervention followed a different pattern. Mothers in the Intervention group displayed similarlevels of maternal sensitivity to those in the Comparison group at 6 months (0.34), droppedless in sensitivity at 12 months (0.20), and recovered to a substantially higher level at thefollow-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 weresigniﬁcant. A goal of the intervention program was to ameliorate the decline in sensitivity observedby Krupka (1995); therefore, a second analysis was performed using a categorical assessmentof change in sensitivity. Two groups were formed based on a rational distinction between thepattern 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 maintainedsensitive levels of interaction. This group included 48 mothers for whom sensitivity scoresincreased and whose 24-month sensitivity score was at least 0, plus 11 additional mothers whodisplayed some decrease in sensitivity, but retained a 24-month sensitivity score of greater than0.40. Thirty-one mothers (34%) were placed in the Negative Outcome Group, consisting ofthose who decreased sensitivity or maintained low sensitivity. This group was composed of 27mothers who declined in sensitivity to a 24-month sensitivity of less than 0.4, plus four motherswhose sensitivity increased somewhat, but remained below 0 at 24 months. A signiﬁcantlygreater number of mothers in the Intervention group (76%) was found to be in the PositiveOutcome 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 impacton the quality of mother – infant interactions. However, examining the data in terms of Positiveand 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 werecarried out to identify factors that might account for the variation in the effectiveness of theintervention across individuals. Based on attachment theory and on our understanding of thecharacteristics of adolescent mothers, two factors were examined more closely: the mother’sstate of mind with regard to attachment and the mother’s experience of trauma, as determinedby her responses in the Adult Attachment Interview (AAI) when the baby was 6 months old.
Teen Mother Attachment and Intervention Stress ● 241FIGURE 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%) inthe Intervention and 19 (or 38%) in the Comparison Group]. To examine the effectiveness ofthe intervention in relation to Unresolved/disoriented state of mind on the AAI, 2 analyseswere performed on the frequencies of Secure attachment in dyads in which the mothers wereor 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 theComparison group were classiﬁed as Secure (33% and 32%, respectively, 2 (1) 0.01, ns) inthe 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 interventionon the quality of the attachment relationship could be traced to the impact of the interventionon the sensitivity of the mothers. Maternal sensitivity scores for Intervention and Comparisongroups 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. Between12 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 whowere 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 repeatedmeasures ANOVA of maternal sensitivity at infant ages 6, 12, and 24 months, with Intervention
242 ● G. Moran et al.and Unresolved/disoriented status as between-subject factors, revealed a main effect for infantage [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 themother’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 analternative analysis using the same metric of change in sensitivity described above. Mothersparticipating 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 ComparisonGroup who were not Unresolved/disoriented were in the Positive Outcome Group (83% and57%, respectively, 2(1) 4.74, p 0.05, w 0.22). In contrast, for mothers who wereUnresolved/disoriented, the number of mothers in the Positive Outcome Group did not differsigniﬁcantly 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. Duringthe 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. Therewere 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 morelikely 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 thePositive 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, theintervention had no signiﬁcant impact on sensitivity change groups (Intervention 68% andComparison Group 50% in the Positive Outcome Group [ 2(1) 1.50, ns]). DISCUSSIONThis study was prompted by a set of inter-related observations and conjectures: the childrenof 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 arelikely to have had a history of physical and sexual abuse in their own childhoods that maywell underlie their dysfunctional interactions with their infants; and ﬁnally, attachment-basedinterventions in the ﬁrst year of life have been shown to enhance mother – infant interactionsand to promote Secure attachment relationships. This study explored the impact of a brief earlyintervention on the sensitivity of maternal interactions over the ﬁrst two years of an infant’slife and on the quality of the attachment relationship in a group of adolescent mothers and theirinfants. Particular attention was paid to the moderating effect on the intervention of a maternalhistory of childhood trauma associated with an Unresolved/disoriented state of mind regardingattachment. The results conﬁrmed that interaction-focused intervention in the ﬁrst year of life canimprove the quality of the relationship between adolescent mothers and their infants and thatthe improvement in interactions persists into at least the second year of the child’s life. Theseresults parallel and extend published studies of mothers who were not drawn from a high-risk
Teen Mother Attachment and Intervention Stress ● 243population (van den Boom, 1994, 1995; Van IJzendoorn et al., 1995). The study also providesanother 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 overridingdeterminant of the quality of the relationship. Theory and much supporting empirical evidenceindicate that this relationship forms a critical foundation for the future social and emotionaldevelopment of the child, and that a failure to develop an organized attachment relationship isassociated with developmental risk. Our intervention was directed at the quality of this earlyinteraction and it succeeded in enhancing sensitivity in most adolescent mothers, thus makingit 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 effectivesupport for infants who might otherwise be at risk for serious developmental difﬁculties thatare 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 ofobserved interactions between the adolescent mother and her infant. Unexpectedly, however,a statistically signiﬁcant difference in sensitivity between those mothers who participated inthe intervention program and those who did not was not observed in interactions in the homeuntil the children were 24 months of age. This ﬁnding is inconsistent with the fact that thepositive 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 apparentlypuzzling 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 inadolescent mothers declines substantially between 6 and 12 months of the infants’ age. Thistrend would tend to mask any positive impact of intervention, perhaps simply eliminating orreducing such a decline rather than producing an increase in sensitivity at 12 months. Perhapsmore importantly, as discussed in detail below, the results of this study indicate that somemothers, those with a history of trauma associated with an Unresolved/disoriented state of mindregarding 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 theintervention 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 increasedin sensitivity between 12 and 24 months and displayed a substantially higher level of sensitivityat the end of the study. The fact that this complex but distinct pattern of change in sensitivitywas not revealed in a statistically unambiguous manner in our ANOVA may be more a functionof a loss of power resulting from the division of the sample into relatively small groups thana 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 inmaternal sensitivity in mothers who did not receive intervention in this study was consistentwith that observed in earlier work in our research group. Adolescent mothers displayed areasonably positive style of interaction with their infants until about 6 months of age, but inthe absence of support, the average level of sensitivity drops dramatically by the time theirinfants are one year of age (Krupka, 1995). For the majority of mothers receiving interventionin 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 wasparalleled by a relatively higher percentage of Secure attachment relationships assessed in theStrange Situation at 12 months when compared to the Comparison group of mothers and infants.
