Development and Psychopathology 18 ~2006!, 623–649 Copyright © 2006 Cambridge University Press Printed in the United States of America DOI: 10.10170S0954579406060329 Fostering secure attachment in infants in maltreating families through preventive interventions DANTE CICCHETTI,a FRED A. ROGOSCH,b and SHEREE L. TOTHb aInstitute of Child Development, University of Minnesota; and bMt. Hope Family Center, University of Rochester Abstract The malleability of insecure and disorganized attachment among infants from maltreating families was investigated through a randomized preventive intervention trial. Findings from research on the effects of maltreatment on infant attachment were incorporated into the design and evaluation of the intervention. One-year-old infants from maltreating families ~N ϭ 137! and their mothers were randomly assigned to one of three intervention conditions: ~a! infant–parent psychotherapy ~IPP!, ~b! psychoeducational parenting intervention ~PPI!, and ~c! community standard ~CS! controls. A fourth group of infants from nonmaltreating families ~N ϭ 52! and their mothers served as an additional low-income normative comparison ~NC! group. At baseline, mothers in the maltreatment group, relative to the nonmaltreatment group mothers, reported greater abuse and neglect in their own childhoods, more insecure relationships with their own mothers, more maladaptive parenting attitudes, more parenting stress, and lower family support, and they were observed to evince lower maternal sensitivity. Infants in the maltreatment groups had significantly higher rates of disorganized attachment than infants in the NC group. At postintervention follow-up at age 26 months, children in the IPP and PPI groups demonstrated substantial increases in secure attachment, whereas increases in secure attachment were not found for the CS and NC groups. Moreover, disorganized attachment continued to predominate in the CS group. These results were maintained when intent to treat analyses were conducted. The findings are discussed in terms of the utility of translating basic research into the design and evaluation of clinical trials, as well as the importance of preventive interventions for altering attachment organization and promoting an adaptive developmental course for infants in maltreating families. An overarching goal of the field of prevention dation for prevention science ~Cicchetti & science is to intervene in the course of devel- Hinshaw, 2002; Cicchetti & Toth, 1992; Ia- opment to ameliorate or eliminate the emer- longo et al., 2006; Institute of Medicine, 1994!. gence of maladaptation and psychopathology An organizational perspective on devel- ~Ialongo et al., 2006!. The discipline of devel- opment has been an influential theoretical opmental psychopathology, with its major fo- approach in the field of developmental psy- cus on the dialectic between the study of chopathology ~Cicchetti, 1993; Cicchetti & normality and pathology, is in a unique posi- Schneider-Rosen, 1986; Cicchetti & Sroufe, tion to provide an important theoretical foun- 1978; Sroufe & Rutter, 1984!. Theorists who adhere to an organizational perspective direct prevention science to focus on the progressive This research was supported by grants from the Admin- organization of developmental competencies istration of Children, Youth, and Families, the National and incompetencies in the course of epigene- Institute of Mental Health ~MH54643!, and the Spunk sis with the goal of structuring preventive ef- Fund, Inc. Address correspondence and reprint requests to: Dante forts ~Cicchetti & Toth, 1992; Ialongo et al., Cicchetti, Institute of Child Development, University of 2006; Toth & Cicchetti, 1999!. To effect change Minnesota, 51 East River Road, Minneapolis, MN 55455. in the course of development and avert psy- 623 624 D. Cicchetti, F. A. Rogosch, and S. L. Toth chopathological outcomes, preventive inter- Child maltreatment poses severe risks for ventions informed by an organizational long-term maladjustment and the develop- perspective should focus on promoting com- ment of psychopathology ~Cicchetti & Toth, petence and reducing ineffective resolution of in press; Cicchetti & Valentino, 2006!. Child the stage-salient developmental issues that maltreatment exemplifies a pathogenic rela- emerge at different periods in ontogenesis. By tional environment that is far beyond the range adopting the approach emphasized by organi- of what is normatively encountered and en- zational theorists, the deflection of maladap- genders substantial risk for maladaptation tation onto more adaptive developmental across diverse domains of biological and psy- pathways may be achieved, thereby enhanc- chological development ~Cicchetti & Manly, ing the individual’s capacity for