Discussion Post: RAD

Paediatr Child Health Vol 9 No 8 October 2004 541

Infant-parent attachment: Definition, types, antecedents, measurement and outcome

Diane Benoit MD FRCPC

Department of Psychiatry, University of Toronto, Toronto; The Research Institute and Infant Psychiatry Program, The Hospital for Sick Children, Toronto, Ontario

Correspondence and reprints: Dr Diane Benoit, The Research Institute, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5T 1X8. Telephone 416-813-7528, fax 416-813-6565, e-mail [email protected]

D Benoit. Infant-parent attachment: Definition, types,

antecedents, measurement and outcome. Paediatr Child Health

2004;9(8):541-545.

Attachment theory is one of the most popular and empirically

grounded theories relating to parenting. The purpose of the present

article is to review some pertinent aspects of attachment theory and

findings from attachment research. Attachment is one specific aspect

of the relationship between a child and a parent with its purpose

being to make a child safe, secure and protected. Attachment is dis-

tinguished from other aspects of parenting, such as disciplining,

entertaining and teaching. Common misconceptions about what

attachment is and what it is not are discussed. The distinction

between attachment and bonding is provided. The recognized

method to assess infant-parent attachment, the Strange Situation

procedure, is described. In addition, a description is provided for the

four major types of infant-parent attachment, ie, secure, insecure-

avoidant, insecure-resistant and insecure-disorganized. The antecedents

and consequences of each of the four types of infant-parent attachment

are discussed. A special emphasis is placed on the description of disor-

ganized attachment because of its association with significant emo-

tional and behavioural problems, and poor social and emotional

outcomes in high-risk groups and in the majority of children who have

disorganized attachment with their primary caregiver. Practical appli-

cations of attachment theory and research are presented.

Key Words: Attachment; Attachment relationships; Infant-parent

attachment

L’attachement entre le nourrisson et le parent : la définition, les modèles, les antécédents, les mesures et les issues

La théorie de l’attachement est l’une des théories les plus populaires et les

plus empiriques à être reliée au rôle parental. Le présent article vise à

examiner certains aspects pertinents de la théorie de l’attachement et

certaines observations tirées des recherches sur l’attachement.

L’attachement est un aspect précis de la relation entre un enfant et un

parent, dont l’objectif consiste à ce que l’enfant se sente en sécurité,

sécurisé et protégé. L’attachement est différencié d’autres aspects du rôle

parental, tels que la discipline, l’amusement et l’enseignement. Des idées

fausses courantes sur ce qu’est l’attachement et ce qu’il n’est pas sont

abordées. La distinction entre l’attachement et les liens affectifs est

présentée. La méthode de la « situation étrange », reconnue pour évaluer

l’attachement entre le nourrisson et le parent, est décrite. Les quatre

principaux modèles d’attachement entre le nourrisson et le parent sont

également décrits, soit les modèles sécure, anxieux-ambivalant, anxieux-

évitant et désorganisé-désorienté. Les antécédents et les conséquences de

chacun de ces quatre modèles d’attachement entre le nourrisson et le

parent sont étudiés. L’attachement désorganisé est décrit de manière plus

approfondie, en raison de son association avec des troubles affectifs et

comportementaux marqués, avec des issues sociales et affectives négatives

dans les groupes très vulnérables et chez la majorité des enfants qui

présentent un attachement désorganisé avec la principale personne qui

s’occupe d’eux. Des applications pratiques de la théorie de l’attachement

et des recherches sont présentées.

Parents play many different roles in the lives of their chil-dren, including teacher, playmate, disciplinarian, care- giver and attachment figure. Of all these roles, their role as

an attachment figure is one of the most important in pre-

dicting the child’s later social and emotional outcome (1-3).

DEFINITION

Attachment is one specific and circumscribed aspect of

the relationship between a child and caregiver that is

involved with making the child safe, secure and protected

(4). The purpose of attachment is not to play with or

entertain the child (this would be the role of the parent as

a playmate), feed the child (this would be the role of the

parent as a caregiver), set limits for the child (this would

be the role of the parent as a disciplinarian) or teach the

child new skills (this would be the role of the parent as a

teacher). Attachment is where the child uses the primary

caregiver as a secure base from which to explore and,

when necessary, as a haven of safety and a source of com-

fort (5).

