A Prospective Longitudinal Study of Attachment Disorganization/Disorientation

Transcription

1 Child Development, August 1998, Volume 69, Number 4, Pages A Prospective Longitudinal Study of Attachment Disorganization/Disorientation Elizabeth A. Carlson The research explores the antecedents and consequences of attachment disorganization from a prospective longitudinal perspective. The relations of attachment disorganization I disorientation to endogenous (e.g., maternal medical history, infant temperament) and environmental (e.g., maternal caregiving quality, infant history of abuse) antecedents and to behavioral consequences from 24 months to 19 years are examined. For the 157 participants in the longitudinal study, attachment disorganization was correlated significantly with environmental antecedents (e.g., maternal relationship and risk status, caregiving quality, and infant history of maltreatment), but not with available endogenous antecedents. Infant history of attachment disorganization was correlated with consequent variables related to mother-child relationship quality at 24 and 42 months, child behavior problems in preschool, elementary school and high school, and psychopathology and dissociation in adolescence. Structural models suggest that disorganization may mediate the relations between early experience and later psychopathology and dissociation. The findings are considered within a developmental view of psychopathology, that is, pathology defined in terms of process, as a pattern of adaptation constructed by individuals in their environments. INTRODUCTION During the first year of life infants exhibit a repertoire of preadapted behaviors that become organized around an available adult caregiving figure. The behaviors (e.g., orienting, crying, clinging, signaling, and proximity-seeking) are directed toward the caregiver under conditions of fatigue, illness, threat, or stress, promoting the infant's survival (Bowlby, 1969 /1982; Tracy, Lamb, & Ainsworth, 1976). This emerging organization or regulation of infant behavior with respect to the caregiver is attachment. At the core of attachment for human infants is the regulation of emotional experience, including the experience of fear. Three major patterns of attachment in infancy (secure, anxious avoidant, and anxious resistant) are thought to represent organized dyadic strategies, regulating arousal or maintaining organization when the infant is alarmed and providing a secure base for exploration (Main & Hesse, 1990; Sroufe & Waters, 1977). For infants classified as secure, the caregiver is experienced as available and responsive when the infant is overly aroused, and emotions are thought to operate in an integrated smoothly regulated fashion to serve the inner organization and felt security of the child (Sroufe, 1990). In contrast, anxious avoidant and anxious resistant organizational patterns reflect coherent means of maintaining proximity (in case of extreme threat) in the context of unavailable or intermittently available and unresponsive caregiving. For some infants, however, no coherent organization of attachment behavior may evolve from the infant caregiver relationship. These infants may exhibit a diverse array of inexplicably disorganized, disoriented, and seemingly undirected or conflicting behavioral responses to the caregiver presence in the laboratory assessment of attachment, the Strange Situation (Main & Solomon, 1990). The responses include inconsistencies in usual sequences of behavior (e.g., approaching the door upon hearing the caregiver and running to the opposite side of the room upon the caregiver's entrance) and unusual behaviors (e.g., freezing, stilling) and stereotypies in the presence of the caregiver. Such cases are classified as anxious! y attached, disorganized I disoriented. Whereas it is not uncommon for an infant to show stress-related behaviors at low levels of intensity when the caregiver is absent, when behaviors of this type are seen at higher levels of intensity in the caregiver's presence the behavior becomes difficult to explain. It is believed that for these infants incomprehensible frightening or frightened caregiver behavior has disrupted or interfered with the formation of a coherent pattern of attachment (Main & Hesse, 1990). Whereas infants frightened or alarmed by an external environmental source inevitably seek proximity with the caregiver, caregiver behavior that frightens the attached infant places the infant in an irresolvable paradox in which the infant can neither approach the 1998 by the Society for Research in Child Development, Inc. All rights reserved I 98 I $01.00

2 1108 Child Development caregiver nor flee or shift attention to the environment. The caregiver serves as a source of fear as well as the biologically based, expectable source of reassurance. In contrast to moderate levels of anger or anxiety that may serve to maintain closeness in anxious avoidant and anxious resistant attachment relationships, the concurrent activation of fear and attachment behavioral systems produces strong conflicting motivations for the child exhibiting disorganized behaviors. The infant is challenged to manage extreme arousal at a time when infant capabilities are insufficient to ensure self-regulation (when organization depends upon dyadic regulation). Proximity-seeking mixed with avoidance may result as infants attempt to balance conflicting tendencies. Freezing, dazing, and stilling may be the result of their mutual inhibition. Such extreme conflict and the premature reliance upon individual coping mechanisms are thought to interfere with the development and stability of effective relational strategies of emotional communication and ability to maintain internal organization. Although validation by systemic home observations is just beginning (Jacobvitz, Hazen, & Riggs, 1997; Schuengel, van IJzendoorn, Bakermans-Kranenburg, & Blom, 1997), disorganized/ disoriented attachment patterns are thought to be the direct effect of frightening behavior or trauma, or the second generation effect of frightened caregivers who have not resolved their own experiences of trauma or loss (Main & Hesse, 1990). In the latter case, the caregiver may withdraw from the infant as though the infant were the source of alarm or the caregiver may lapse into dissociated or trance-like states, greatly taxing the infant's organizing capacities. Research findings provide some support for these hypotheses. High levels of attachment disorganization/ disorientation in infancy have been related to parental experiences of unresolved mourning (Main & Hesse, 1990) and to maternal histories of loss due to divorce, separation, and death (Lyons-Ruth, Repacholi, McLeod, & Silva, 1991). Attachment disorganization/ disorientation (including the unclassifiable A/C pattern) has been related to infant histories of maltreatment (Carlson, Cicchetti, Barnett, & Braunwald, 1989), hostile and intrusive caregiving (Lyons-Ruth et al., 1991), maternal depression (Radke-Yarrow, Cummings, Kuczynski, & Chapman, 1985), and prenatal alcohol (O'Connor, Sigman, & Brill, 1987) and drug exposure (Rodning, Beckwith, & Howard, 1991). In studies of prenatal alcohol and drug exposure, researchers suggest that caregiver relationships were compromised by the ongoing drug or alcohol use and patterns of use interfering with parenting interaction and the parenting role. Disorganized I disoriented behaviors such as stereotypies may be expected in neurologically impaired infants; however, there is no evidence that attachment disorganization reflects stable constitutional deficiencies in infants in normal samples (Main & Hesse, 1990). For example, no relation has been found between disorganized attachment status of infants with mother and a second parent (Main & Solomon, 1990; Steele, Steele, & Fonagy, in press) or infants with mother and a day-care provider (Krentz, 1982). For the three major attachment relationship patterns, internalized regulatory patterns and expectations derived from a history of caregiver-infant interactions form the basis for rules that govern the child's interpretation and expression of emotions and behavior. Well-functioning regulatory patterns or distortions in early dyadic regulation serve as prototypes for later individual styles of maintaining emotional security (Kobak & Shaver, 1987; Main & Hesse, 1990; Sroufe, 1996; Sroufe & Waters, 1977). From this perspective, disturbed attachment relationships are linked to later psychopathology, not as early disorders of the infant, but as markers of a beginning pathological process, risk factors for later pathology in the context of a complex model of interactive biological and environmental variables (Cicchetti, Toth, & Bush, 1988; Sameroff & Emde, 1989; Sroufe, 1997). Consistent with this probabilistic view, anxious avoidant and anxious resistant attachment organizational patterns are thought to represent working defensive strategies developed in response to insensitive (rejecting or unpredictable but not frightening) caregiving behavior. These patterns are likely to lead to classic disorders only in the context of continued caregiving difficulties and in combination with stressful or traumatic experience where defensive strategies are likely to break down. In contrast with the coherent behavioral strategies of avoidant and resistant attachment, attachment disorganization is identified only through lapses or slippages in control, orientation, and/ or organization when the caregiver, the only source of safety, is at the same time the source of alarm (Main, in press). The collapse of relational behavioral and attentional strategies in infancy may place infants at heightened risk for later pathology. Attachment disorganization/ disorientation has been found to be related to child behavior problems (characterized by aggression) although only a minority of children classified as disorganized in infancy

