ARTICLE

A Review of Attachment
Theory in the Context of
Adolescent Parenting
Serena Cherry Flaherty, MSN, RN, CPNP,
& Lois S. Sadler, PhD, PNP-BC, FAAN

ABSTRACT This article provides a review of attachment theory

The purpose of this article is to review attachment theory and re- and relates the attachment perspective to the unique
late the attachment perspective to adolescent mothers and their challenges of clinical work with adolescent mothers
children. Attachment theory explains positive maternal-infant and their children. Infants of adolescent mothers are
attachment as a dyadic relationship between the infant and
at risk for poor attachment outcomes that are associated
mother that provides the infant with a secure base from which
to explore the world. With respect to cognitive, social, and be-
with long-term adverse consequences in cognitive,
havioral domains, securely attached infants tend to have more adaptive, and behavioral domains (Belsky & Fearon,
favorable long-term outcomes, while insecurely attached infants 2002; Karen, 1990). A secure attachment relationship
are more likely to have adverse outcomes. Adolescent parent- evolves from a mother’s ability to be reflective,
hood can disrupt normal adolescent development, and this dis- responsive, and sensitive to her infant’s needs
ruption influences development of the emotional and cognitive and results in the infant’s development of trust,
capacities necessary for maternal behaviors that foster secure at- confidence, and resilience in later life (Karen, 1990).
tachment. However, it appears that if specialized supports are in Adolescent mothers
place to facilitate the process of developing attachment, infants may not intuitively be
of adolescent mothers can obtain higher rates of secure attach-
It is critical for
able to assume these
ment than normative samples in this population. J Pediatr Health
characteristics that fos-
clinicians to be able
Care. (2011) 25, 114-121.
ter secure attachment to recognize signs
because of their own of poor
KEY WORDS
developmental stage
Attachment, maternal-infant attachment, adolescent mother
(Sadler & Cowlin,
attachment.and
2003). It is critical for to learn to model
Serena Cherry Flaherty, Pediatric Nurse Practitioner, The Door -
clinicians to be able to favorable parenting
Adolescent Health Center, New York, NY.
recognize signs of
Lois S. Sadler, Associate Professor Yale School of Nursing and poor attachment that
behaviors that
Yale Child Study Center, Assitant Dean for Academic Affairs, Yale
School of Nursing.
can most easily be enhance
picked up by observa- attachment.
This work was supported by the following grants: NIH/NINR
tions of the mother’s in-
(P30NR08999), NIH/NICHD (R21HD048591), and NIH/NICHD
(R01HD057947). teractions with her infant and to learn to model
favorable parenting behaviors that enhance attach-
Conflicts of interest: None to report.
ment. Secure attachment is a critical part of the founda-
Correspondence: Serena Cherry Flaherty, MSN, RN, CPNP, The tion for a healthy life. Therefore, maternal-infant
Door - Adolescent Health Center, 121 Avenue of the Americas,
interactions, particularly in this high-risk adolescent
New York, NY 10013; e-mail: [email protected].
population, need to be assessed in the context of pedi-
0891-5245/$36.00 atric clinical care.
Copyright Q 2011 by the National Association of Pediatric Attachment theory has evolved from work by numer-
Nurse Practitioners. Published by Elsevier Inc. All rights ous researchers, primarily John Bowlby and Mary Ains-
reserved.
worth, and later Mary Main (Ainsworth, 1982;
doi:10.1016/j.pedhc.2010.02.005 Ainsworth, 1985; Ainsworth, Blehar, Waters, & Wall,