Attachment is not ‘bonding’. ‘Bonding’ was a concept

developed by Klaus and Kennell (6) who implied that par-

ent-child ‘bonding’ depended on skin-to-skin contact dur-

ing an early critical period. This concept of ‘bonding’ was

proven to be erroneous and to have nothing to do with

attachment. Unfortunately, many professionals and nonpro-

fessionals continue to use the terms ‘attachment’ and ‘bond-

ing’ interchangeably. When asked what ‘secure attachment’

looks like, many professionals and nonprofessionals describe

a ‘picture’ of a contented six-month-old infant being

©2004 Pulsus Group Inc. All rights reserved

REVIEW ARTICLE

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breastfed by their mother who is in a contented mood;

they also often erroneously imply that breastfeeding per se

promotes secure attachment. Others picture ‘secure attach-

ment’ between a nine-year-old boy and his father as the

father and son throw a ball in the backyard, go on a fishing

trip or engage in some other activity. Unfortunately, these

‘pictures’ have little, if anything, to do with attachment,

they are involved with other parental roles (eg, their role as

a caregiver in the case of the breastfeeding mother and as a

playmate in the case of the father and son playing catch in

the backyard). One might ask why the distinction between

attachment and ‘bonding’ matters. The answer may lie in

the fact that ‘bonding’ has not been shown to predict any

aspect of child outcome, whereas attachment is a powerful

predictor of a child’s later social and emotional outcome.

TYPES OF ATTACHMENT

AND THEIR ANTECEDENTS

There are four types of infant-parent attachment: three

‘organized’ types (secure, avoidant and resistant) and one

‘disorganized’ type (Table 1). The quality of attachment

that an infant develops with a specific caregiver is largely

determined by the caregiver’s response to the infant when

the infant’s attachment system is ‘activated’ (eg, when the

infant’s feelings of safety and security are threatened, such

as when he/she is ill, physically hurt or emotionally upset;

particularly, frightened). Beginning at approximately

six months of age, infants come to anticipate specific care-

givers’ responses to their distress and shape their own

behaviours accordingly (eg, developing strategies for deal-

ing with distress when in the presence of that caregiver)

based on daily interactions with their specific caregivers (7-9).

Three major patterns of responses to distress have been

identified in infants, which lead to three specific ‘organized’

attachment patterns.

Infants whose caregivers consistently respond to distress

in sensitive or ‘loving’ ways, such as picking the infant up

promptly and reassuring the infant, feel secure in their

knowledge that they can freely express negative emotion

which will elicit comforting from the caregiver (9). Their

strategy for dealing with distress is ‘organized’ and ‘secure’.

They seek proximity to and maintain contact with the care-

giver until they feel safe. The strategy is said to be ‘organ-

ized’ because the child ‘knows’ exactly what to do with a

sensitively responsive caregiver, ie, approach the caregiver

when distressed. Infants whose caregivers consistently

respond to distress in insensitive or ‘rejecting’ ways, such as

ignoring, ridiculing or becoming annoyed, develop a strategy

for dealing with distress that is also ‘organized’, in that they

avoid their caregiver when distressed and minimize displays

of negative emotion in the presence of the caregiver (9).

The strategy is said to be ‘organized’ because the child

‘knows’ exactly what to do with a rejecting caregiver, ie, to

avoid the caregiver in times of need. This avoidant strategy

is also ‘insecure’ because it increases the risk for developing

adjustment problems. Infants whose caregivers respond in

inconsistent, unpredictable and/or ‘involving’ ways, such as

expecting the infant to worry about the caregiver’s own

needs or by amplifying the infant’s distress and being over-

whelmed, also use an ‘organized’ strategy for dealing with

distress; they display extreme negative emotion to draw the

attention of their inconsistently responsive caregiver. The

strategy is said to be ‘organized’ because the child ‘knows’

exactly what to do with an inconsistently responsive care-

giver, ie, exaggerate displays of distress and angry, resistant

responses, ‘hoping’ that the marked distress response can-

not possibly be missed by the inconsistently responsive

caregiver. However, this resistant strategy is also ‘insecure’

because it is associated with an increase in the risk for

developing social and emotional maladjustment.

