Skip to main content

Preventive interventions and sustained attachment security in maltreated children

  • Erin Pickreign Stronach (a1), Sheree L. Toth (a1), Fred Rogosch (a1) and Dante Cicchetti (a1) (a2)

Thirteen-month-old maltreated infants (n = 137) and their mothers were randomly assigned to one of three conditions: child–parent psychotherapy (CPP), psychoeducational parenting intervention (PPI), or community standard (CS). A fourth group of nonmaltreated infants (n = 52) and their mothers served as a nonmaltreated comparison (NC) group. A prior investigation found that the CPP and the PPI groups demonstrated substantial increases in secure attachment at postintervention, whereas this change was not found in the CS and the NC groups. The current investigation involved the analysis of data obtained at a follow-up assessment that occurred 12 months after the completion of treatment. At follow-up, children in the CPP group had higher rates of secure and lower rates of disorganized attachment than did children in the PPI or the CS group. Rates of disorganized attachment did not differ between the CPP and the NC groups. Intention to treat analyses also showed higher rates of secure attachment at follow-up in the CPP group relative to the PPI and the CS groups. However, groups did not differ on disorganized attachment. Both primary and intention to treat analyses demonstrated that maternal-reported child behavior problems did not differ among the four groups at the follow-up assessment. This is the first investigation to demonstrate sustained attachment security in maltreated children 12 months after the completion of an attachment theory informed intervention. The findings also suggest that, although effective in the short term, parenting interventions alone may not be effective in maintaining secure attachment in children over time.

Corresponding author
Address correspondence and reprint requests to: Erin Pickreign Stronach, Mt. Hope Family Center, University of Rochester, 187 Edinburgh Street, Rochester, NY 14608;; or Sheree L. Toth, Mt. Hope Family Center, University of Rochester, 187 Edinburgh Street, Rochester, NY 14608;
Hide All
Abrams, K., Rifkin, A., & Hesse, E. (2006). Examining the role of parental frightened/frightening subtypes in predicting disorganized attachment within a brief observation procedure. Development and Psychopathology, 18, 345361.
Achenbach, T. M. (1992). Manual for the Child Behavior Checklist/2–3 and 1992 profile. Burlington, VT: University of Vermont, Department of Psychiatry.
Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Hillsdale, NJ: Erlbaum.
Azar, S. T. (2002). Parenting and child maltreatment. In Bornstein, M. H. (Ed.), Handbook of parenting: Vol. 4. Social conditions and applied parenting (2nd ed., pp. 361388). Mahwah, NJ: Erlbaum.
Ballen, N., Bernier, A., Moss, E., Tarabulsy, G. M., & St.-Laurent, D. (2010). Insecure attachment states of mind and atypical caregiving behavior among foster mothers. Journal of Applied Developmental Psychology, 31, 118125.
Banyard, V. L., Williams, L. M., & Siegal, J. A. (2003). The impact of complex trauma and depression on parenting: An exploration of mediating risk and protective factors. Child Maltreatment, 8, 333349.
Barnett, D., Ganiban, J., & Cicchetti, D. (1999). Maltreatment, negative expressivity, and the development of Type D attachments from 12 to 24 months of age. Monographs of the Society for Research in Child Development, 64, 97118.
Barnett, D., Manly, J. T., & Cicchetti, D. (1993). Defining child maltreatment: The interface between policy and research. In Cicchetti, D. & Toth, S. L. (Eds.), Child abuse, child development, and social policy (pp. 773). Norwood, NJ: Ablex.
Beauchaine, T. P., Webster-Stratton, C., & Reid, M. J. (2005). Mediators, moderators, and predictors of 1-year outcomes among children treated for early-onset conduct problems: A latent growth curve analysis. Journal of Consulting and Clinical Psychology, 73, 371388.
Bernard, K., Dozier, M., Bick, J., Lewis-Morrarty, E., Lindhiem, O., & Carlson, E. (2012). Enhancing attachment organization among maltreated children: Results of a randomized clinical trial. Child Development, 83, 623636.
Bernstein, D. P., Stein, J. A., Newcomb, M. D., Walker, E., Pogge, D., Ahluvalia, T., et al. (2003). Development and validation of a brief screening version of the Childhood Trauma Questionnaire. Child Abuse & Neglect, 27, 169190.
