Attachment-Based Interventions : Comments on Dozier, Egeland, and Benoit

Mt. Hope Family Center, University of Rochester, USA
, 2nd ed.

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Attachment theory provides a powerful perspective for investigating the nature of the relationship between experiences of caregiving and developmental outcome.1,2,3 Attachment organization in infants and toddlers has been linked with future adaptation.4,3 Therefore, it is important to promote secure attachment relationships between caregivers and their offspring. In the last decade, investigators have increasingly directed their efforts toward understanding and modifying attachment relationships in high-risk and psychiatric populations.5,6,7 Dozier, Egeland, and Benoit have been at the forefront of theoretical and research initiatives designed to prevent insecure relationships and  promote secure attachment relationships in young children. In these articles, the authors review the literature on attachment-based interventions and highlight key empirical findings regarding the efficacy of prevention and intervention initiatives.

Research and Conclusions

Dozier begins by reviewing how the type of caregiving provided affects the quality of children’s attachment. She goes on to explain that the strongest predictor of infant attachment is parental state of mind regarding attachment. Dozier also discusses the variations among intervention strategies utilized to enhance attachment security. She draws upon a 2003 meta-analysis conducted by Bakermans-Kranenburg, van Ijzendoorn and Juffer, in which they concluded that interventions that target parental sensitivity and are initiated after approximately six months of age are more effective than interventions with more global goals that begin during the early months.8 Moreover, she concludes that brief interventions are at least as effective as those that are longer in duration.

Egeland emphasizes that security of attachment during infancy has been consistently shown to predict aspects of social development during childhood, with secure attachment relating to more optimal developmental outcomes and insecure attachment predicting socioemotional maladaptation. Egeland further states that attachment relationships may have long-term effects on the course of biological development. Consistent with Dozier, Egeland therefore concludes that it is critical to design and evaluate programs to promote a secure parent-infant attachment relationship. Like Dozier, Egeland also discusses two broad types of intervention strategies designed to foster secure attachment relationships: 1) strategies that target parental sensitivity; and 2) strategies that strive to alter parental representation with respect to their own histories of caregiving. A central tenet of attachment theory is that the early relationships between infants and their caregivers lead to the formation of mental representations of the self, others, and of the self in relation to others. Therefore, the focus of interventions on modifying these mental representations or targeting caregiver behaviour assumes importance. Egeland proffers an important caveat to findings that support the utilization of short-term interventions that target modifying parental sensitivity. Specifically, Egeland cautions that although these programs are successful with relatively low-risk samples, more comprehensive and long-term interventions are likely to be necessary with high-risk families.

Benoit’s article is focused on a particular pattern of insecure attachment, the disorganized classification. Unlike organized attachments, in which coherent strategies for relating to the caregiver in times of stress are present, disorganized attachment is not characterized by any consistent strategy of relating to the caregiver. Disorganized attachment has been identified as particularly significant in putting youngsters at risk for socioemotional maladjustment and psychopathology. Benoit emphasizes that although caregiver sensitivity has been linked with organized patterns of attachment, it has not been shown to relate to disorganized attachment. Benoit discusses the fact that, in an analysis of 15 studies from their 2003 meta-analysis, Bakermans-Kranenburg and colleagues concluded that attachment interventions that focus on preventing or reducing disorganized attachment may need to target the reduction of atypical caregiver behaviours.Specifically, frightened or frightening caregiver behaviour has been implicated in the etiology of disorganized attachment.

Implications for Development and Policy

Taken in tandem, all three of these papers support the importance of preventing insecure relationships and promoting secure attachment relationships between young children and their caregivers. Over the last several decades, evidence has mounted regarding the importance of establishing secure attachment for future adaptive development. Increasingly, prevention and intervention programs have targeted security of attachment as an outcome goal. Although there has been some evidence suggesting that short-term interventions that target parental sensitivity are efficacious and perhaps superior to long-term approaches that strive to modify parental state of mind regarding attachment, this controversy is far from resolved. In fact, it would be extremely premature to conclude that one approach is preferable to the other. As Egeland cautions, short-term behavioural approaches may be effective with lower-risk groups of infants and mothers, but we still do not have evidence that they would be as effective, or effective at all, with higher-risk populations.