3 Elizabeth A. Carlson 1109 were highly aggressive in preschool (Lyons-Ruth, Alpern, & Repacholi, 1993). In this prospective study, psychosocial problems contributed to the child's outcome for one subgroup of children classified as disorganized in infancy who later developed behavior problems. The effects of attachment status and maternal psychosocial problems (documented history of child maltreatment, inpatient psychiatric hospitalization, or reported depressive symptoms) were independent and additive rather than interactive; however, the authors note that previous analyses had indicated that mothers with psychosocial problems were more likely to develop insecure attachment relationships. Liotti (1992) has suggested a link between early disorganization and later dissociative disorders based on a phenotypic resemblance between trancelike states and some forms of disorganized/ disoriented behavior. Some infants receiving high ratings of disorganization/ disorientation may enter hypnotic or trance-like states as a defense against frightening or frightened caregiver behavior (Liotti, 1992). Whereas not all disorganized behaviors relate clearly to dissociative phenomena, infant postures and sequences of behavior such as stilling resemble the lapses or slippages in orientation and control associated with dissociative disorders as described by Putnam (1985, 1989, 1993) and Hilgard (1986). Putnam (1993) notes that frequent trance-like states are the single best predictor of dissociative disorders in children. Such disorganized infants may be vulnerable to the development of dissociative disorders (e.g., fugue states, multiple personality disorder) should traumatic circumstances continue or intervene in later life (Liotti, 1992). Interactions with a caregiver who periodically becomes unpredictably frightening or frightened may leave the disorganized infant more vulnerable than others to developing anomalous ideation regarding space-time relations and physical causality (Liotti, 1992). Moreover, experiences that occur while the child is in a trance-like state may be processed differently or encoded in an altered form and, as a result, be difficult to retrieve or revise later. Based on the idea that the brain changes in a use dependent manner and organizes in response to experience during development, Perry and his colleagues (Perry, Pollard, Blakley, Baker, & Vigilante, 1995) suggest that the internalization of specific patterns of neuronal activity associated with acute responses may account for vulnerability to dissociative disorders. Thus, "if in the midst of traumatic experience, a child dissociates and stays in a dissociative state for a long period of time (e.g., by re-exposure to evocative stimuli), the child will internalize a sen- sitized neurobiology related to dissociation predisposing to the development of dissociative disorders" (Perry et al., 1995, p. 283). On the other hand, if the child utilizes a hyper arousal response to trauma, prolonged or repeated reactivati8n of this "fight or flight" response pattern may sensitize neurobiological systems to an alternate form of dysregulation. Traumatic events or reminders of traumatic events may lead to abnormal persistence of fear or hyperaroused behavioral states (e.g., hypervigilance, hyperactivity, impulsivity). In either case, neurological components of an adaptive response to traumatic experience may become sensitized and more pervasive, resulting in maladaptive regulatory symptomatology. In the present study, prospective longitudinal data are utilized to validate the rating of attachment disorganization and examine hypotheses related to antecedents and consequences of patterns of attachment disorganization/ disorientation. First, the relations of attachment disorganization to endogenous (e.g., maternal medical history, infant temperament) and environmental (e.g., maternal caregiving quality, infant history of abuse) antecedent variables are explored. The goal of these analyses was to determine whether attachment disorganization results from relationship experience as hypothesized by Main and Hesse (1990) and/or endogenous factors as suggested by the nature of disorganized behaviors. Second, behavioral consequences of attachment disorganization/ disorientation from 24 months to 19 years are examined. Attachment disorganization was expected to be related to subsequent mother-infant relationship quality and to individual psychopathology, in particular, dissociative symptomatology. Third, the contributions of attachment disorganization/ disorientation to predictions of psychopathology and dissociation in adolescence are examined in relation to intervening measures of socioemotional functioning. Finally, the role of attachment disorganization as mediator of the effects of caregiving quality on later psychopathology and dissociation is examined. The study focuses on the correlational relations between continuous ratings of attachment disorganization/ disorientation and antecedent and consequent measures to maximize the use of existing codable attachment assessment data. METHOD Participants Participants were 157 infants (92 males, 65 females) and mothers drawn from a longitudinal study

4 1110 Child Development of children and families (Egeland & Brunnquell, 1979). Mothers were recruited while receiving prenatal care at public health clinics in Minneapolis in Children with sensory handicaps were excluded from the study. At tb\e time of delivery, the mothers ranged in age from 12 to 34 years (M = 20.66, SD = 3.87); 68% of the mothers were single. Thirtynine percent of the mothers had not completed high school. Eighty percent of the mothers were European American, 13% were African American, and the remaining 7% were American Indian, Latino, or Asian. Based on U.S. census occupational categories, 40% of heads of households were employed as either clerical, service workers, operatives, or craftsmen, 5% were employed in technical, managerial, or sales positions, 36% were unemployed when the infants were born, and 14% were students. This sample was found to be representative of the larger original sample (N = 267); the current participants and the attrition sample did not differ significantly with respect to demographic variables. Procedure Because longitudinal multivariate data afford the opportunity for multiple analyses regarding a particular phenomenon, it becomes critical to define a clear rationale or strategy for variable selection. The goal of the current study was to examine specific hypotheses concerning the antecedents and sequelae of disorganized attachment relations: the relations between early biological and environmental factors and attachment disorganization and links between attachment disorganization and later psychopathology. With this aim in mind, variables were chosen for inclusion in the study based on two criteria: whether they were (1) representative of constructs of interest (e.g., infant temperament, quality of caregiver infant regulation, child behavior problems, psychopathology) and (2) had proven to be powerful indicators in previous studies. All variables examined in the statistical analyses were explicitly chosen for this study based on these criteria, and all results of these analyses are reported here. When possible throughout the study, data were combined to minimize subject loss, to utilize all information available, to minimize some sources of error, to keep the number of variables in the analyses as small as possible, and to insure high-quality data. In some cases, this involved averaging multiple assessments. Thus, measures of behavior problems were averaged across grades 1 through 6. The procedure not only counteracts idiosyncracies of individual teachers but also maintains an adequate sample size (if data were not available for a participant in a given year, the average from the other 3 years would be adequate). Descriptive statistics for antecedent and consequent variables are presented in Tables 1 and 2, respectively. Descriptive statistics for the participant sample and the remaining sample (cases for whom no attachment assessments were available for rating of disorganization) were compared. Significant differences were found with respect to two consequent variables: Teacher's Report Form (TRF) rating of dissociation, grades 1-6, t (189) = 2.32, p <.05, current sample m = 1.26, SD = 1.32, n = 143; remaining sample m =.77, SD = 1.01, n = 48, TRF rating of dissociation, high school, t(189) = 2.32, p <.05, current sample m = 1.22, SD = 1.19, n = 143, remaining sample m ==.77, SD =.98, n = 48. Gender differences within the participant sample were found with respect to the composite emotional health outcome variable only (see below). Measures Antecedent Endogenous Variables Measures of endogenous infant characteristics (i.e., medical history, infant anomalies at birth, Brazelton assessments, Carey ratings) were included despite the fact that they may be considered weak or outdated indicators of temperament or biological factors. Given the nature of disorganized behaviors, it was considered important to examine hypotheses regarding biological I neurological contributions to attachment disorganization to the degree possible within the constraints of the longitudinal data set. Medical history. Variables representing the mother's history of medical problems and complications during pregnancy and birth were derived from hospital records. These included (1) number of mother's serious medical problems prior to pregnancy, (2) number of medical complications during the mother's pregnancy, (3) drug/alcohol use prior to and/ or during pregnancy (coded 0, 1, 2), (4) presence (coded 1) or absence (coded 0) of premature birth, and (5) number of medical complications at the time of delivery. Infant anomalies. A variable representing frequency and severity of infant anomalies at birth was derived from hospital records. Infant conditions were rated on a 3 point scale taking into account number and severity of conditions reported. At the high end of the scale (rating = 3), multiple severe conditions (e.g., multiple infections at birth) were reported. At the low end of the scale (rating = 0), no anomalous conditions were reported. Neonatal Behavioral Assessment Scale. The Neonatal

5 Table 1 Descriptive Statistics for Antecedent Variables of Disorganized/Disoriented Attachment in Infancy Frequency Variables M so Range 0 1 n Endogenous: Maternal medical problems Pregnancy complications Drug I alcohol use Premature birth Delivery complications Infant anomalies Brazelton (7, 10 days) Carey temperament (3 months): Adaptability to Intensity to Low threshold to Infant social behavior (3 months) to Environmental: Relationship status Maternal abuse history Psychological problems Maternal risk status (at infant's birth) Maternal caretaking skill to Maternal affective quality (3 months) to Maternal cooperation/ sensitivity (6 months) Infant abuse Overall abuse Physical abuse Verbal abuse Psychological unavailability Neglect Table 2 Descriptive Statistics for Consequent Variables of Disorganized/Disoriented Attachment in Infancy Sample Variables M so Range Size Quality of mother-child relationship (24 months) Quality of mother-child relationship (42 months) Preschool behavior problems ( years) Teacher's Report Form (1, 2, 3, 6 grade): Total score Externalizing Internalizing Dissociation Emotional health rank (1, 2, 3, 6 grade) Boundary dissolution (13 years) Teacher's Report Form (high school): Total score Externalizing Internalizing Dissociation Emotional health rank (high school) K-SADS ( years): Psychopathology rating Dissociation DES dissociation (19 years)