114 Volume 25  Number 2 Journal of Pediatric Health Care

1978; Bowlby, 1969/1982; Bowlby, 1973; Bowlby, 1980; The many challenges and consequences associated
Main, Kaplan, & Cassidy, 1985). Attachment, according with teen pregnancy and parenthood are well
to Ainsworth (1963) provides a secure base from which documented, but less is known about attachment rela-
the child can explore the world, and this idea has since tionships among adolescent mother-infant dyads
remained a fundamental principle of attachment the- (Manlove, Ikramullah, Mincieli, Holcombe, & Danish,
ory. Bowlby (1969/1982) subsequently described at- 2009; Moore & Brooks-Gunn, 2002; Patterson, 1997).
tachment as a unique relationship between an infant Many of the background and developmental
and his or her caregiver that is the foundation for further characteristics of adolescent mothers also may be
healthy development. Bowlby described attachment linked to poor attachment outcomes in their infants.
theory as an inherent biological response and behav- Poverty, poor parental modeling, growing up in
ioral system in place to provide satisfaction of basic hu- single-parent homes, and lack of educational opportu-
man needs. Mary Main, a student of Ainsworth’s, found nities and career goals often are associated with teen
that adult attachment representations, the construct of pregnancy and early parenthood (Coley & Chase-
how adults remember their own childhood experi- Lansdale, 1998; Manlove et al., 2009; Moore & Brooks-
ences, might influence the attachment categorization Gunn, 2002; Patterson, 1997). Adolescent mothers are
of their children (Main et al., 1985). less likely to receive adequate prenatal care and are
Attachment security and the theory of the internal more likely to experience pregnancy and birth
working model are two hallmark ideas that comprise at- complications, often because they are likely to be
tachment theory and influence how the child views living in poverty (Coley & Chase-Lansdale, 1998). An
himself or herself and other relationships (Belsky & analysis of the National Longitudinal Study of
Fearon, 2002; Cassidy, 2008). Whether mother-child Adolescent Health from 1994 through 2008 revealed
interactions are positive or negative, some level of that adolescent parents are more likely to be from fam-
attachment security and subsequent internal working ilies that report incomes below 200% of the federal
model develops (Carlson & Sroufe, 1995). According poverty level (FPL) (59% of survey respondents
to Bowlby (1969/1982), individuals develop ‘‘internal reported living in families with incomes below 200%
working models’’ of attachment that describe the rela- of the FPL, and 41% reported living in families with
tionship between the infant’s self and his or her attach- incomes greater than or equal to 200% of the FPL)
ment figure. In response to experiences and behavior of (The National Campaign to Prevent Teen and
the attachment figure toward the infant, the infant is Unplanned Pregnancy, 2009). Adolescent mothers are
able to formulate mental responses to the attachment more likely to suffer from depression and have a higher
figure’s behavior that are catalogued as mental repre- substance abuse potential (Clemmens, 2001;
sentations of the infant’s view of himself or herself Panzarine, Slater, & Sharps, 1995; Reid & Meadows-
and understanding of the attachment figure Oliver, 2007; Spieker, Gillmore, Lewis, Morrison, &
(Bretherton, 1992). The infant’s ability to explore the Lohr, 2001). In addition, they often have fewer
world and relationships within it hinges on the type resources, less social support, and an increased
of attachment security that develops during the first potential for child abuse and neglect (de Paul &
year of life (Belsky & Cassidy, 1994). In the context of Domenech, 2000; Panzarine et al., 1995; Turner,
attachment theory, it is important to distinguish Grindstaff, & Phillips, 1990; Whitman, Borkowski,
attachment behavior and attachment bond. Attachment Keogh, & Weed,, 2001; Zuravin & DiBlasio, 1992).
behavior is behavior on the part of the infant that pro- These factors, independently and collectively, heighten
motes proximity to the attachment figure, such as smil- the risk of compromised parenting behaviors with
ing and vocalization (Carlson & Sroufe, 1995; Cassidy, these young families. Parenting behaviors among ado-
2008). Attachment bond, however, is described by lescent mothers vary, but many of them experience
Ainsworth and Bowlby not as a dyadic and reciprocal higher degrees of stress related to parenting and tend
relationship existing between the infant and his or her to be less responsive, less sensitive, more detached,
caregiver, but rather as the infant’s interpretation of and more likely to exhibit intrusive behaviors with their
his or her relationship to his or her mother (Cassidy, infants (Berlin, Brady-Smith, & Brooks-Gunn, 2002;
2008). Evidence supports the positive influence of Whitman et al., 2001). These parenting characteristics
secure mother-child attachment on later development specific to adolescent parents are precisely what place
and aptitude (Slade & Aber, 1992). A secure attachment them at risk for compromised attachment
system serves as a foundation for expression of relationships. We are only beginning to learn about
emotions and communication in future relationships, the quality of attachment relationships among infants
provides opportunities for self-regulation of affect of adolescent mothers, but it appears they often are
(the ability to consider emotional processes before compromised, leading to less optimal infant outcomes
responding), and creates potential for resilience in developmental and socioemotional domains, all of
(Belsky & Cassidy, 1994; Carlson & Sroufe, 1995; which are more likely to be the case when there are
Cassidy, 2008; Karen, 1990). limited supportive programs or family members