In fact, studies recently conducted at Mt. Hope Family Center have offered compelling evidence that preventive interventions that target maternal representations of relationships are very effective in promoting attachment security.  In the first investigation, toddler offspring of mothers who had experienced a major depressive disorder since the birth of the child were randomly assigned to an attachment-theory informed intervention or to a community standard condition. A group of non-depressed mothers served as a normative comparison group. Although at baseline toddlers with depressed mothers evidenced higher rates of insecurity than did toddlers with non-depressed mothers, at the completion of the intervention the group that received the attachment-theory informed intervention had significantly higher rates of security than did participants who received the community standard intervention. Importantly, rates of security in the mother-child dyads that received the attachment-theory informed intervention did not differ from those present in the dyads where mothers were not depressed.For toddlers who participated in the attachment intervention, there was also a greater maintenance of secure attachment organization among those who were initially secure, as well as a greater shift from insecure to secure attachment groupings. Similarly compelling results have been obtained with maltreated infants, where baseline rates of insecurity were over 90% and where post-intervention attachment security did not differ from that of non-maltreated infants. Maltreated infants randomized to the community standard condition continued to evidence extremely high rates of insecure attachment consistent with that present at baseline.9 Interestingly, in the latter preventive intervention, a didactic and more behaviourally focused intervention was just as effective as one dealing with maternal representations in promoting secure attachment. Conversely, in the evaluation of a preventive intervention for maltreated preschool-aged children, only an intervention that targeted maternal representations resulted in improvement in child representations of caregivers and of self.10 Thus, the issue of preferred intervention strategy appears to be far from resolved and caution must be exercised in bringing premature closure to this issue.

A number of other important issues need to be considered before definitive conclusions can be reached on how best to promote secure attachment organization. First, it is unclear how durable the effects of the interventions are and whether durability might vary as a function of the length and intensity of the intervention being provided. Second, few if any investigations have sought to elucidate mediators of the intervention outcome. That is, while we may know that a given intervention has been efficacious, we know considerably less about the mechanisms that may be contributing to its efficacy. Such knowledge could be extremely helpful in identifying critical aspects of an intervention and eliminating those that may be costly but do not add to the overall value of the intervention. Finally, the bulk of evaluations have involved well-controlled efficacy trials that utilize clear inclusion/exclusion criteria and well-trained and supervised clinicians, and also monitor the fidelity of the intervention being provided. Although such randomized clinical trials are necessary in order to establish a knowledge base, we must also work toward exporting these clinical methods into real-world arenas and then continue to evaluate their effectiveness. Only then will we truly know how best to promote secure attachment and what approaches may be most effective for a given population.


  1. Ainsworth MDS, Blehar MC, Waters E, Wall S. Patterns of attachment: A psychological study of the strange situation. Hillsdale, NJ: Lawrence Erlbaum Associates; 1978.
  2. Main M, Kaplan N, Cassidy JC. Security in infancy, childhood and adulthood: A move to the level of representation. Monographs of the Society for Research in Child Development 1985;50(1-2):66-104.
  3. Sroufe LA. Infant-caregiver attachment and patterns of adaptation in preschool: The roots of maladaptation and competence. Minnesota symposia on child psychology 1983;16:41-83.
  4. Elicker J, Englund M, Sroufe LA. Predicting peer competence and peer relationships in childhood from early parent-child relationships. In: Parke RD,  Ladd GW, eds. Family-peer relationships: Modes of linkage. Hillsdale, NJ: Lawrence Earlbaum Associates; 1992:77-106.
  5. Cicchetti D, Toth SL, Rogosch FA. The efficacy of toddler-parent psychotherapy to increase attachment security in offspring of depressed mothers. Attachment and Human Development 1999;1(1):34-66.
  6. Lieberman AF, Pawl JH. Disorders of attachment and secure base behavior in the second year of life: Conceptual issues and clinical intervention. In: Greenberg MT, Cicchetti D, Cummings EM, eds. Attachment in the preschool years: Theory, research, and intervention. Chicago, Ill: University of Chicago Press; 1990:375-397.
  7. van Ijzendoorn MH, Juffer F, Duyvesteyn MGC. Breaking the intergenerational cycle of insecure attachment: A review of the effects of attachment-based interventions on maternal sensitivity and infant security. Journal of Child Psychology and Psychiatry and Allied Disciplines 1995;36(2):225-248.
  8. Bakermans-Kranenburg MJ, van Ijzendoorn MH, Juffer F. Less is more: Meta-analyses of sensitivity and attachment interventions in early childhood. Psychological Bulletin 2003;129(2):195-215.
  9. Cicchetti D, Toth SL, Rogosch FA. The efficacy of interventions for maltreated infants in fostering secure attachment. In preparation.
  10. Toth SL, Maughan A, Manly JT, Spagnola M, Cicchetti D. The relative efficacy of two interventions in altering maltreated preschool children's representational models: Implications for attachment theory. Development and Psychopathology 2002;14(4):877-908.

How to cite this article:

Toth SL. Attachment-Based Interventions : Comments on Dozier, Egeland, and Benoit. In: Tremblay RE, Boivin M, Peters RDeV, eds. van IJzendoorn MH, topic ed. Encyclopedia on Early Childhood Development [online]. Updated: March 2007. Accessed February 8, 2023.

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