6 1112 Child Development Behavioral Assessment Scale (Brazelton, 1973) was administered for each infant at home on the infant's seventh and tenth days of life. The NBAS consists of 27 behavioral items (e.g., habituation to visual, auditory, and tactile stimulation, muscle tone, alertness) rated on 9 point scales and 17 reflex items (e.g., Babinski, moro, rooting, and sucking reflexes) rated as low, medium, or high. A nonoptimal score defined as the number of items on which the infant was judged to be functioning in the nonoptimal range indicates the infant's overall level of functioning. The average of the nonoptimal scores from the two assessments was used in the analyses. Five examiners administered the NBAS. Two had been trained by Brazelton's associates, and three established reliability with the original trainees using the criteria of no more than one disagreement on the reflex items and I or no more than one scale score disagreement of more than one point. The two primary testers examined 67% of the infants. Interrater agreements averaged.93 for the entire sample. Carey Infant Temperament Questionnaire (3 months). The Carey Infant Temperament Questionnaire (Carey, 1970) was completed by mothers at 3 months. The questionnaire assesses nine dimensions of temperament, including mood, approachability, adaptability, intensity, activity, persistence, threshold, rhythmicity, and distractibility. For each dimension, three responses are possible (e.g., low, medium, or high). (See Vaughn, Deinard, & Egeland, 1980, for comparison of Carey results from this sample and the standardization sample.) A principal components analysis with V ARIMAX rotation of the nine items yielded three factors labeled: adaptability I demandingness (items related to adaptability, mood, and approachability), intensity I activity (items related to intensity, activity, and persistence), and low threshold (items related to low threshold, rhythmicity, and distractibility). The three factor scores were used as variables in this study. Infant social behavior during feeding (3 months). At 3 months postpartum, infant-mother pairs were observed in their homes during a feeding. Observers rated a range of maternal behaviors, infant behaviors, and interactions between the mother and infant (e.g., frequency of looking at the infant, cuddling by the infant, responsiveness of the caregiver to infant initiatives). A total of 33 maternal and child behaviors were rated by independent observers. The mean range of scores was 7 for the 15 9-point scales, 6 for the 10 7-point scales, 4 for 2 6-point scales, 4 for 4 5-point scales, and 2 for 1 3-point scale. Prior to making home visits and collecting data, the observers were trained using videotaped feedings and established a median reliability of.85 using the Lawlis and Lu index (1972). Reliability checks throughout the course of the study maintained the overall level of agreement at 85%. The Lawlis and Lu measure of interrater reliability is defined as the proportion of ratees on whom the raters agree within the limits set, corrected for number of agreements expected by chance. The data derived from the feeding observations were factor analyzed using a principal components analysis with V ARIMAX rotation. A three factor solution was identified that accounted for 54.8% of the total variance. The first two factors were identified primarily by variables assessing the mother's caregiving skills (e.g., sensitivity, response to crying) and the quality of her affective interactions with the infant (e.g., expressiveness, verbalization). These two factors accounted for 41% and 37% of the common variance, respectively. The third factor was identified primarily by infant variables (e.g., infant social behavior, infant disposition). Descriptions of the items and the factor structure of the variables have been presented by Vaughn, Taraldson, Crichton, and Egeland (1980) and are not reproduced here. The three factors were used in the analyses presented here. Antecedent Environmental Variables Maternal histories of abuse and psychological problems. The presence (coded 1) or absence (coded 0) of maternal history of abuse and presence or absence of maternal history of psychological problems, including suicide attempts, were derived from hospital medical records (Egeland, Jacobvitz, & Sroufe, 1988). Maternal relationship status (infant's birth). The status of the mother's marital or primary social relationships at the time of her infant's birth was recorded. The status was coded 1 (single, divorced, or longterm separation) or 0 (married or involved in a longterm relationship). Maternal risk status (infant's birth). Mother's risk status for parenting difficulties was rated at the time of the infant's birth on a 3 point scale by public health clinic staff. Ratings were based on interview responses concerning maternal knowledge of development, expectations and preparation for the baby, and motivation to care for the baby. Mothers were rated 3 for high risk, 2 if expected to do well with support, and 1 for low risk (i.e., mother considered mature, competent, and motivated to care for the baby). Reliability coefficients were not available for this variable. Maternal caretaking skill and affective quality during

7 Elizabeth A. Carlson 1113 feeding (3 months). Factors related to maternal caretaking skill and affective quality during infant feeding were derived from home observations when infants were 3 months old. See "Infant Social Behavior during Feeding," above, for descriptions of the feeding observation and factor analysis. Maternal Cooperation/Interference and Sensitivity/Insensitivity scales (6 months). Mother-infant interactions were rated on Ainsworth's Cooperation/Interference (intrusiveness) and Sensitivity /Insensitivity scales (Ainsworth, Blehar, Waters, & Wall, 1978) from feeding and play situations in the home when infants were 6 months old. Mothers and infants were observed for approximately 30 min during each of two feeding situations and for 20 min in a standardized play situation. In the first component of the play situation, mothers were asked to engage the infant in physical play, not mediated with toys; next, mothers were given a toy truck attached to a string and asked to "teach" the baby to retrieve the toy by pulling on the string. In the final component, the mothers were given several toys and asked to play with the baby in any way they chose. The overall ratings of cooperation/interference and sensitivity I insensitivity across the feeding and play observations were used in these analyses. The central issue of the 9 point Cooperation/Interference scale is the extent to which the mother adapts the timing and quality of her interactions and initiations to the baby's state, mood, and current interests rather than disrupting the baby's ongoing activity. Maternal cooperation/interference has been found to be correlated negatively with subsequent behavior problems (Egeland, Pianta, & O'Brien, 1993). The focus of the 9 point Sensitivity /Insensitivity scale is the extent to which the mother reads and responds to her infant's cues and demonstrates an awareness of the infant's subjective state by adjusting her own behavior. This measure was shown to be a highly significant predictor of quality of attachment in this sample (Egeland & Farber, 1984). Observers were graduate students and interviewers experienced with the families and measures and trained to reliability in the laboratory prior to home assessments. The Tinsley-Weiss index (Tinsley & Weiss, 1975) of interrater agreement for ordinal scales was calculated for each scale. The index is based on the Lawlis and Lu (1972) measure of interrater reliability, the proportion of ratees on whom the raters agree within the limits set, corrected for number of agreements expected by chance. The Tinsley and Weiss T value, patterned after Cohen's (1960) kappa, is concerned with the degree to which agreement is better than chance. The index ranges from 0 to 1.00, with 0 indicating expected chance agreement and 1 indicating perfect agreement (which in this case was defined as a 2 point or less discrepancy). The T values were.80 for the Cooperation I Interference scale and.66 for the Sensitivity I Insensitivity scale based on 24 cases. The Cooperation I Interference and Sensitivity I Insensitivity ratings were aggregated for purposes of this study (r =.81, N = 195). Infant abuse history. Infant maltreatment was identified on the basis of information regarding childrearing practices and maternal attitudes toward the child derived from (1) home observations of mother and infant when the infants were 7 and 10 days old and at 3, 6, 9, and 12 months; (2) home interviews with mothers including the Child Care Rating Scale (Egeland & Deinard, 1975) and questions regarding caregiving skills, feelings toward the infant, and disciplinary practices; (3) observations of the dyads and interviews with mothers conducted during motherchild visits to the public health clinic; and (4) laboratory observations of the dyads when the infants were 9, 12, and 18 months old. Behaviors considered to be physically abusive ranged from frequent and intense spanking to unprovoked angry outbursts resulting in serious injuries, such as severe cigarette burns. In all instances, the abuse was seen as potentially physically damaging to the child. Mothers identified as hostile I verbally abusive chronically found fault with their children and criticized them in an extremely harsh fashion. Whereas many physically abusive mothers were not constantly hostile or rejecting (but rather prone to violent, unprovoked outbursts), verbally abusive mothers engaged in constant berating and harassment of their children. At 24 months, children of hostile I verbally abusive mothers with or without physical abuse exhibited more frustration and anger compared with the control group, and toddlers with experiences of hostile but not physical abuse demonstrated more frustration oriented toward their mothers (Egeland & Sroufe, 1981). Mothers considered to be psychologically unavailable were unresponsive to their children and, in many cases, passively rejecting of them. These mothers appeared detached and uninvolved with their children, interacting with them only when necessary. In general, they were withdrawn, displayed flat affect, and seemed depressed. At 24 months, frequency of frustration, whining and negative affect was greatest for children who had experienced psychologically unavailable care without physical abuse (Egeland & Sroufe, 1981). Mothers rated as neglectful were irresponsible or