a greater like- 2001; Cicchetti & Valentino, 2006; DeBellis, lihood of subsequent successful adaptation 2001!. Both the proximal environment of the ~Cicchetti, 1993; Cicchetti & Tucker, 1994; immediate family and the more distal fac- Sroufe, 1989!. Inherent in the organizational tors associated with the culture and the com- perspective is the importance of early inter- munity, as well as the transactions that occur vention, before developmental liabilities may among these ecological contexts, conspire to become consolidated ~Cicchetti, Toth, & Bush, undermine normal biological and psychologi- 1988; Toth & Cicchetti, 1999!. cal developmental processes in maltreated chil- Although the quintessential goal of preven- dren ~Cicchetti, 2002; Cicchetti & Lynch, 1993; tion science is to right the developmental DeBellis, 2001; Pollak, Cicchetti, Klorman, course and prevent the emergence of psycho- & Brumaghim, 1997!. Efforts to prevent the pathology, the results of prevention trials also deleterious consequences of maltreatment are possess important implications for develop- thus of critical importance. mental theory. As developmental experiments, In this paper, we report on the evaluation prevention trials provide a wealth of informa- of the efficacy of two theoretically informed, tion about the processes of typical and atypi- randomized preventive interventions for mal- cal development ~Cicchetti & Hinshaw, 2002; treating mothers and their 1-year-old infants. Cicchetti & Toth, in press; Hinshaw, 2002; Guided by an organizational perspective on Howe, Reiss, & Yuh, 2002; Ialongo et al., development, and by the translation of empir- 2006; Kellam & Rebok, 1992!. The transla- ical research that documents that maltreated tion of developmental theory into the design children manifest impairments in attachment and implementation of preventive interven- organization, in this investigation we inter- tions ~Cicchetti & Toth, 1992; Noam, 1992; vened early in the life course of maltreated in- Shirk, 1999; Toth & Cicchetti, 1999! and the fants to prevent the compromised developmental results of preventive interventions must form attainments that accompany maltreatment and a circular link back to the conceptual frame- that are precursors to later maladaptation and work to advance both the theory and future psychopathology. randomized intervention trials ~Cicchetti & The capacity for preferential attachment Hinshaw, 2002; Ialongo et al., 2006!. originates during early experiences and inter- If the developmental course is altered due to actions with the caregiver ~Gunnar & Vazquez, a preventive intervention, and the risk of the 2006; Schore, 2003; Sroufe, 1979, 1996!. The disorder or negative outcome is reduced, then preattachment parent–infant environment helps the research results will contribute to our under- to shape children’s physiological regulation standing of developmental processes ~Cic- and biobehavioral patterns of response ~Gun- chetti & Rogosch, 1999; Coie et al., 1993!. nar & Vazquez, 2006; Hofer, 1987; Pipp & Conversely, if the reduction of a targeted risk Harmon, 1987!. Near the end of the first year factor does not appear to have altered the patho- of life, normally developing infants derive feel- genic process, then that risk factor would not ings of security from their caregivers and use be viewed as a causal agent, but may be a marker them as a base from which to explore the of atypical development ~Cicchetti & Hinshaw, environment ~Cummings & Davies, 1996; 2002; Hinshaw, 2002; Kraemer et al., 1997!. Sroufe, 1979, 1996!. Dyadic interactions, Fostering secure attachment in infants 625 marked by relatedness and synchrony, resil- issue primes the way subsequent developmen- iency to stress, and appropriate affective inter- tal tasks are likely to be negotiated ~Cicchetti change, are associated with the development & Schneider-Rosen, 1986; Sroufe & Rutter, of a secure attachment relationship ~Sroufe, 1984!. Because maltreated infants predomi- 1979, 1996!. In the absence of regular contin- nantly develop insecure attachments, there is a gent responsivity, neither infant nor caregiver high probability that these babies will unsuc- derives feelings of efficacy in the relationship cessfully resolve subsequent developmental is- and the development of a secure attachment sues, paving the way for these infants to proceed is likely to be impeded ~Ainsworth, Blehar, along maladaptive developmental pathways. Waters, & Wall, 1978; Sroufe & Waters, The likelihood that maladaptation and psycho- 1977!. pathology will occur is exacerbated by the Because there are many enduring problem- preponderance of Type D attachments in the atic characteristics of the home environments maltreated babies. The developmental sequelae where maltreatment