244 ● G. Moran et al.However, approximately 25% of mothers involved in the intervention failed to show increasedsensitivity in their interactions when their infants were two years of age and their interactionsremained 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 morelikely to have been classiﬁed on the AAI as having an Unresolved/disoriented state of mindassociated with childhood experiences of loss or abuse than those who beneﬁted from theintervention. For these mothers, a brief behavior-focused program of intervention failed toprevent the decline in the quality of the interactions that were critical to the formation of aSecure relationship with their infants. Why might this be so? Within attachment theory, traumais 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 approachto intimate interaction, which is essential for an organized relationship. That is, although thetrauma of loss or abuse often interferes with the development of an organized state of mindregarding intimate relationships, this maladaptive Unresolved/disoriented representational stateis not seen in those who manage to integrate and resolve these experiences. It is the absenceof an organized representational state rather than the direct effects of loss or trauma that createsrelational 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, arelikely 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 correctinteractions that might be distorted by such behavior, and a pervasive disruption of the essentialelements of a framework for adaptive mother – infant interaction. Our ﬁnding that a maternalUnresolved/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 supportsthe 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 andpersistent 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 mothersto integrate their own childhood trauma within an organized state of mind regarding attachmentis likely to be manifest by symptoms of Post Traumatic Stress Disorder (PTSD). They proposeda link between the established psycho-emotional characteristics of PTSD and the maladaptiveinteractions of Unresolved/disoriented mothers and their infants. DeOlivera, Bailey, Moranand Pederson (2004) have elaborated on this suggestion, outlining a model in which thesymptoms associated with chronic childhood trauma are reﬂected in particular deﬁcits in thosekey aspects of early mother – infant interaction that support the normal development of affectregulation. They argue that the acquisition of organized patterns of affect regulation, a processthat is dependent on these early interactions, is critical for the establishment of an organizedattachment 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 – infantinteractions 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
Teen Mother Attachment and Intervention Stress ● 245that is ultimately highly dysfunctional, but, at the time, may be an unavoidable outcome of themother’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 notablethat the intervention had no effect on the likelihood of observing Disorganized patterns ofattachment. It appears that the intervention procedures aimed at enhancing maternal sensitivityhad little impact on those dyads who were destined to develop Disorganized relationships, thecategory of relationship most often linked to substantial developmental problems for the child.This result constitutes another challenge in conducting research and designing programs ofintervention for high-risk populations. As noted by Bakermans-Kranenburg et al. (2003), be-havior-focused intervention programs, including the one presented here, have been designedto increase maternal sensitivity and, in turn, the likelihood of Secure attachment relationships.However, the antecedents of a Disorganized attachment relationship may lie in other featuresof the mother’s behavior and, as a result, may need to be addressed by a distinct interventionprogram. 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 promisefor 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. Forexample, Benoit, Madigan, Lecce, Shea, and Goldberg (2001), in their work with a clinicalsample of mothers and infants referred with a range of serious developmental problems, utilizevideo records of interactions to provide the mother with unusually directive feedback regardingthe most atypical aspects of her interactions with her child. Heinicke et al.’s (1999) interventionprogram 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 formationand the development of a therapeutic atmosphere of trust in which the mother’s personalpsychological issues could be addressed. In a ﬁnal example of a program aimed at assistingat-risk mothers and their infants, Marvin, Cooper, Hoffman, and Powell’s (2002) “Circle ofSecurity” involves an innovative application of basic attachment principles in a group inter-vention model. Although each of these approaches resulted in positive outcomes, the diversityof 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 posessuch an impediment to both sensitive, effective mother – infant interactions, and to the successof interventions aimed at increasing maternal sensitivity, is to explore the speciﬁc nature ofthe emotional and psychological symptoms associated with the trauma the mothers have ex-perienced. Identiﬁcation of these symptoms is a prerequisite to understanding their relation tomother – infant interactions and to designing effective approaches to removing the impedimentto 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 resultsof a more-detailed study of the childhood experiences of these same adolescent mothers andtheir reports of trauma-related symptoms. REFERENCESAinsworth, M.D.S., Bell, S.M., & Stayton, D.J. (1971). Individual differences in strange situation behavior of one-year-olds. In H.R. Schaffer (Ed.), The origins of human social relations (pp. 17–57). London: Academic Press.
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