Approximately 15% of infants in low psychosocial risk

and as many as 82% of those in high-risk situations do not

use any of the three organized strategies for dealing with

stress and negative emotion (9). These children have disor-

ganized attachment. One recently identified pathway to

children’s disorganized attachment includes children’s expo-

sure to specific forms of distorted parenting and unusual

caregiver behaviours that are ‘atypical’ (10,11). Atypical

caregiver behaviours, also referred to as “frightening, fright-

ened, dissociated, sexualized or otherwise atypical” (10), are

aberrant behaviours displayed by caregivers during interac-

tions with their children that are not limited to when the

child is distressed. There is evidence to suggest that care-

givers who display atypical behaviours often have a history

of unresolved mourning or unresolved emotional, physical

or sexual trauma, or are otherwise traumatized (eg, post-

traumatic stress disorder or the traumatized victim of

domestic violence) (12).

MEASUREMENT

The three ‘organized’ strategies (secure, avoidant and resistant)

are assessed in the Strange Situation (SS) (7), a 20 min labo-

ratory procedure where patterns of infant behaviour toward

the caregiver following two brief separations are categorized as

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Paediatr Child Health Vol 9 No 8 October 2004542

TABLE 1 Types of attachment and antecedents

Quality of caregiving Strategy to deal with distress Type of attachment

Sensitive Loving Organized Secure

Insensitive Rejecting Organized Insecure-avoidant

Insensitive Inconsistent Organized Insecure-resistant

Atypical Atypical Disorganized Insecure-disorganized

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secure or insecure (avoidant or resistant). The SS can be

used when infants are 12 to 20 months old. Infants with

secure attachment greet and/or approach the caregiver

and may maintain contact but are able to return to play,

which occurs in 55% of the general population (9).

Infants with insecure/avoidant attachment fail to greet

and/or approach, appear oblivious to their caregiver’s

return and remain focused on toys, essentially avoiding

the caregiver, which occurs in 23% of the general popula-

tion (9). Infants with insecure/resistant attachment are

extremely distressed by the separations and cannot be

soothed at reunions, essentially displaying much distress

and angry resistance to interactions with the caregiver,

which occurs in 8% of the general population (9).

As with the ‘organized’ strategies, disorganization is

measured using the SS, and the Main and Solomon’s

(13,14) scoring scheme for disorganization. When dis-

tressed, infants who used a disorganized strategy for dealing

with distress display unusual or disorganized behaviours in

the SS, including misdirected or stereotypical behaviour,

simultaneous display of contradictory behaviours, stilling

and freezing for substantial periods, and direct apprehen-

sion or even fear of the parent. Such behaviours are partic-

ularly meaningful when they are intense and occur in the

presence of the parent (9,14). They reflect an inability of

the infant with disorganized attachment to find a solution

to fear and distress, so the infants (momentarily) display

bizarre or contradictory behaviour. Infants with disorgan-

ized attachment face an unsolvable dilemma: their haven of

safety is also the source of their fear and distress (9). When

infants face this dilemma, the three ‘organized’ strategies

are not efficient in restoring feelings of safety and security

in the presence of the attachment figure (13,15).

OUTCOME

Longitudinal research has shown that having a ‘loving’ pri-

mary caregiver and developing ‘organized and secure’

attachment to a primary caregiver acts as a protective factor

against social and emotional maladjustment for infants and

children (16,17). Attachment insecurity (avoidant and

resistant) has been proven to be a risk factor for later devel-

opment, but its high base rate in the normal population

(approximately 40%) has reduced its predictive value for

psychopathology (2).