Bowlby, J. (1969). Attachment and loss: Vol. 1. Attachment (rev. ed.). Harmondsworth: Penguin.
Bowlby, J. (1973). Attachment and loss: Vol. 2. Separation: Anxiety and anger. Harmondsworth: Penguin.
Bureau, J. F., Easterbrooks, M. A., & Lyons-Ruth, K. (2009). Attachment disorganization and controlling behavior in middle childhood: Maternal and child precursors and correlates. Attachment and Human Development, 11, 265284.
Cassidy, J., & Marvin, R. S. (1992). Attachment organization in preschool children: Procedures and coding manual. Unpublished manuscript, Pennsylvania State University and University of Virginia.
Cicchetti, D. (1984). The emergence of developmental psychopathology. Child Development, 55, 17.
Cicchetti, D. (1993). Developmental psychopathology: Reactions, reflections, projections. Developmental Review, 13, 471502.
Cicchetti, D. (2002). The impact of social experience on neurobiological systems: Illustration from a constructivist view of child maltreatment. Cognitive Development, 17, 14071428.
Cicchetti, D., & Barnett, D. (1991). Attachment organization in maltreated preschoolers. Development and Psychopathology, 3, 397411.
Cicchetti, D., & Lynch, M. (1995). Failures in the expectable environment and their impact on individual development: The case of child maltreatment. In Cicchetti, D. & Cohen, D. J. (Eds.), Developmental psychopathology: Vol. 2. Risk, disorder, and adaptation (pp. 3271). Oxford: Wiley.
Cicchetti, D., Rogosch, F., & Toth, S. L. (2006). Fostering secure attachment in infants in maltreating families through preventive interventions. Development and Psychopathology, 18, 623649.
Cicchetti, D., & Toth, S. L. (1995). A developmental perspective on child abuse and neglect. Journal of the American Academy of Child & Adolescent Psychiatry, 34, 541565.
Cicchetti, D., & Toth, S. L. (2005). Child maltreatment. Annual Review of Clinical Psychology, 1, 409438.
Cicchetti, D., Toth, S. L., & Lynch, M. (1995). Bowlby's dream comes full circle: The application of attachment theory to risk and psychopathology. In Ollendick, T. & Prinz, R. (Eds.), Advances in clinical child psychology (pp. 175). New York: Plenum Press.
Cicchetti, D., & Valentino, K. (2006). An ecological–transactional perspective on child maltreatment: Failure of the average expectable environment and its influence on child development. In Cicchetti, D. & Cohen, D. (Eds.), Developmental psychopathology (Vol. 3, pp. 129201). Hoboken, NJ: Wiley.
Cohen, L. R., Hien, D. A., & Batchelder, S. (2008). The impact of cumulative maternal trauma and diagnosis on parenting behavior. Child Maltreatment, 13, 2738.
Cort, N. A., Toth, S. L., Cerulli, C., & Rogosch, F. (2011). Maternal intergenerational transmission of childhood multitype maltreatment. Journal of Aggression, Maltreatment & Trauma, 20, 2039.
Cyr, C., Euser, E., Bakermans-Kranenburg, M. J., & van IJzendoorn, M. (2010). Attachment security and disorganization in maltreating and high-risk families: A series of meta-analyses. Development and Psychopathology, 22, 87108.
Easterbrooks, M. A., Davidson, C., & Chazan, R. (1993). Psychosocial risk, attachment, and behavior problems among school-aged children. Development and Psychopathology, 5, 389402.
Egeland, B., Jacobvitz, D., & Sroufe, A. (1988). Breaking the cycle of child abuse. Child Development, 59, 10801088.
Fearon, R. P., Bakermans-Kranenburg, M. J., van IJzendoorn, M., Lapsley, A., & Roisman, G. I. (2010). The significance of insecure attachment and disorganization in the development of children's externalizing behavior: A meta-analytic study. Child Development, 81, 435456.
Fisher, P. A., Kim, H. K., & Pears, K. C. (2009). Effects of multidimensional treatment foster care for preschoolers (MTFC-P) on reducing permanent placement failures among children with placement instability. Children and Youth Services Review, 31, 541546.
Forgatch, M. S., Patterson, G. R., DeGarmo, D. S., & Beldavs, Z. G. (2009). Testing the Oregon delinquency model with 9-year follow-up of the Oregon Divorce Study. Development and Psychopathology, 21, 637660.