8 111~ Child Development incompetent in managing day-to-day child-care activities. They failed to provide for the necessary health or physical care of the children and did little to protect them from possible dangers in the home. Whereas these mothers sometimes expressed interest in their children's well-being, they lacked the skill, knowledge, or understanding to provide consistent, adequate care. The validity of group placement was supported by a variety of information. All mothers in the physical abuse group had been under the care of child protection or had been referred to child protection by someone outside of the longitudinal project. Independent raters' observations of mothers and infants in limitsetting tasks at 12 and 18 months and a problemsolving task at 24 months supported the identification of hostile/ verbally abusive mothers and psychologically unavailable mothers. Mothers rated as neglectful were or had been under the care of the public health nurse or child protection. For purposes of the present study, dyads were coded 1 for presence or 0 for absence of each of the four conditions: physical abuse, verbal abuse, psychological unavailability, and neglect (Egeland & Sroufe, 1981; Egeland, Sroufe, & Erickson, 1983). Dyads also were assigned a composite rating of abuse (0-4). Quality of attachment (12, 18 months). Attachment assessments were conducted using Ainsworth's Strange Situation procedure (Ainsworth et al., 1978). The standardized laboratory procedure consists of eight brief episodes designed to activate infant attachment behavior through an increasingly stressful series of infant-mother separations and reunions. Individual differences in attachment relationships are coded with respect to the infant's gaining comfort in the mother's presence when stressed and using the mother as a secure base from which to explore. Based on the patterning of the infant's behavior across all episodes, infant-mother dyads are assigned to one of three major classifications: secure, anxious avoidant, or anxious resistant. Strange Situation assessments were videotaped, and scoring was based on these records. Assessments at 12 and 18 months were coded by independent experienced coders. Two additional scorers were used to establish scoring agreement. Agreement with independent rescoring of the entire 12 month sample was 89% for the A, B, and C classifications. Agreement with independent rescoring of 25 randomly selected 18 month assessments was 92%. Disagreements were resolved by the more experienced coder after reviewing the videotape. Videotaped Strange Situation assessments were available for disorganization/ disorientation coding for 157 of the original participants in the longitudinal study.' Both 12 and 18 month assessments were available for 48 participants. Assessments at either 12 or 18 months were available for 74 and 35 participants, respectively. Strange Situation assessments were coded for attachment disorganization/ disorientation using the classification scheme developed by Main and Solomon (1990). Indices of disorganization/ disorientation include (1) sequential display of contradictory behavior patterns; (2) simultaneous ctisplay of contradictory behavior patterns; (3) undirected, misdirected, incomplete, and interrupted movements and expressions; (4) stereotypies, asymmetrical movements, mistimed movements, and anomalous postures; (5) freezing, stilling, and slowed movements and expressions; (6) direct indices of apprehension regarding the parent; (7) direct indices of disorganization or disorientation (see Appendix A for brief description). Disorganization I disorientation in infantparent attachment was rated on a 9 point scale, and a disorganized/ ctisoriented classification assigned to infant-mother dyads receiving a rating of 5 or higher (see Appendix B for rating criteria). Coders were trained by Mary Main, and interrater agreement was 86% based on 35 cases (selected at random with the restriction that half, or 17 cases, were classified as disorganized by the primary coder). Kappa was calculated to be.72. Attachment disorganization ratings ranged from 1 to 9 with a mean rating of 3.75 (SO = 2.29, N = 157). See Table 3 for mean ratings of disorganization by major attachment classification. For purposes of analyses presented here, the overall rating of disorganization/ disorientation (the highest rating assigned across the 12 and 18 month assessments) was used (Main, personal communication, 1995). For the subsample of 48 for whom both 12 and 18 month assessments were available, disorganization ratings were positively correlated, r(46) =.38, p <.01. Of this subsample, 17 were classified disorganized I disoriented at both time periods, and 21 were stably classified as not disorganized. Seven participants moved from not ctisorganized to disorganized status. (Two of these participants simultaneously changed from resistant to avoidant attachment, two changed from secure to avoidant, and three were stably secure.) Three participants changed 1. All Strange Situation assessments were recorded originally on reel-to-reel tapes. Some assessments were lost initially because tapes were recycled and used for multiple assessments. Other assessments were lost due to the deterioration of reel-toreel tape quality.

9 Elizabeth A. Carlson 1115 Table 3 Mean Disorganization Ratings by Major Attachment Classification at 12 and 18 Months Assessment and Major Classification Mean Rating Disorganized Classification SD n Frequency (%) 12 month: Anxious, avoidant 4.24 Secure 2.31 Anxious, resistant 4.33 Total 18 month: Anxious, avoidant 4.54 Secure 3.26 Anxious, resistant 4.10 Total (35%) (43%) from disorganized to not disorganized status. (Two of these participants changed from resistant to secure attachment, and one moved from avoidant to resistant.) Consequent Variables: Early Childhood Quality of mother-child relationship (24 months). The quality of the mother-child relationship at 24 months was assessed in a laboratory problem-solving procedure described by Matas, Arend, and Sroufe (1978). In this situation, the child is challenged to solve a series of problems of graded difficulty with mother available to help. The child's overall experience in this laboratory assessment was rated on a 5 point Likert-type scale. A high rating (rating = 5) is assigned when it is judged that the child has had a positive experience and would be even more confident in facing problems in subsequent experiences. A low rating (rating= 1) is assigned when it is judged that the child has had a very poor experience either due to belittling taunting, or abuse from the mother, or breaking down (losing control or having to leave the scene) with the mother failing to come to the rescue. This variable has been validated extensively as an index of the overall quality and effectiveness of the mother-child pair at this developmental period (Egeland et al., 1983; Erickson, Sroufe, & Egeland, 1985). Assessments were coded by two independent coders. Interrater reliability (Pearson product-moment correlation) was.87. Quality of mother-child relationship (42 months). The quality of the mother-child relationship at 42 months was observed in a series of teaching tasks: (1) building block towers of specific proportions, (2) naming things with wheels, (3) matching colors and shapes on a form board, and (4) tracing a preset pattern through an etch-a-sketch maze. The tasks are just beyond the ability of most children, requiring the parent I caregiver to help the child complete the task and capturing the coping skills of the child and his or her capacity to use the mother as a supportive resource (see Erickson et al., 1985). The quality of the mother-child interaction is reflected in a variety of variables derived from the teaching task. One of the most powerful variables related to regulation in the mother-child relationship, child's experience in the session, was selected for this study as an early indicator of dyadic functioning. The scale reflects the degree to which the child's experience in the session would result in feelings of success and competence on the tasks and of confidence in having a good relationship with his or her mother. At the high end of the 7 point scale, there are very positive interactions between mother and child, and through appropriate maternal assistance the child is able to complete the tasks with some sense of autonomy or problem-solving success. At the low end of the scale, the child is judged to have a negative experience in the session. There may be many motherchild conflicts or the mother may dominate or reject the child in ways that contribute to lower expectations of his or her own competence. This relationship regulation variable discriminates children with and without a history of abuse in early childhood (Egeland et al., 1983) and children with and without behavior problems in preschool (Erickson et al., 1985). Assessments were coded by two independent coders. Average interrater reliability (Pearson product-moment correlation) was.78 for 87 participants. Preschool behavior problems ( 41J2 years). At 41f2-5