Of the four patterns of attachment (secure, avoidant,

resistant and disorganized), disorganized attachment in

infancy and early childhood is recognized as a powerful pre-

dictor for serious psychopathology and maladjustment in

children (2,18-24). Children with disorganized attachment

are more vulnerable to stress (25,26), have problems with

regulation and control of negative emotions (9), display

oppositional, hostile, aggressive behaviours and coercive

styles of interaction (20,27-31). Disorganized attachment is

over-represented in groups of children with clinical prob-

lems and those who are victims of maltreatment (eg, nearly

80% of maltreated infants have disorganized attachment)

(32-34). The combination of disorganization and a parental

rating of a difficult temperament is a potent predictor of

aggressive behaviour in children at five years of age (35). In

addition, disorganized attachment in infancy has been

linked to internalizing and externalizing problems in the

early school years (20,36), poor peer interactions and

unusual or bizarre behaviour in the classroom (37), and

higher teacher ratings of dissociative behaviour and inter-

nalizing symptoms in middle childhood (19). Concurrent

disorganized/controlling behaviour rated in the preschool

and early school years related to oppositional defiant disor-

ders in boys (38), parent-rated externalizing and internaliz-

ing problems (30), and high levels of teacher-rated social

and behavioural difficulties in class (39,40). Children classi-

fied as disorganized with their primary caregiver at ages five

to seven years have lower mathematics attainment at

eight years of age (39). These academic problems appear to

be mediated through effects on self-esteem and confidence

in the academic setting (2). Children with disorganized

attachment have low self-esteem (41), and at nine years of

age are more often rejected by peers (42,43).

Adolescents who had disorganized attachment with

their primary caregiver during infancy have higher levels of

overall psychopathology at 17 years of age (19), and those

classified as disorganized at five to seven years of age exhibit

impaired formal operational skills and self-regulation at

17 years of age (44). Finally, children with disorganized

attachment are vulnerable to altered states of mind, such as

dissociation in young adulthood (19,45). A meta-analysis of

12 studies (n=734) addressing the association of disorgani-

zation and externalizing behaviour problems (9), found

effect sizes ranging from 0.54 to 0.17, with a mean correla-

tion coefficient of 0.29. The presence of negative findings

suggests that the relation is not straightforward: Lyons-Ruth

(28) found that 25% of children with disorganized attach-

ment in infancy were not disturbed at seven years of age.

Nonetheless, it appears that the majority of children with

disorganized attachment suffer adverse outcomes.

SUMMARY AND PRACTICAL APPLICATIONS

A discussion of intervention in situations where there are

difficulties in the infant-parent attachment relationship is

beyond the scope of the present article; however,

• The quality of the infant-parent attachment is a

powerful predictor of a child’s later social and

emotional outcome.

• By definition, a normally developing child will develop

an attachment relationship with any caregiver who

provides regular physical and/or emotional care,

regardless of the quality of that care. In fact, children

develop attachment relationships even with the most

neglectful and abusive caregiver. Therefore, the question

is never, ‘is there an attachment between this parent and

this child?’ Instead, the question is, ‘what is the quality

of the attachment between this parent and this child?’

Infant-parent attachment

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• Children develop a hierarchy of attachments with

their various caregivers. For example, a child with

three different caregivers (mother, father and nanny)

will have a specific attachment relationship with each

caregiver based on how that specific caregiver responds

to the child in times when the child is physically hurt,

ill or emotionally upset; particularly, when frightened.

If the mother reacts in loving ways most of the time,

the child will develop an organized and secure

attachment with the mother. That same child could

develop an organized, insecure and avoidant

attachment with the father if the father reacts in

rejecting ways to the child’s distress most of the time.

That same child could develop a disorganized

attachment with the nanny if the nanny displays

atypical behaviours during interactions with the child

and has unresolved mourning or trauma.

• In situations with multiple foster placements, neglect

or institutionalization, children may develop disorders

of nonattachment (49).