Fraiberg, S., Adelson, E., & Shapiro, V. (1975). Ghosts in the nursery: A psychoanalytic approach to impaired infant–mother relationships. Journal of the American Academy of Child Psychiatry, 14, 387421.
Fraiberg, S., Lieberman, A. F., Pekarsky, J. H., & Pawl, J. H. (1981). Treatment and outcome in an infant psychiatry program: I. Journal of Preventive Psychiatry, 1, 89111.
George, M. R. W., Cummings, E. M., & Davies, P. T. (2010). Positive aspects of fathering and mothering, and children's attachment in kindergarten. Early Child Development and Care, 180, 107119.
Hesse, E., & Main, M. (2006). Frightened, threatening, and dissociative parental behavior in low-risk samples: Description, discussion, and interpretations. Development and Psychopathology, 18, 309343.
Hildyard, K. L., & Wolfe, D. A. (2002). Child neglect: Developmental issues and outcomes. Child Abuse & Neglect, 26, 679695.
Isabella, R. A. (1993). Origins of attachment: Maternal interactive behavior across the first year. Child Development, 64, 605621.
Jaccard, J., & Guilamo-Ramos, V. (2002). Analysis of variance frameworks in clinical child and adolescent psychology: Issues and recommendations. Journal of Clinical Child and Adolescent Psychology, 31, 130146.
Jonson-Reid, M., Presnall, N., Drake, B., Fox, L., Bierut, L., Reich, W., et al. (2010). Effects of child maltreatment and inherited liability on antisocial development: An official records study. Journal of the American Academy of Child & Adolescent Psychiatry, 49, 321332.
Kim, J., & Cicchetti, D. (2003). Social self-efficacy and behavior problems in maltreated children. Journal of Clinical Child and Adolescent Psychology, 32, 106117.
Lau, A. S., Valeri, S. M., McCarty, C. A., & Weisz, J. R. (2006). Abusive parents' reports of child behavior problems: Relationship to observed parent–child interactions. Child Abuse & Neglect, 30, 639655.
Lieberman, A. F. (2007). Ghosts and angels: Intergenerational patterns in the transmission and treatment of traumatic sequelae of domestic violence. Infant Mental Health Journal, 28, 422439.
Lieberman, A. F., Ghosh Ippen, C., & Van Horn, P. (2006). Child–parent psychotherapy: 6-month follow-up of a randomized controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 45, 913918.
Lieberman, A. F., & Van Horn, P. (2005). Don't hit my mommy: A manual for child parent psychotherapy with young witnesses of family violence. Washington, DC: Zero to Three Press.
Lieberman, A. F., Van Horn, P., & Ghosh Ippen, C. (2005). Toward evidence-based treatment: Child–parent psychotherapy with preschoolers exposed to marital violence. Journal of the American Academy of Child & Adolescent Psychiatry, 44, 12411248.
Lieberman, A. F., Weston, D. R., & Pawl, J. H. (1991). Preventive intervention and outcome with anxiously attached dyads. Child Development, 62, 199209.
Lyons-Ruth, K., & Block, D. (1996). The disturbed caregiving system: Relations among childhood trauma, maternal caregiving, and infant affect and attachment. Infant Mental Health Journal, 17, 257275.
Lyons-Ruth, K., Bronfman, E., & Parsons, E. (1999). Atypical attachment in infancy and early childhood among children at developmental risk: Part IV. Maternal frightened, frightening, or atypical behavior and disorganized infant attachment patterns. Monographs of the Society for Research in Child Development, 64, 6796.
Lyons-Ruth, K., Connell, D. B., Grunebaum, H. U., & Botein, S. (1990). Infants at social risk: Maternal depression and family support services as mediators of infant development and security of attachment. Child Development, 61, 8598.
Lyons-Ruth, K., Connell, D. B., Zoll, D., & Stahl, J. (1987). Infants at social risk: Relations among infant maltreatment, maternal behavior, and infant attachment behavior. Developmental Psychology, 23, 223232.
Lyons-Ruth, K., Easterbrooks, M. A., & Cibelli, C. D. (1997). Infant attachment strategies, infant mental lag, and maternal depressive symptoms: Predictors of internalizing and externalizing problems at age 7. Developmental Psychology, 33, 681692.