10 1116 Child Development years, the children participated in preschool or daycare. For each child, the Preschool Behavior Questionnaire (Behar & Stringfield, 1974) was completed by a teacher or child-care provider. This measure consists of 30 items associated with socioemotional problems in young children. The teacher was asked to check for each item: "Certainly applies" (scored 3 points), "Applies sometimes" (2 points), "Does not apply" (1 point). The Preschool Behavior Questionnaire was standardized on a sample of 496 children enrolled in normal preschools and 102 children enrolled in special education programs for emotionally disturbed children. The measure significantly discriminated normal and deviant groups of children. Interrater reliability (mean r =.84) and test-retest reliability (mean r =.87) were moderate. Teachers also completed the 31 item Behavior Problem Scale (Erickson & Egeland, 1981), using the same format as the Preschool Behavior Questionnaire. The scale was devised to assess more severe behavior disturbances than those represented in the Preschool Behavior Questionnaire. Items are similar to those included in the Child Behavior Checklist (Achenbach & Edelbrock, 1986). Scores from the two scales were positively correlated (r =.82, N = 98). The combined total score from the two measures (Erickson et al., 1985) was used in this study. Consequent Variables: Middle Childhood and Adolescence Teacher's Report Form (grades 1, 2, 3, 6, high school). The Teacher's Report Form (TRF), the teacher version of the Child Behavior Checklist (CBCL; Achenbach & Edelbrock, 1986) was completed by the child's teacher toward the end of first, second, third, and sixth grades along with other measures of classroom adjustment. In high school, the measure was completed by the student's English teacher in grade 10. The Teacher's Report Form consists of 113 items describing behavioral problems associated with middle childhood (e.g., "Disobedient at school," "Gets in many fights," "Likes to be alone"). Each item is scored by the teacher to reflect occurrence, frequency, and severity of the problem ("Often and very true" = 2, "Sometimes or somewhat true" = 1, "Not true" = 1). The measure yields a total score, broad-band scores representing externalizing and internalizing dimensions of behavior problems, and a set of empirically derived factor scores representing syndromes of maladaptive behavior. For this study, elementary and high school data were analyzed separately. For the elementary years, composite Total, Externalizing, and Internalizing scores were derived by averaging T scores across grades 1, 2, 3, and 6. For the high school years, Total, Externalizing, and Internalizing T scores represent a single assessment. The TRF has been normed on a large, representative national sample. Two-week test-retest reliabilities for the TRF Externalizing, Internalizing, and subscales ranged from.70 to.89 for girls (ages 6-11) and.82 to.92 for boys (ages 6-11). For adolescents, reliabilities ranged from.64 to.98 for girls (ages 12-16) and.74 to.92 for boys (ages 12-16). The authors report good convergent validity for the subscales ( with corresponding scales of the Conner's Teacher Rating Scale) and good criterion-related validity in the form of significant differences between demographically similar referred and nonreferred children on all the TRF scales for all sex I age groups. Cronbach' s alpha was calculated for each of the elementary school composite variables used in the present study (Total, alpha =.79; Externalizing, alpha =.82; Internalizing, alpha =.63). The TRF Total score stability coefficients ranged from.44 to.60 for grades 1 to 6 and.17 to.30 for elementary years to high school; Externalizing coefficients ranged from.50 to.61 for grades 1 to 6 and.24 to.38 for elementary to high school; and Internalizing coefficients ranged from.27 to.44 for grades 1 to 6 and -.02 to.18 for elementary to high school. From the TRF, a scale representing dissociative symptoms was derived for each assessment period (grades 1, 2, 3, 6, and high school). Items were selected based on criteria for diagnoses of dissociative disorders (American Psychiatric Association, 1994; Putnam, 1989) and moderate to high item-total score correlations. The dissociative scales include five items: "Confused or seems to be in a fog"; "Gets hurt a lot, accident-prone"; "Explosive and unpredictable behavior"; "Stares blankly"; "Strange behavior." For the high school period, the dissociative scale includes the item "Deliberately harms self or attempts suicide" in place of the item "Gets hurt a lot, accidentprone" used in middle childhood. Cronbach' s alpha was calculated for each of the dissociative scales (grade 1, alpha =.68; grade 2, alpha =.53; grade 3, alpha =.68; grade 6, alpha =.53; grades 1 through 6 combined, alpha =.68; high school, alpha =.63). Stability coefficients ranged from.20 to.46 for grades 1 to 6 and.08 to.15 for the elementary grades to high school. Teacher rankings of emotional health/self-esteem (grades 1, 2, 3, 6, high school). The rank order measure of emotional health/self-esteem employs a teacher nomination procedure developed by staff of the longitudinal study. Rankings rather than ratings were used as a way of calibrating the hundreds of teachers involved in assessing the children. At grades 1, 2, 3,

11 Elizabeth A. Carlson , and in high school, teachers were asked to rank order the students in their classes based on a written description of emotional health/ self-esteem with the child most closely resembling the description to be ranked at the top. The emotional health/ self-esteem measure refers to the degree to which the child is confident, curious, self-assured, and enjoys new experiences and challenges, becoming involved in whatever she or he does. The child's score on this measure was recorded as the ratio of the inverse of the child's rank divided by the number of students in the class (i.e., if the child were ranked eleventh in a class of 30, she or he received a score of.66 = ( ) I 30}. The reliability and validity of this procedure was supported by the findings of Connolly and Doyle (1981). Because a single teacher completed the rank orders, reliability figures are not available for the scales with this sample. In a separate study, however, multiple counselors independently rank ordered children participating in a 4 week summer camp. Interrater reliability coefficients ranged from.63 to.81 on the emotional health rank orders. The rankings by teachers show significant stability from year to year: grades 1-2, r(171} =.62, p <.001, grades 2-3, r(178) =.60, p <.001, grades 3-6, r(178) =.44, p <.001, grade 6 to high school, r(172} =.34, p <.001. The rankings are significantly correlated with ratings of behavior problems: TRF Total score in grades 1-6, r(189) = -.71, p <.001, TRFTotalscoreinhighschool,r(172) =-.53, p <.001, and with observed peer competence, r(190) =.82, p <.001 (Hiester, Carlson, & Sroufe, 1993). For this study, emotional health rankings for grades 1, 2, 3, and 6 were averaged, and the composite was used in the analyses. Mean composited emotional health rankings for males and females differed significantly in elementary school, t(142) value = 2.28, p <.OS, males m = 43.56, SD = 22, n = 83; females m = 51.98, SD = 21, n = 61. Parent-child relationship quality (13 years). At 13 years, adolescents and their mothers were videotaped in a laboratory situation. (Because only 44 "fathers" were living with the children at age 13, triadic data are not reported here.) The dyads were asked to complete four structured interaction tasks (based on Block & Block, 1980): (1) plan an antismoking campaign, (2) assemble a series of puzzles while the parent was blindfolded (the child was asked to guide the assembly), (3) discuss the effects of two imaginary I hypothetical happenings, and (4) complete a Q-sort of an ideal person. The dyadic interactions were assessed using a series of 7 point rating scales (J. Sroufe, 1991}. For the current analyses, the scale measuring boundary dissolution between parent and child was used as an indicator of dysfunction in the relationship. The scale captures the extent to which generational boundaries in the parent-child relationship are violated in one or more of the following ways: (1) spousification: the child is placed in the role of meeting the parent's needs for nurturance or assumes a leadership role in relation to the parent, (2) role diffusion characterized by peer-like behavior. These are viewed as problems in the developmental context of early adolescent emancipation. At the high end of the scale, indicators of generational boundary dissolution are frequent and pervasive, occurring consistently throughout the session. Examples include: (1} numerous or explicit examples of spousification with both parent and child initiating the behaviors, (2) high child caregiving or child control, coupled with disrespect of the parent by the child, and (3) high level of peer-like behavior and peer-like bickering. At the midpoint in the scale, appropriate parent-child roles are maintained during much of the session; however, indicators are prevalent, and appropriate boundaries are not fully reinstated when needed. Examples include: (1) a pervasive quality of sweetness or preciousness of the child to the parent, mild physical signs of spousification, or high playfulness with sexually provocative quality, (2) signs that the parent is avoiding parenting responsibilities with the child assuming the caregiving or executive functions, and (3) peer-like behavior or lack of parental leadership with the introduction of negative interaction when the situation requires leadership. At the low end of the scale, clear and appropriate parentchild boundaries are maintained. Ratings for this sample ranged from 1 to 7 (M = 2.75, SD = 1.60). Interrater reliability for this scale was r =.62 (n = 129). Percent agreement within 1 point was.79. Because the majority of assessments were rated by two coders, the final conferenced data are likely to be somewhat more reliable than indicated by the correlation coefficient. Kiddie Schedule for Affective Disorders and Schizophrenia Rating (1llf2 years). At age 171J2, adolescents were administered the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS). The K-SADS provides both comprehensive assessment of symptoms relevant for a range of major psychiatric disorders and flexibility for interviewers to clarify questions and pursue inconsistencies that emerge during the interview. The K-SADS used in the present study integrates elements of two versions of the instrument. The present state edition (K-SADS-P) was employed to make graduated ratings of the severity of present symptoms and disorders on 6 and 4 point scales. The K-SADS-P was originally developed by Puig-Antich and Chambers (1978) and modified for DSM-III-R by

