Journal of Consulting and Clinical Psychology Copyright 2006 by the American Psychological Association 2006, Vol. 74, No. 6, 1006–1016 0022-006X/06/$12.00 DOI: 10.1037/0022-006X.74.6.1006 The Efficacy of Toddler–Parent Psychotherapy to Reorganize Attachment in the Young Offspring of Mothers With Major Depressive Disorder: A Randomized Preventive Trial Sheree L. Toth, Fred A. Rogosch, and Dante Cicchetti Jody Todd Manly University of Minnesota University of Rochester The development of insecure attachment relationships in the offspring of mothers with major depressive disorder (MDD) may initiate a negative trajectory leading to future psychopathology. Therefore, the provision of theoretically guided interventions designed to promote secure attachment is of paramount importance. Mothers who had experienced MDD since their child’s birth were recruited (n ϭ 130) and randomized to toddler–parent psychotherapy (DI) or to a control group (DC). Nondepressed mothers with no current or history of major mental disorder and their toddlers also were recruited for a nondepressed comparison group (NC; n ϭ 68). Children averaged 20.34 months of age at the initial assessment. Higher rates of insecure attachment were present in both the DI and the DC groups at baseline, relative to the NC group. At postintervention, at age 36 months, insecure attachment continued to predominate in the DC group. In contrast, the rate of secure attachment had increased substantially in the DI group and was higher than that for the DC and the NC groups. These results demonstrate the efficacy of toddler–parent psychotherapy in fostering secure attachment relationships in young children of depressed mothers. Keywords: attachment, maternal depression, preventive intervention Research coalesces to support the fact that young offspring of in offspring of depressed mothers is not depression per se but mothers with depressive disorders are at increased risk for the inadequate parenting (Goodman & Gotlib, 2002). Mothers with development of mental disorders (Birmaher et al., 1996; Cicchetti MDD have been shown to be less sensitive parents, to exhibit & Toth, 1998; Kovacs, 1989, 1996). Early difficulties in develop- greater negativity and less positive affect during mother–child ing a secure attachment relationship in these children may be one interactions, and to be poor disciplinarians (cf. Cicchetti & Toth, factor that contributes to the emergence of future psychopathology 1995; Downey & Coyne, 1990; Gelfand & Teti, 1990; Lovejoy, (Cummings & Cicchetti, 1990). Therefore, the provision of a Graczyk, O’Hare, & Neuman, 2000; Lyons-Ruth, Lyubchik, preventive intervention designed to promote attachment security Wolfe, & Bronfman, 2002). Children of depressed mothers also among these offspring assumes both theoretical and clinical sig- have been shown to be at increased risk for the development of nificance. In this article, we evaluate the efficacy of an attachment- insecure attachment relationships, because they often have expe- theory-informed preventive intervention, toddler–parent psycho- rienced maternal physical and psychological unavailability (Cum- therapy (TPP; Cicchetti, Toth, & Rogosch, 1999; Lieberman, mings & Cicchetti, 1990). Bowlby (1969, 1973, 1980) maintained 1992), for fostering attachment security in the toddler offspring of that separation from the primary caregiver leads to anxiety for mothers with a major depressive disorder (MDD). children. He argued that when children are confronted with periods of prolonged loss, including parental psychological unavailability, Depression and Caregiving the development of a secure internal working model of the care- giver is impaired. In fact, insecure attachment during the early There is considerable evidence that maternal depression is as- years of life has been consistently linked with unresponsive, in- sociated with impaired caregiving to offspring. In fact, the single sensitive, and rejecting caregiving (see DeWolff & van IJzen- most prominent mechanism to explain maladaptive development doorn, 1997, and Teti & Nakagawa, 1990, for reviews). Therefore, there is significant evidence to suggest that being reared by a depressed caregiver places children at risk for the development of Sheree L. Toth, Fred A. Rogosch, and Jody Todd Manly, Mount Hope insecure attachment relationships (Cicchetti et al., 1999; Coyl, Family Center, University of Rochester; Dante Cicchetti, Institute of Child Roggman, & Newland, 2002). Development, University of Minnesota. This research was supported by National Institute of Mental Health Grant R01 MH45027. Thanks go to the children and families who partic- Depression and Attachment ipated in this investigation and to Maureen Carroll for her assistance with manuscript