Lyons-Ruth, K., & Jacobvitz, D. (2008). Attachment disorganization: Genetic factors, parenting contexts, and developmental transformation from infancy to adulthood. In Cassidy, J. & Shaver, P. R. (Eds.), Handbook of attachment: Theory, research, and clinical applications (2nd ed., pp. 666697). New York: Guilford Press.
Madigan, S., Moran, G., & Pederson, D. R. (2006). Unresolved states of mind, disorganized attachment relationships, and disrupted interactions of adolescent mothers and their infants. Developmental Psychology, 42, 293304.
Main, M., & Cassidy, J. (1988). Categories of response to reunion with parent at age 6: Predictable from infant attachment classifications and stable over a 1-month period. Developmental Psychology, 24, 415426.
Main, M., & Hesse, E. (1990). Parents' unresolved traumatic experiences are related to infant disorganized attachment status: Is frightened and/or frightening parental behavior the linking mechanism. In Greenberg, M.T., Cicchetti, D., & Cummings, E. M. (Eds.), Attachment in the preschool years: Theory, research, and intervention (pp. 161182). Chicago: University of Chicago Press.
Main, M., Kaplan, N., & Cassidy, J. (1985). Security in infancy, childhood, and adulthood: A move to the level of representation. Monographs of the Society for Research in Child Development, 50, 66104.
Main, M., & Solomon, J. (1990). Procedures for identifying infants as disorganized/disoriented during the Ainsworth Strange Situation. In Greenberg, M. T., Cicchetti, D., & Cummings, E. M. (Eds.), Attachment in the preschool years: Theory, research, and intervention (pp. 121160). Chicago: University of Chicago Press.
Manly, J. T., Kim, J. E., Rogosch, F. A., & Cicchetti, D. (2001). Dimensions of child maltreatment and children's adjustment: Contributions of developmental timing and subtype. Development and Psychopathology, 13, 759782.
Mesman, J., & Koot, H. M. (2000). Child-reported depression and anxiety in preadolescence: I. associations with parent- and teacher-reported problems. Journal of the American Academy of Child & Adolescent Psychiatry, 39, 13711378.
Moran, G., Pederson, D. R., & Krupka, A. (2005). Maternal unresolved attachment status impedes the effectiveness of interventions with adolescent mothers. Infant Mental Health Journal, 26, 231249.
Moss, E., Cyr, C., & Dubois-Comtois, K. (2004). Attachment at early school age and developmental risk: Examining trajectories of controlling-caregiving, controlling-punitive and behaviorally disorganized children. Developmental Psychology, 40, 519532.
Moss, E., Dubois-Comtois, K., Cyr, C., Tarabulsy, G. M., St.-Laurent, D., & Bernier, A. (2011). Efficacy of a home-visiting intervention aimed at improving maternal sensitivity, child attachment, and behavioral outcomes for maltreated children: A randomized control trial. Development and Psychopathology, 23, 195210.
Moss, E., & St.-Laurent, D. (2001). Attachment at school age and academic performance. Developmental Psychology, 37, 863874.
Munson, J. A., McMahon, R. J., & Spieker, S. J. (2001). Structure and variability in the developmental trajectory of children's externalizing problems: Impact of infant attachment, maternal depressive symptomatology, and child sex. Development and Psychopathology, 13, 277296.
Olds, D. L., Henderson, C. R., Cole, R., Eckenrode, J., Kitzman, H., Luckey, D., et al. (1998). Long-term effects of home visitation on children's criminal and antisocial behavior. Journal of the American Medical Association, 280, 12381244.
Olds, D. L., & Kitzman, H. (1990). Can home visitation improve the health of women and children at environmental risk? Pediatrics, 86, 108116.
Osofsky, J. D., Kronenberg, M., Hammer, J. H., Lederman, C., Katz, L., Adams, S., et al. (2007). The development and evaluation of the intervention model for the Florida infant mental health pilot program. Infant Mental Health Journal, 28, 259280.
Osofsky, J. D., & Lieberman, A. F. (2011). A call for integrating a mental health perspective into systems of care for abused and neglected infants and young children. American Psychologist, 66, 120128.