12 1118 Child Development Ambrosini and colleagues (e.g., KSADS-III-R; Ambrosini, Metz, Prabucki, & Lee, 1989). The epidemiological version of the instrument (K-SADS-E; Orvaschel, Puig-Antich, Chambers, Tabrizi, & Jolmson, 1982) was used to rate past symptoms and disorders dichotomously (i.e., yes = present, no = absent). Modifications in questions were based upon provisional diagnostic criteria for DSM-IV (American Psychiatric Association, 1994). The validity of the K-SADS-E was demonstrated by the finding that virtually all former patients reassessed obtained the same diagnosis as in their earlier assessment. The validity of the K-SADS-P has been shown in studies of sensitivity to changes during treatment and of biological correlates of diagnoses (e.g., reviewed by Costello, 1991). Research on test-retest reliability within a 72 hr period (Chambers et al., 1985) found varied but generally moderate levels of agreement for major diagnoses, with low concordance for a heterogeneous group of anxiety disorders. Work by Ambrosini and colleagues (Ambrosini et al., 1989) on the interrater reliability of K-SADS-111-R found the mean kappa to be. 79 for child-derived diagnoses and.84 for all motherderived and child-derived diagnoses based on symptom information during the previous 12 months. Mean kappas for individual diagnoses were: major depression, kappa =.83; overanxious disorder, kappa =.85; separation anxiety, kappa =.85, simple phobia disorder, kappa =.64, oppositional disorder, kappa =.89, and attention deficit disorder, kappa =.88. For purposes of the longitudinal study, the adolescent's overall history of psychopathology was rated on a 7 point Likert-type scale. Number and severity of past and present diagnoses are considered in assigning ratings. At the high end of the scale (rating = 7), the individual qualifies for multiple diagnoses of pathology, both past and present. At the low end of the scale, the individual qualifies for a single diagnosis that is less serious, such as simple phobia (rating = 2), or neither past nor present diagnoses (rating = 1). The adolescent's overall history of dissociative experiences was represented by the total number of past and present diagnoses of brief dissociative episodes, depersonalization episodes, and dissociative epi3odes derived from the K-SADS. Dissociative Experiences Scale (DES) (19 years). The Dissociative Experiences Scale (DES) is a self-report form of the frequency of dissociative experiences in an individual's daily life, intended to be used as a screening device for dissociative disorders. Individuals quantify experiences by marking a response scale (0%-100%) for each of 28 items. The scale items cover experiences of memory disturbances, identity, awareness, and cognition (e.g., frequent daydreaming, lack of memory for significant past events). The DES discriminates clinical and nonclinical samples and demonstrates good construct and criterion validity (Carlson & Putnam, 1993). Internal reliability (r =.80) and test-retest reliability (r =.83) are high. RESULTS Results of the study are presented in four sections. First, the relations of attachment disorganization to early endogenous and environmental factors are examined. Second, consequences of attachment disorganization are explored. Third, results of hierarchical multiple regression analyses are presented. These analyses examine the relative contribution of attachment disorganization to later psychopathology and dissociation. Finally, results of structural equation modeling are presented. The models test hypotheses that attachment disorganization may mediate the effect of early caregiving on later psychopathology and dissociation. Antecedents of Attachment Disorganization Zero order correlations were calculated to examine the relations between early endogenous and environmental variables and overall ratings of attachment disorganization (see Table 4). Attachment disorganization was associated with single parenthood and with maternal risk for parenting difficulties. Infants with high ratings of disorganization were more likely to have experienced insensitive I intrusive caregiving as well as a variety of forms of maltreatment in the first year of life. Attachment disorganization was not associated with maternal history of serious medical problems or psychological problems, medical complications during pregnancy or delivery, or reported maternal history of abuse or drug/ alcohol use. Also, disorganization was not associated with infant anomalies, Brazelton scores at birth, or infant temperament and behavior ratings at 3 months. Consequences of Attachment Disorganization Zero order correlations were calculated to examine the relations between attachment disorganization in infancy and indices of socioemotional difficulties or pathology from 24 months through adolescence (see Table 5). Overall ratings of disorganization were correlated in expected directions with measures of mother-child relationship quality at 24 and 42 months, behavior problems in elementary school

13 Elizabeth A. Carlson 1119 Table 4 Correlations between Antecedent Endogenous and Environmental Factors and Disorganized/Disoriented Attachment Disorganized/ Disoriented Antecedent Variables Attachment n Endogenous variables: Maternal medical history".07 (150) Pregnancy complications'.02 (151) Maternal drug/ alcohol useh -.02 (157) Premature birthb -.07 (157) Delivery complications' -.05 (150) Infant anomaliesh.04 (149) Infant Brazelton (7, 10 days)'.11 (151) Carey questionnaire (3 months): Infant adaptability".03 (151) Infant intensity" -.05 (151) Infant low threshold' -.05 (151) Infant social behavior (3 months)' -.03 (146) Environmental variables: Maternal relationship statush.25*** (156) Maternal history of abuseh.12 (81) Maternal psychological problemsb.10 (157) Maternal risk statush (at infant's birth).27** (79) Maternal caretaking skill' -.29*** (146) Maternal affective quality' (3 months) -.03 (146) Maternal cooperation/ sensitivity' (6 months) -.38*** (129) Infant abuse: Overall abuseh.29*** (157) Physical abuseb.20** (157) Verbal abuseb.09 (157) Psychological unavailabilityb.23*** (157) Neglecth.20** (157) Two-tailed Pearson product-moment correlation coefficients. b Kendall tau correlation coefficients. * p <.05; p <.01; p <.001. Table 5 Correlations between Disorganized/Disoriented Attachment and Consequent Measures of Relationship Quality and Individual Psychopathology from 24 Months to 19 Years Disorganized I Disoriented Outcome Variables Attachment n Mother-child relationship quality: Confidence with mother (24 months) -.24* (135) Experience with mother (42 months) -.25** (141) Preschool behavior problem index ( years).40*** (78) Teacher Report Form (grades 1, 2, 3, 6): Total Score.17 (143) Externalizing.03 (143) Internalizing.19* (143) Dissociation.26** (143) Emotional health rank (grades 1, 2, 3, 6) -.17* (144) Parent-child boundary dissolution (13 years) -.11 (128) Teacher Report Form (high school): Total Score.21* (133) Externalizing.11 (133) Internalizing.18* (131) Dissociation.22** (133) Emotional health rank (high school) -.14 (134) K-SADS ( years): Psychopathology rating.34*** (129) Dissociation'.19* (129) DES (19 years): Dissociation.36*** (128) Note: Coefficients are two-tailed Pearson product-moment correlations unless otherwise indicated. 'Kendall tau correlation coefficient. p <.05; ** p <.01; *** p <.001. (TRF Internalizing scores and emotional health rankings), behavior problems in high school (TRF Total and Internalizing scores) and ratings of psychopathology at age l?lf2. Attachment disorganization was correlated with TRF-derived dissociative scores in middle childhood and adolescence. In particular, disorganization was associated with the items "confused, seems to be in a fog," r(141) =.31, p <.001, and "gets hurt alot, accident prone," r(141) =.26, p <.01, in elementary school, and the items "confused, seems to be in a fog," r(130) =.18, p <.05, "strange behavior," r(131) =.24, p <.01, and "deliberately harms self or attempts suicide," r{l30) =.20, p <.02, in high school. Disorganization also was related to overall history and concurrent self-report of dissociative episodes as measured by the K-SADS at age 17lf2 and DES at age 19, r(127) =.34 and r(126) =.36, p <.001, respectively. Hierarchical Regression Analyses Predicting Psychopathology and Dissociation from Attachment Disorganization Prediction of Psychopathology Hierarchical multiple regression procedures were used to examine the prediction of psychopathology in adolescence (rating of psychopathology derived from the K-SADS) from attachment organization and disorganization and intervening individual and relationship indices of socioemotional functioning (combined index of child behavior problems in grades 1-6 and parent-child relationship quality at 13 years). For purposes of regression analyses, avoidant, resistant, and overall insecure (avoidant or resistant) attachment data were recoded assigning scores of 0, 1, 2 for the number of times (at 12 and 18 months) infants were classified avoidant, resistant, and insecure, respectively. Attachment organization (avoid-