• Reactive attachment disorder (RAD) is a special

problem. The diagnosis of RAD, whether using

criteria from the International Classification of

Diseases: Clinical Descriptions and Diagnostic

Guidelines (46) or Diagnostic and Statistical Manual of

Mental Disorders, 4th edition (47), was developed

without the benefit of data, and research evidence to

support its validity are still sparse (2). Zeanah and

his colleagues (48,49) criticized the criteria for RAD

as inadequate to describe children who have seriously

disturbed attachment relationships rather than no

attachment relationships. Another significant

problem with the psychiatric diagnosis of RAD is

that it suggests that the attachment difficulties lie

within the child (ie, it is the child who receives the

psychiatric diagnosis), when in fact, attachment

involves the relationship between a child and

caregiver. Finally, to my knowledge, there is no

convincing empirical evidence to suggest that RAD

is associated with any of the four types of attachment

(secure, avoidant, resistant and disorganized).

• Will letting an infant cry during the first six months of

life affect the attachment relationship between that

infant and the caregiver who lets the infant cry? Many

child protection workers and health and mental

professionals recommend that parents place a child safely

in a crib when frustrated or angry instead of shaking the

baby. Such a recommendation should continue to be

made; however, one should closely monitor how

frequently the parent needs to place the child in the crib

and not respond. It is also acceptable for a child to cry

when intrusive medical procedures need to be done to

save the life of a child, treat a sick infant or give

immunizations. Although, it may be advisable to have

the primary caregiver present and promptly hold and

comfort the infant. However, letting a baby cry because

it is ‘good for their lung development’ (as some parents

argue clinically), because it will ‘spoil’ the baby or

because the baby needs to find their own ways to self-

soothe might not be advisable during the first six months

of life. Similarly, it is acceptable to let a baby cry during

the second six months of life when the crying is not

related to attachment (eg, when the child is not

physically hurt, ill or frightened/emotionally distressed).

Therefore, it is acceptable, from an attachment

perspective, to use the Ferber method (50) or another

sleep method, but only if the child does not have an ear

infection, teething, etc.

• During the first six months of life, promptly picking up a

baby who is crying is associated with four major outcomes

by the end of the first year of life. First, the baby cries

less. Second, the baby has learned to self-soothe. Third, if

the baby needs the caregiver to soothe him/her, the baby

will respond more promptly. And finally, the caregiver

who responded promptly and warmly most of the time

(not all the time; nobody can respond ideally all of the

time) to the baby’s cries, will have created secure,

organized attachment with all of the associated benefits.

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Paediatr Child Health Vol 9 No 8 October 2004544

REFERENCES 1. Dozier M, Stovall KC, Albus KA. Attachment and psychopathology in

adulthood. In: Cassidy J, Shaver PR, eds. Handbook of Attachment. New York: Guilford Press, 1999:497-519.

2. Green J, Goldwyn R. Annotation: attachment disorganisation and psychopathology: new findings in attachment research and their potential implications for developmental psychopathology in childhood. J Child Psychol Psychiatry 2002;43:835-46.

3. Greenberg MT. Attachment and psychopathology in childhood. In: Cassidy J, Shaver PR, eds. Handbook of Attachment. New York: Guilford Press, 1999:469-98.

4. Bowlby J. Attachment and Loss. Volume 1: Attachment, 2nd edn. New York: Basic Books, 1982.

5. Waters E, Cummings EM. A secure base from which to explore close relationships. Child Dev 2000;71:164-72.

6. Klaus MH, Kennell JH. Maternal-Infant Bonding: The Impact of Early Separation or Loss on Family Development. St Louis: Mosby, 1976.

7. Ainsworth MDS, Blehar MD, Waters E, Wall S. Patterns of Attachment. Hillsdale: Erlbaum, 1978.

8. Sroufe LA. The role of infant-caregiver attachments in development. In: Belsky J, Nezworski T, eds. Clinical Implications of Attachment. Hillsdale: Erlbaum, 1988:18-38.

9. van IJzendoorn MH, Schuengel C, Bakermans-Kranenburg MJ. Disorganized attachment in early childhood: Meta-analysis of precursors, concomitants and sequelae. Dev Psychopathol 1999;11:225-49.

10. Lyons-Ruth K, Bronfman E, Atwood G. A relational diathesis model of hostile-helpless states of mind: Expressions in mother-infant interactions. In: Solomon J, George C, eds. Attachment Disorganization. New York: Guilford Press, 1999:33-70.