preparation. Investigations have examined the quality of attachment relation- Correspondence concerning this article should be addressed to Sheree L. ships in the offspring of parents with a mood disorder (see, e.g., Toth, Mount Hope Family Center, University of Rochester, 187 Edinburgh Cicchetti et al., 1999; DeMulder & Radke-Yarrow, 1991; Radke- Street, Rochester, NY 14608. E-mail: [email protected] Yarrrow, Cummings, Kuczynski, & Chapman, 1985; Teti, Gel- 1006 SPECIAL SECTION: TODDLER ATTACHMENT AND MDD 1007 fand, Messinger, & Isabella, 1995). Overall, associations have Preventive Interventions for Insecure Attachment been found between maternal depression and higher rates of inse- cure attachment as well as between more severe and chronic Although initially attachment theory was more firmly grounded depression and disorganized attachment (Campbell, Cohn, Meyers, in developmental research than in clinical applications, in recent Ross, & Flanagan, 1993; Goodman & Gotlib, 2002; Lyons-Ruth, years the relevance of this body of work for the development of Connell, Grunebaum, & Botein, 1990; Murray, 1992; Teti et al., interventions has been much more widely appreciated (Cicchetti & 1995). Campbell et al. (1993) reported that insecure attachments Toth, 2006; Oppenheim, 2004). Because offspring of depressed were more prevalent in infants who had a mother with postpartum caregivers are at increased risk for the development of insecure depression that exceeded the first 6 months of their baby’s life. attachment relationships, the importation of research on attach- Similarly, Murray (1992) found that insecure attachment was more ment into the development and evaluation of preventive interven- frequent among toddlers of postnatally depressed mothers than tions for this population is particularly salient. Moreover, because among toddlers of well mothers. Insecure attachment also has been even infants with secure attachment relationships may develop shown to be associated with maternal depression in preschoolers, insecure attachments over time (Thompson, 1998), preventive and mothers with more chronic depression have children who do interventions for young offspring of depressed caregivers emerge not exhibit coherent attachment strategies (Teti et al., 1995). as an important avenue to pursue. Although depressed women may It is important to note, however, that not all children of de- receive therapeutic interventions that involve pharmacological pressed parents develop insecure attachment relationships. DeMul- treatments, individual psychotherapy, or both, it is less likely that der and Radke-Yarrow (1991) found that the rate of insecure such interventions consider the woman as a mother and also attachment in children of mothers with unipolar depression did not address the relationship that is forming between mother and child. differ from that of children with nondepressed mothers. Frankel, Disregard for this evolving relationship may result in an increased Maslin-Cole, and Harmon (1991) also reported that attachment risk for the emergence of an insecure attachment relationship and security in 3-year-olds did not differ among children with de- associated developmental maladaptations for the child. pressed and well mothers. These conflicting results highlight the A number of interventions for offspring of depressed mothers importance of considering issues related to sample characteristics have been developed and evaluated (Cicchetti et al., 1999; Cooper and recruitment (e.g., community vs. treatment samples, chronic & Murray, 1997; Field et al., 2000; Gelfand, Teti, Seiner, & vs. postpartum-only depression, middle-income vs. impoverished Jameson, 1996). Field et al. (1996) explored the effects of massage samples). therapy versus a rocking control in 1- to 3-month-old infants of In a meta-analytic review of 16 published investigations of the depressed adolescent mothers. Infants assigned to the massage relationship between disorganized attachment and parental depres- group were found to be more likely to sleep following the inter- sion, van IJzendoorn, Schuengel, and Bakermans-Kranenburg vention; gained more weight; and evidenced improvement on (1999) found only a small and nonsignificant effect size of .06. measures of emotionality, sociability, and soothability dimensions When only samples meeting criteria for clinically diagnosed de- of temperament as well as on physiological indicators of lowered pression were examined, a significant but still small effect size was stress. Investigations also have found that teaching mothers to found (van IJzendoorn et al., 1999). Because this meta-analysis interact with or to touch their infants may yield improved parent- focused only on correlates of disorganized attachment and not on ing