Pears, K. C., & Capaldi, D. M. (2001). Intergenerational transmission of abuse: A two-generational prospective study of an at-risk sample. Child Abuse & Neglect, 25, 14391461.
Robins, L. N., Cottler, L. B., Bucholz, K. K., Compton, W. M., North, C. S., & Rourke, K. M. (2000). Diagnostic Interview Schedule for the DSM-IV (DIS-IV). St. Louis, MO: Washington University School of Medicine.
Rogosch, F. A., Cicchetti, D., Shields, A., & Toth, S. L. (1995). Parenting dysfunction in child maltreatment. In Bornstein, M. H. (Ed.), Handbook of parenting (Vol. 4, pp. 127159). Hillsdale, NJ: Erlbaum.
Schneider-Rosen, K., Braunwald, K. G., Carlson, V., & Cicchetti, D. (1985). Current perspectives in attachment theory: Illustration from the study of maltreated infants. Monographs of the Society for Research in Child Development, 50, 194210.
Schuengel, C., Bakermans-Kranenburg, M. J., & van IJzendoorn, M. H. (1999). Frightening maternal behavior linking unresolved loss and disorganized attachment. Journal of Consulting and Clinical Psychology, 67, 5463.
Shonk, S. M., & Cicchetti, D. (2001). Maltreatment, competency deficits, and risk for academic and behavioral maladjustment. Developmental Psychology, 37, 317.
Simon, N. M., Herlands, N. N., Marks, E. H., Mancini, C., Letamendi, A., Li, Z., et al. (2009). Childhood maltreatment linked to greater severity and poorer quality of life and function in social anxiety disorder. Depression and Anxiety, 26, 10271032.
Sroufe, L. A. (1983). Infant–caregiver attachment and patterns of adaptation in preschool: The roots of maladaptation and competence. In Permutter, M. (Ed.), Development and policy concerning children with special needs: Minnesota Symposia on Child Psychology (Vol. 16, pp. 4183). Hillsdale, NJ: Erlbaum.
Sroufe, L. A., & Rutter, M. (1984). The domain of developmental psychopathology. Child Development, 55, 1729.
Toth, S. L., & Cicchetti, D. (1999). Developmental psychopathology and child psychotherapy. In Russ, S. & Ollendick, T. (Eds.), Handbook of psychotherapies with children and families (pp. 1544). New York: Plenum Press.
Toth, S. L., Cicchetti, D., Macfie, J., Rogosch, F. A., & Maughan, A. (2000). Narrative representations of moral–affiliative and conflictual themes and behavioral problems in maltreated preschoolers. Journal of Clinical Child Psychology, 29, 307318.
Toth, S. L., Maughan, A., Manly, J. T., Spagnola, M., & Cicchetti, D. (2002). The relative efficacy of two interventions in altering maltreated preschool children's representational models: Implications for attachment theory. Development and Psychopathology, 14, 877908.
Toth, S. L., Rogosch, F. A., Manly, J. T., & Cicchetti, D. (2006). The efficacy of toddler–parent psychotherapy to reorganize attachment in the young offspring of mothers with major depressive disorder: A randomized preventive trial. Journal of Consulting and Clinical Psychology, 74, 10061016.
van IJzendoorn, M. H., Schuengel, C., & Bakermans-Kranenburg, M. (1999). Disorganized attachment in early childhood: Meta-analysis of precursors, concomitants, and sequelae. Development and Psychopathology, 11, 225250.
Walker, E. A., Unutzer, J., Rutter, C., Gelfand, A., Saunders, K., VonKorff, M., et al. (1999). Costs of health care use by women HMO members with a history of childhood abuse and neglect. Archives of General Psychiatry, 56, 609613.
Weinfield, M., Sroufe, L. A., Egeland, B., & Carlson, E. (1999). The nature of individual difference in infant–caregiver attachment. In Cassidy, J. & Shaver, D. (Eds.), Handbook of attachment: Therapy, research, and clinical implications (pp. 6888). New York: Guilford Press.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Development and Psychopathology
  • ISSN: 0954-5794
  • EISSN: 1469-2198
  • URL: /core/journals/development-and-psychopathology
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Full text views

Total number of HTML views: 21
Total number of PDF views: 265 *
Loading metrics...

Abstract views

Total abstract views: 749 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 23rd May 2018. This data will be updated every 24 hours.