www.jpedhc.org March/April 2011 115

available to help the young mother in her new and anxious-avoidant attachment (Group A), and anxious-
complex parenting roles. resistant attachment (Group C) (Ainsworth et al.,
In addition to the socioeconomic profile of many 1978). Subsequently, Mary Main later classified an
adolescent mothers that may contribute to poor attach- additional insecure group as Group D, which repre-
ment outcomes, adolescent mothers differ develop- sents disorganized-disoriented attachment (Main &
mentally from most adult mothers because they are Solomon, 1990).
working to combine their adolescent developmental Securely attached infants account for 65% to 70% of
tasks with the new tasks and roles of parenthood infants, and they actively seek attention from their
(Flanagan, McGrath, Meyer, & Garcia Coll, 1995; mothers, may become distressed upon the mother’s de-
Moriarty Daley, Sadler & Reynolds, in press; Sadler & parture or may decrease play and exploration, and are
Cowlin, 2003). When a pregnancy occurs during able to be consoled during the reunion episode of the
adolescence, the period of development during SSP (Ainsworth et al., 1978). Anxious-avoidant infants
which adolescents develop the cognitive skills to represent about 20% to 25% of U.S. samples and can
assume parenting responsibilities is interrupted behave similarly to securely attached infants until the
(Whitman et al., 2001). As a result, many adolescent separation period of the SSP, when they do not appear
mothers may not have the developmental capacity to to be affected by mother’s departure. During the
adopt parenting behaviors that enhance the maternal- reunion episode, anxious-avoidant infants will not
infant attachment relationship. Adolescents tend to be approach their mother and may protest her return by
idealistic, have a diminished capacity for reflection, avoiding her (Ainsworth et al., 1978; Slade & Aber,
and tend to embody egocentricity, individuality, and 1992). Anxious-resistant infants account for less than
independence (Hamburg, 1998). Adolescent develop- 10% of U.S. infants (Slade & Aber, 1992). They tend to
ment allows for the transition to higher levels of cogni- lack comfort in exploration in a strange environment,
tive function and ability to appreciate more abstract are significantly distressed during the separation
processes (Elkind, 1998). Maternal characteristics episode, and at the point of reunion are torn between
that enhance the attachment relationship, such as sensi- a desire for proximity and resistance to comfort
tive parenting, reflectivity, and responsiveness, are (Ainsworth et al., 1978; Carlson & Sroufe, 1995; Slade
challenging for adolescent mothers to intuitively adopt & Aber, 1992). Disorganized-disoriented infants have
because often they do not have the cognitive awareness no standard response to stress of separation and
afforded by full adult development (Moriarty Daley reunion and appear to have disorganized and unpre-
et al., in press; Sadler, Anderson, & Sabatelli, 2001). dictable patterns of behavior (Main & Solomon, 1990).
Literature exists to suggest cross-cultural application
MEASUREMENT OF ATTACHMENT of these attachment patterns. Sagi-Schwartz and Van
Historically, the Strange Situation Procedure (SSP) has IJzendoorn (2008) reviewed cross-cultural attachment
been the standard method for assessing attachment research and determined that the three attachment pat-
(Ainsworth et al., 1978). In a laboratory setting with terns applied using the SSP are universal. Attachment
a mother and her infant present, the attachment classification, therefore, is dependent on the relation-
relationship is stressed and the attachment system is ac- ship of the infant and mother, and although there may
tivated by various episodes of the mother and a stranger be cultural factors that affect emotional responses and
coming and going. The infant’s response to the behaviors, it does not appear that attachment outcomes
situation, particularly during the mother-child reunion, are directly associated with specific race or culture.
is reflective of the child’s attachment pattern (Ainsworth
et al., 1978; Van IJzendoorn & Kroonenberg, 1988). The PATTERNS OF ATTACHMENT AND
SSP is videotaped, and the attachment category is SUBSEQUENT OUTCOMES
determined by standardized procedures for scoring Secure attachment can be protective and provide a foun-
(Ainsworth et al., 1978). Mary Main later developed dation for exploration and normal development, while
the Adult Attachment Interview to assess adult compromised attachment can lead to negative develop-
attachment representations, which reveals how adults mental outcomes in these domains (Greenberg, Speltz,
interpret their own childhood experiences (Hesse, & DeKlyen, 1993). Additionally, secure attachment
1999; Main et al., 1985; van IJzendoorn, 1995). relationships are associated with appropriate social
development and the ability to interact with others
ATTACHMENT CLASSIFICATIONS throughout life, and persons with insecure attachment
Patterns of attachment and attachment classifications are more likely to lack social aptitude (Belsky &
are associated with various outcomes. Ainsworth Cassidy, 1994; Belsky & Fearon, 2002). Specifically,
(1978) established a rating system based on the infant’s children with anxious-avoidant and anxious-resistant
behavior during the SSP, particularly during the reunion attachment styles have been reported to have behavior
episodes with the mother. She described three cate- problems, emotional difficulties, and social incompe-
gories of attachment: secure attachment (Group B), tence (Belsky & Cassidy, 1994; Carlson & Sroufe, 1995).