11. Schuengel C, Bakermans-Kranenburg MJ, van IJzendoorn MH, Blom M. Unresolved loss and infant disorganization: Links to frightening maternal behavior. In: Solomon J, George C, eds. Attachment Disorganization. New York: Guilford Press, 1999:71-94.

12. Zeanah CH, Danis B, Hirshberg L, Benoit D, Miller D, Heller SS. Disorganized attachment associated with partner violence: A research note. Infant Ment Health J 1999;20:77-86.

Benoit.qxd 24/09/2004 2:52 PM Page 544

Infant-parent attachment

Paediatr Child Health Vol 9 No 8 October 2004 545

13. Main M, Solomon J. Discovery of an insecure- disorganized/disoriented attachment pattern. In: Brazelton TB, Yogman MW, eds. Affective Development in Infancy. Norwood: Ablex, 1986:95-124.

14. Main M, Solomon J. Procedures for identifying infants as disorganized/disoriented during the Ainsworth Strange Situation. In: Greenberg MT, Cummings EM, eds. Attachment in the Preschool Years. Chicago: University Press, 1990:121-60.

15. Main M, Hesse E. Parents’ unresolved traumatic experiences are related to infant disorganized attachment status: Is frightened and/or frightening behavior the linking mechanism? In: Greenberg MT, Cicchetti D, Cummings EM, eds. Attachment in the Preschool Years. Chicago: University of Chicago Press, 1990:161-82.

16. Egeland B, Hiester M. The long-term consequences of infant day-care and mother-infant attachment. Child Dev 1995;66:474-85.

17. van IJzendoorn MH, Sagi A, Lambermon MWE. The multiple caretaker paradox: Data from Holland and Israel. In: Pianta RC, ed. New Directions for Child Development. No 57. Beyond the Parent: The role of Other Adults in Children’s Lives. San Francisco: Jossey-Bass, 1992:5-24.

18. Boris NW, Fueyo M, Zeanah CH. Clinical assessment of attachment in children under five. J Am Acad Child Adolesc Psychiatry 1997;36:291-3.

19. Carlson EA. A prospective longitudinal study of attachment disorganized/disoriented. Child Dev 1998;69:1107-28.

20. Lyons-Ruth K, Block D. The disturbed caregiving system: Relations among childhood trauma, maternal caregiving and infant affect and attachment. Infant Ment Health J 1996;17:257-75.

21. Lyons-Ruth K, Alpern L, Repacholi B. Disorganized infant attachment classification and maternal psychosocial problems as predictors of hostile-aggressive behavior in the preschool classroom. Child Dev 1993;64:572-85.

22. Main M, Cassidy J. Categories of response to reunion with the caregiver at age six: Predictable from infant attachment classifications and stable over a one-month period. Dev Psychopathol 1988;24:415-26.

23. Main M, Morgan H. Disorganization and disorientation in infant strange situation behavior: Phenotypic resemblance to dissociative states? In: Michelson LK, Ray WJ, eds. Handbook of Dissociation: Theoretical, Empirical and Clinical Perspectives. New York: Plenum Press, 1996:107-38.

24. Zeanah CH, Boris NW, Larrieu JA. Infant development and developmental risk: A review of the past 10 years. J Am Acad Child Adolesc Psychiatry 1997;36:165-78. Erratum in: 1998;37:240.

25. Hertsgaard L, Gunnar M, Erickson MF, Nachmias M. Adrenocortical responses to the strange situation in infants with disorganized/disoriented attachment relationships. Child Dev 1995;66:1100-6.

26. Splanger G, Grossmann KE. Biobehavioral organization in securely and insecurely attached infants. Child Dev 1993;64:1439-50.

27. Greenberg MT, Speltz ML, DeKlyen M. The role of attachment in the early development of disruptive behavior problems. Dev Psychopathol 1993;3:413-30.

28. Lyons-Ruth K. Attachment relationships among children with aggressive behavior problems: The role of disorganized early attachment patterns. J Consult Clin Psychol 1996;64:64-73.