14 1120 Child Development ant score) was entered first in the regression equation to examine the hypothesis that disorganization may explain psychopathology in adolescence beyond that predicted by insecure attachment alone. Because resistant and overall insecure attachment scores were found not to be related significantly to psychopathology ratings in adolescence, these variables were not included in regression analyses. Zero order correlations of the independent variables included in the regression equation with the outcome ratings of adolescent psychopathology were as follows: avoidant attachment score, r(127) =.26, p <.01, attachment disorganization rating, r(127) =.34, p <.001, composite TRF behavior problem Total score for grades 1 to 6, r(127) =.45, p <.001, parentchild relationship quality rating at 13 years, r(119) =.19, p <.05. In regression analyses, avoidant attachment scores, attachment disorganization ratings, elementary school behavior problem scores, and ratings of parent-child relationship quality at 13 years each contributed significantly to the prediction of psychopathology in adolescence. The combined set of variables produced a multiple correlation of.55, accounting for 31% of the overall variance (see Table 6). Attachment disorganization ratings also significantly predicted psychopathology ratings controlling for avoidant attachment, behavior problems, and parent-child relationship quality, R 2 change =.05, F change (4, 116) = 7.49, p <.05. Prediction of Dissociation Hierarchical multiple regression procedures were used to examine the prediction of dissociation in adolescence (DES scores) from attachment disorganization and intervening individual and relationship socioemotional variables (combined index of child behavior problems in grades 1-6, parent-child relationship quality at 13 years). Avoidant, resistant, and overall insecure attachment scores (coded 0, 1, 2) were not correlated with DES scores and were not included in regression analyses. Zero order correlations of the independent variables included in the regression equation with the outcome DES scores were as follows: attachment disorganization rating, r(126) =.36, p <.001, composite TRF behavior problem Total score for grades 1-6, r(126) =.22, p <.05, parent-child relationship quality rating at 13 years, r(117) =.05, ns. In regression analyses, attachment disorganization ratings and elementary school behavior problem scores contributed significantly to the prediction of dissociation in adolescence. The combined set of variables produced a multiple correlation of.42, accounting for 17% of the overall variance (see Table 7). Also, attachment disorganizaton ratings significantly predicted dissociation scores controlling for elementary school behavior problems and parent-child relationship quality, R 2 change =.10, F change (2, 116) p <.001. Structural Models Examining Attachment Disorganization as Mediator of Early Caregiving Experience Structural equation modeling (Browne & Cudeck, 1993; Browne & Mels, 1992) was employed to test Table 6 Hierarchical Regression Predicting Ratings of Psychopathology (K-SADS) at 17 1 /z Years from Disorganized Attachment in Infancy, Behavior Problem Index (TRF) in Middle Childhood, and Family Relationship Quality in Early Adolescence (N = 120) R' Overall Step and Independent Variables Change Beta B T R' F df L Prediction from disorganized attachment controlling for avoidant attachment: 1. Avoidant attachment score (12-18 months) ** ** 1, Avoidant attachment score * Disorganization rating (12-18 months) ** *** 2, Avoidant attachment score Disorganization rating * TRF total score (grades 1, 2, 3, 6) *** *** 3, Avoidant attachment score Disorganization rating ** TRF total score *** Relationship rating (13 years) * *** 4,116 Note: Index of psychopathology in adolescence is 7 point rating of number and severity of K-SADS diagnoses. * p <.05; ** p <.01; *** p <.001.

15 Elizabeth A. Carlson 1121 Table7 Hierarchical Regression Predicting Dissociation Scores (DES) at 19 Years from Disorganized Attachment in Infancy, Behavior Problem Index (TRF) in Middle Childhood, and Family Relationship Quality in Early Adolescence (N = 118) R' Overall Step and Independent Variables Change Beta B T R' F df I. Prediction from disorganized attachment: 1. Disorganization rating (12-18 months) *** *** 1, Disorganization rating *** TRF total score (grades 1, 2, 3, 6) ** *** 2, Disorganization rating *** TRF total score ** Relationship rating (13 years) *** 3,115 Note: Index of psychopathology in adolescence is 7 point rating of number and severity of K-SADS diagnoses. * p <.05; ** p <.01; *** p <.001. hypotheses that attachment disorganization may mediate the relations between (1) early caregiving and psychopathology at age 171fz and (2) early caregiving and dissociative experiences at age 19. The first hypothesized model (Model M 1 ), shown in Figure 1, examined the relations between early caregiving, attachment disorganization, and psychopathology. The model includes paths linking (1) early caregiving and attachment disorganization ratings, (2) early caregiving and psychopathology ratings, and (3) attachment disorganization ratings and psychopathology ratings. Three measured indicators of early caregiving included ratings of maternal caretaking skill at 3 months, ratings of maternal cooperation I sensitivity at 6 months, and infant history of abuse. Listwise Pearson correlations among the indicators of early caregiving and manifest variables (attachment disorganization ratings in infancy and K-SADS psychopathology ratings in adoles- cence) are presented in Appendix C. All factor loadings and path coefficients from early caregiving to attachment disorganization and attachment disorganization to psychopathology were significant at or beyond the.01level. Results of the chi-square test of the model suggest an adequate fit to the data. The second structural model (Model M 2, shown in Figure 2) tested the hypothesis that attachment disorganization may mediate the effects of early caregiving on dissociation (DES) scores at age 19. The model includes paths linking (1) early caregiving and attachment disorganization ratings, (2) early caregiving and DES scores, and (3) attachment disorganization ratings and DES scores. Three measured indicators of early caregiving were ratings of caretaking skill, ratings of maternal cooperation/ sensitivity, and infant abuse history. Listwise Pearson correlations among manifest variables are presented in Appendix D. All factor loadings and path coefficients X 2 [4] ** li- 117 Caretaking skill score -.14 n.s. Cooperation/ sensitivity rating t Psychopathology rating Abuse score Figure 1 Structural model, M 1 : Attachment disorganization as mediator of relations between early caregiving environment and psychopathology ratings (K-SADS) in adolescence. Error variances for measured indicators are not shown. The model accounts for 12% of the variance of the psychopathology rating. **p <.01.

16 1122 Child Development X 2 ( **.lt Caretaking skill score Cooperation/ sensitivity rating ~--'----! Dissociation score Abuse score Figure 2 Structural model, M 1 : Attachment disorganization as mediator of relations between early caregiving environment and dissociation score (DES) in adolescence. Error variances for measured indicators are not shown. The model accounts for 15% of the variance of the dissociation score. *p <.05; **p <.01. from early caregiving to attachment disorganization and attachment disorganization to dissociation as well as the direct path from early caregiving to dissociation were significant at or beyond the.01 level. These results suggest that the effects of caregiving on dissociation may be direct as well as mediated by attachment disorganization. Results of the chi-square test of the mediation model suggest an adequate fit to the data. DISCUSSION In the present study, the etiology and consequences of attachment disorganization were examined using a prospective longitudinal design. Two central issues related to the validity of attachment disorganization/ disorientation were tested: (1) the origins of disorganization in patterns of care (rather than in endogenous neuropathology) and (2) the consequences of disorganization for psychopathology and dissociative symptoms. Other critical propositions, such as the link between disorganization and infant experiences of abuse, were replicated. Structural equation models were employed to extend the understanding of relations between early caregiving experience and later symptomatic behavior and the mediating role of attachment disorganization. With respect to the first hypothesis, results from analyses of disorganization etiology suggest that environmental factors (i.e., caregiving) influence the development of attachment disorganization. Attachment disorganization was related significantly to early environmental risk variables including maternal relationship status (i.e., living alone with an infant), maternal overall risk status, maternal caregiving style (intrusive versus cooperative, insensitive versus sensitive) as well as specific forms of maltreatment (e.g., physical abuse, psychological unavailability, and neglect). In this study, no evidence was found to support relations between endogenous factors and attachment disorganization. Disorganization ratings were not related to maternal medical history, pregnancy and delivery complications, infant anomalies, or infant temperament or behavior at birth and 3 months. These null findings are noteworthy given the nature of behaviors used to judge disorganization and disorientation. Analyses of disorganization outcome data suggest that the quality of caregiving difficulties reflected in attachment disorganization may have significant consequences for the mother-child relationship and individual socioemotional functioning. In this study, attachment disorganization was related to the quality of the mother-child relationship at 24 and 42 months, individual behavior problems in preschool, elementary school, and high school, and diagnostic ratings of psychopathology at age Such simple predictability from infant behavior to disturbance at age 17 is unprecedented. Results of regression analyses and structural modeling begin to elucidate the contribution and relation of disorganization to later psychopathology. The findings suggest that (1) attachment disorganization may mediate the effects of caregiving quality on later psychopathology, (2) a history of attachment disorganization may contribute to or increase a child's risk for psychopathology even with