116 Volume 25  Number 2 Journal of Pediatric Health Care

It also is understood that compromised attachment both to affect the quality of attachment (Calkins & Fox,
relationships often are correlated with developmental 1992) and to have no influence on attachment security
cognitive delays (Carlson & Sroufe, 1995). Behavioral (Belsky & Rovine, 1987; Mangelsdorf & Frosch, 2000).
problems, particularly aggression, have been associated There is speculation that infant gender influences the
with disorganized-disoriented attachment (Lyons-Ruth, quality of attachment (Greenberg, 1999). Furthermore,
Alpern, & Repacholi, 1993). The idea that attachment poor infant health is thought to compromise the quality
classifications correlate with later developmental course of attachment. Literature on this topic specifically ad-
is central to attachment theory (Bowlby, 1969/1982). Re- dresses the influence of preterm status and low-birth
searchers acknowledge the contribution of environmen- weight on maternal-infant attachment (Greenberg,
tal factors, but consistent with Bowlby’s notion of the 1999; Mangelsdorf, Plunkett, Dedrick, & Berlin, 1996;
important developmental considerations related to at- Wille, 1991). Preterm and low-birth weight is not inher-
tachment, researchers continue to assess the impact of ently associated with poor attachment, but those infants
the quality of attachment (Belsky & Cassidy, 1994; may be more at risk for developmental delays and
Greenberg et al., 1993). Belsky & Fearon (2002) found physical, cognitive, and visual impairments. As a result,
correlations between different patterns of attachment attachment behaviors such as smiling, crying, and resis-
and socioemotional and language development but tance to separations may look very different in these in-
also stressed the influence of contextual risk factors fants. However, the maternal response designed to
that contribute to general cognitive development. promote security can still be observed. It is important to
remember that attach-
RISK AND PROTECTIVE FACTORS ment is a reciprocal .although an
A number of risk and protective factors contribute to relationship between
maternal-infant attachment relationships. Maternal the caregiver and the in- infant with
responsiveness and sensitivity refers to the mother’s fant, and although an in- compromised
ability to respond to her infant’s cues and her ability to fant with compromised health status may
understand the infant’s experiences and own mental health status may not
state (Slade, 2005). The greater ability a mother has to respond with the same not respond with
be sensitive and responsive to her infant, the greater attachment behavior the same
likelihood the infant will develop a secure attachment patterns as a healthy attachment
(Bornstein & Tamis LeMonda, 1989; Bornstein & Tamis infant, attachment rela-
LeMonda, 1990; Bornstein & Tamis LeMonda, 1997; tionships can still be as- behavior patterns
Dunham & Dunham, 1990; Goodman, Aber, Berlin, & sessed and enhanced. as a healthy infant,
Brooks-Gunn, 1998; Koren-Karie, Oppenheim, Dolev, Environmental fac- attachment
Sher, & Etzion-Carasso, 2002; Landry, Smith, Miller tors, such as social sup-
Loncar, & Swank, 1998; Olson, Bates, & Kaskie, 1992; port and the influence relationships can
Raval et al., 2001; Seifer & Schiller, 1995; Van Egeren, of multiple caregivers, still be assessed
Barratt, & Roach, 2001). Additionally, a mother’s ability may influence the qual- and enhanced.
to assume the maternal role can affect the quality of ity of attachment. Social
attachment (Aber, Belsky, Slade, & Crnic, 1999; Benoit, support is thought to be
Parker, & Zeanah., 1997). a protective factor in maternal-infant attachment relation-
Conversely, maternal depression and psychological dis- ships (Belsky, 1999; Berlin & Cassidy, 1999; Huth-Bocks,
tress can adversely affect the mother-infant attachment Levendosky, Bogat, & von Eye, 2004; Simpson, 1999).
relationship (Murray, Kempton, Woolgar, & Hooper, Particularly relevant to adolescent mothers is the
1993; Murray, Fiori Cowley, Hooper, & Cooper, 1996; presence of the maternal grandmother, which alters the
Poehlmann & Fiese, 2001; Tronick & Weinberg, 1997). A maternal-infant attachment relationship and provides
mother’s ability to recollect her own childhood and the child with the possibility of multiple attachment rela-
recall her experiences with her primary caregiver tionships (Cassidy, 2008; Howes, 1999; Patterson, 1997;
(maternal representation) also affects the maternal-infant Poehlmann & Fiese, 2001). Mothers have been most
attachment relationship. Poor maternal attachment repre- frequently studied in attachment research, primarily
sentations, when a mother recalls unfavorable relation- because they are most often the parent providing the
ships in her past, may compromise the development of secure base from which the reciprocal attachment
secure infant attachment (Fonagy, Steele, & Steele, 1991; relationship can develop. However, it is increasingly
Goldberg, Benoit, Blokland, & Madigan, 2003; Huth- being recognized that the attachment relationship is not
Bocks, Levendosky, Bogat, & von Eye, 2004; Slade, 2005). limited to mothers and infants, and an infant can
Some literature suggests that infant characteristics develop a positive attachment with other consistent
may play a role in the development of attachment caregivers, including the infant’s father, and often the
relationships. Difficult temperaments have been shown maternal grandmother (Cassidy, 2008).