29. Lyons-Ruth K, Easterbrooks MA, Cibelli CD. Infant attachment strategies, infant mental lag, and maternal depressive symptoms: Predictors of internalizing and externalizing problems at age 7. Dev Psychol 1997;33:681-92.

30. Solomon J, George C, De Jong A. Children classified as controlling at age six: Evidence of disorganized representational strategies and aggression at home and at school. Dev Psychopathol 1995;7:447-63.

31. Speltz ML, Greenberg MT, Deklyen M. Attachment in preschoolers with disruptive behavior: A comparison of clinic-referred and nonproblem children. Dev Psychopathol 1990;2:31-46.

32. Cicchetti D, Barnett D. Attachment organization in maltreated pre-schoolers. Dev Psychopathol 1991;3:397-411.

33. Lyons-Ruth K, Connell D, Zoll D, Stahl J. Infants at social risk: Relations among infant maltreatment, maternal behavior, and infant attachment behavior. Dev Psychol 1987;23:223-32.

34. Lyons-Ruth K, Repacholi B, McLeod S, Silva E. Disorganized attachment behavior in infancy: Short-term stability, maternal and infant correlates, and risk-related subtypes. Dev Psychopathol 1991;3:377-96.

35. Shaw DS, Vondra JI. Infant attachment security and maternal predictors of early behavior problems: A longitudinal study of low-income families. J Abnorm Child Psychol 1995;23:335-57.

36. Lyons-Ruth K, Jacobvitz D. Attachment disorganization: Unresolved loss, relational violence and lapses in behavioral and attentional strategies. In: Cassidy J, Shaver PR, eds. Handbook of Attachment. New York: Guilford Press, 1999:520-54.

37. Jacobvitz D, Hazan N. Developmental pathways from infant disorganization to childhood peer relationships. In: Solomon J, George C, eds. Attachment Disorganization. New York: Guilford Press, 1999.

38. Greenberg MT, Speltz ML, Deklyen M, Endriga MC. Attachment security in pre-schoolers with and without externalizing problems: A replication. Dev Psychopathol 1991;3:413-30.

39. Moss E, Rousseau D, Parent S, St-Laurent D, Saintonge J. Correlates of attachment at school age: Maternal reported stress, mother-child interaction, and behavior problems. Child Dev 1998;69:1390-405.

40. Goldwyn R, Stanley C, Smith V, Green JM. The Manchester Child Attachment Story Task: Relationship with parental AAI, SAT and child behavior. Attach Hum Dev 2000;2:71-84.

41. Cassidy, J. Child-mother attachment and the self in six-year-olds. Child Dev 1988;59:121-34.

42. Verschueren K, Marcoen A. Representation of self and socioemotional competence in kindergartners: Differential and combined effects of attachment to mother and to father. Child Dev 1999;70:183-201.

43. Verschueren K. Narratives in attachment research. Biennial meeting of the European Society of Developmental Psychology. Uppsala, 2001.

44. Jacobsen T, Edelstein W, Hofmann V. A longitudinal study of the relation between representations of attachment in childhood and cognitive functioning in childhood and adolescence. Dev Psychol 1994;30:112-24.

45. Hesse E, van IJzendoorn MH. Parental loss of close family members and propensities towards absorption in offspring. Dev Sci 1998;1:299-305.

46. World Health Organization. International Classification of Diseases: Clinical Descriptions and Diagnostic Guidelines, 10th edn. Geneva: World Health Organization, 1992.

47. American Psychiatric Association. Diagnositic and Statistical Manual of Mental Disorders, 4th edn (DSM-IV). Washington: American Psychiatric Association, 1994.

48. Zeanah CH, Mammen OK, Lieberman AF. Disorders of Attachment. Handbook of Infant Mental Health. New York: Guilford Press, 1993:332-49.

49. Zeanah CH, Boris NW. Disturbances and Disorders of Attachment in Early Childhood. Handbook of Infant Mental Health, 2nd edn. New York: Guilford Press, 2000:358-81.

50. Ferber R. Solve Your Child’s Sleep Problems. New York: Simon & Schuster, 1985.

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