17 Elizabeth A. Carlson 1123 anxious avoidant attachment quality, early behavior problems, and family relationship quality taken into account, and (3) whereas attachment disorganization, behavior problems, and parent child boundary problems independently predict psychopathology, the combination of these experiences best accounts for the occurrence of psychopathology in adolescence. Based on data from this study, attachment disorganization may have particular long-term implications for the development of dissociative symptoms in childhood and adolescence. Attachment disorganization in infancy was related to dissociative symptoms as measured by rationally derived scales in elementary and high school, a semistructured diagnostic interview at age , and a standardized self-report measure at age 19. Because one source of disorganized behaviors may be the second-generation effect of unresolved loss (Main & Hesse, 1990) or trauma (Carlson, 1990) and because many disorganized behaviors are thought to represent microdissociative experiences (Liotti, 1992), these initial relations are important. Similar to patterns of relations between disorganization and psychopathology, results of regression analyses and structural modeling predicting dissociation suggest that (1) attachment disorganization may mediate some effects of early caregiving quality on later dissociative experiences, (2) disorganization may increase a child's risk for the development of dissociative symptomatology even with middle childhood behavior problems taken into account, and (3) the combination of disorganization and middle childhood behavior problems best predicts later dissociative symptomatology. In general, the findings support a view of attachment as a relationship construct, a pattern of regulation or dysregulation that evolves from a dyadic history of interaction (Carlson & Sroufe, 1995; Sroufe, 1996). Variations in infant characteristics may be mediated by caregiver sensitivity to become part of dyadic organization (Susman-Stillman, Kalkoske, Egeland, & Waldman, 1996). Because environment makes possible the steady progress of maturational processes, disorganization of caregiving assistance in infant regulation during early months of rapid growth and maturation may have long-term effects on infant biological organization (Cicchetti, Ganiban, & Barnett, 1991; Collins & Depue, 1992; Greenough & Black, 1992; Kraemer, 1992). In particular, early exposure to trauma may have detrimental effects on neurological organization (Perry et al., 1995). Early distortions in relationship experience, in the regulation of behavior and emotion, place infants on pathways that probabilistically lead to later dis- turbance. From a developmental perspective, maladaptation evolves from the successive adaptations of individuals in their environments (Sroufe, 1997). The preliminary analyses of the contribution of disorganization to later psychopathology and dissociation in this study highlight the complex nature of relations among factors and processes interacting over time. Although results of categorical (disorganized/not disorganized) analyses not reported here paralleled the correlational analyses, relations reported in this study were relatively modest (correlations from.20 to.40), and replication of the findings using the disorganization classification will be important. Researchers can be more confident of the patterns of findings if confirmed using categorical data based on a clinical criterion. For example, the stability of the disorganized attachment classification itself remains uncertain. For the original longitudinal sample, changes in major attachment classification (ABC) over time were found to be related in expectable ways to changes in the participants' lives (e.g., increase I decrease in life stress) (Egeland & Farber, 1984). Whereas changes in disorganization (as well as secure/insecure status) from 12 to 18 months in the subsample of this study tended toward insecurity, contributing factors are unclear. With a larger sample, it may be possible to examine the effects of intervening life events such as caregiver and infant experiences of separation, loss, and trauma. There is also need for a careful etiological study of attachment disorganization, one that includes systematic home observations and measures of caregiver histories of unresolved loss/trauma and dissociative episodes and assessments of infant biological vulnerabilities and experiences of trauma. In the present study, an attempt was made to explore the antecedent relations of variations in patterns of disorganization (e.g., relations between history of abuse and apprehensive behaviors, caregiver history of loss and infant stilling, freezing behaviors, and so forth). The lack of sufficient background information and sample size in the current data set precluded such specific examination. Home observations and documentation of parent-infant interaction (i.e., frightening or frightened caregiver behavior) would provide important validation of disorganized attachment patterns. Two such studies are under way (Jacobvitz et al., 1997; Schuengel et al., 1997). The delineation of relations between caregiver history or infant experience and disorganized behavior patterns may help clarify whether the behaviors represent the lack of dyadic organization, the disorganization and reorganization of coherent patterns of regulation, or distinct attachment patterns. Because

18 1124 Child Development infants exhibiting high levels of disorganization appear to be particularly vulnerable to stress (Hertsgaard, Gunnar, Erickson, & Nachmias, 1995; Spangler & Grossmann, 1993), and the vulnerability appears to have significant long-term effects on social and emotional development, understanding the many aspects of the phenomenon is important and may prove fruitful for early prevention efforts and the development of intervention strategies. The contribution of the current study lies in the support provided for the validity of the rating of attachment disorganization/ disorientation. Future investigators may be more confident that in assessing disorganization they are tapping into the attachment domain, with potential implications for social behavior and pathology. ACKNOWLEDGMENTS Preparation of this work and the research described here were supported by a National Institute of Mental Health postdoctoral training grant (MH 09744) to the author and a National Institute of Mental Health grant (MH ) to L. Alan Sroufe and Byron Egeland. I thank Alan Sroufe and Byron Egeland for their contributions to and support during this project. ADDRESS AND AFFILIATION Corresponding author: Elizabeth A. Carlson, Institute of Child Development, University of Minnesota, 51 East River Road, Minneapolis, MN 55455; carls032@maroon.tc.umn.edu. APPENDIX A INDICES OF DISORGANIZED/DISORIENTED ATTACHMENT (Main & Solomon, 1990) For Infants Months Observed with Parent Present I. Sequential display of contradictory behavior patterns A. Very strong displays of attachment behavior or angry behavior suddenly followed by avoidance, freezing, or dazed behavior B. Calm, contented play suddenly succeeded by distressed, angry behavior II. Simultaneous display of contradictory behavior patterns A. The infant displays avoidant behavior simultaneously with proximity-seeking, contact-maintaining, or contact resisting B. Simultaneous display of other opposing behavioral propensities III. Undirected, incomplete, and interrupted movements and expressions A. Seemingly undirected movements and expressions (many could also be considered misdirected or redirected) B. Incomplete movements C. Interrupted expressions or movements IV. Stereotypies, asymmetrical and mistimed movements, and anomalous postures A. Asymmetries of expression or movement B. Stereotypies C. Assumption of anomalous postures D. Mistimed movements V. Freezing, stilling, and slowed movements and expressions "Freezing" is identified as the holding of movements, gestures, or positions in a posture that involves active resistance to gravity. For example, the infant sits or stands with arms held out waist high and to sides. "Stilling" is distinguished from freezing in that the infant is in a comfortable, resting posture that requires no active resistance to gravity. Freezing is considered a stronger marker of disorientation than stilling. A. Freezing and stilling suggestive of more than momentary interruption of activity B. Slowed movements and expressions suggesting lack of orientation to the present environment VI. Direct indices of apprehension regarding parent A. Expression of strong fear or apprehension directly upon return of parent, or when parent calls or approaches B. Other indices of apprehension regarding the parent VII. Direct indices of disorganization or disorientation A. Any clear indices of confusion and disorganization in first moment of reunion with the parent B. Direct indices of confusion or disorientation beyond the first moments of reunion with the parent APPENDIX B RATING SCALE OF DISORGANIZATION/ DISORIENTATION (Main & Solomon, 1990) 1. No signs of disorganization/ disorientation. 3. Slight signs of disorganization/ disorientation. 5. Moderate indices of disorganization/ disorientation that are not clearly sufficient for a disorganized I disoriented category placement. No very strong indicators are present, and the indices that are present are not frequent enough, intense enough, or clear enough for the coder to be certain of a disorganized category placement. The coder will need to "force" a decision regarding whether the infant should be assigned to a D category based on (1) whether the infant's behavior seems inexplicable, indicative of momentary absence of a behavioral strategy, can be explained only by presuming that the infant is fearful

19 Elizabeth A. Carlson 1125 of the parent, and I or is unable to shift attention away from the parent while simultaneously being inhibited in approaching the parent, (2) the timing of the appearance of disorganized behavior, (3) whether episodes of apparent disorganization are immediately succeeded by an approach to the parent. 7. Definite qualification for disorganized I disoriented attachment status, but disorganized behavior is not extreme. 9. Definite qualification for disorganized I disoriented attachment status: in addition, the indices of disorganization and disorientation are strong, frequent, or extreme. APPENDIX C Table Cl Correlation Matrix for Structural Model, M 1 Variables Construct I indicators: Early caregiving: 1. Caretaking skill factor score (3 months) 2. Cooperation I sensitivity rating (6 months).489*** 3. Infant abuse rating (reversed) (birth to 18 months).370***.309*** Measured variables: 4. Disorganized attachment rating (12-18 months) -.349*** -.422*** -.190* 5. Psychopathology rating (K-SADS) (171J2 years) -.181* -.192* *** Note: N = 117 based on listwise exclusion of cases. p <.05; *** p <.001. APPENDIX D Table Dl Correlation Matrix for Structural Model, M 2 Variables Construct I indicators: Early caregiving: 1. Caretaking skill factor score (3 months) 2. Cooperation/ sensitivity rating (6 months).496*** 3. Infant abuse rating (reversed) (birth to 18 months).377***.307*** Measured variables: 4. Disorganized attachment rating (12-18 months) -.333*** -.373*** -.190* 5. Dissociation score (DES) ( years) -.231* **.340*** Note: N = 116 based on listwise exclusion of cases. * p <.05; p <.01; *** p <.001.

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