www.jpedhc.org March/April 2011 117

 Although there is not a significant amount of research that the dyadic attachment relationship has room to
related to attachment patterns of infants of adolescent evolve in a healthy direction. Furthermore, because
mothers, existing research reveals that adolescent adolescent mothers sometimes have unreasonable
mothers are at risk for poor attachment outcomes. developmental or behavioral expectations for their
Among this group, adolescent mothers living in infants, it also can be helpful to coach or demonstrate
poverty, those with lower educational achievements, the infant’s developmental capacity at different ages
and those with poor social support have lower rates and stages of development.
of secure attachment in their infants. Although there are increasingly more demands and
time constraints around pediatric well child care visits,
CLINICAL APPLICATION introducing attachment behaviors can easily be incor-
Attachment theory provides a framework from which to porated into the course of a routine examination. A
understand and care for adolescent mothers and their well child care visit is a perfect opportunity to assess
infants. For the first time since 1991, the birth rate for the attachment relationship and explain and model
adolescents living in the United States increased in some of the behaviors on the part of the mother in re-
2006, and it increased again in 2007 (Hamilton, sponse to the infant’s behaviors that can improve this
Martin, & Ventura, 2009; Martin et al., 2009; Moore, relationship. Separations and reunions between the in-
2008). As a result of this rise, more pediatric clinicians fant and mother that take place over the course of a visit
will be caring for adolescent parents and their are a simple means by which the clinician can assess
children. Secure attachment relationships can lead to and coach adolescent mothers on ways to improve
favorable outcomes both in the early years and as the the attachment relationship. A securely attached infant
child matures into adulthood, and it is an important will show some suspicion around the stranger (the
foundation that should not be overlooked in the clinician) and will continue to make contact with his
clinical setting. While attachment theory certainly has or her mother, or check in with her to ensure his or
psychological applications, pediatric clinicians in the her safety (Slade & Aber, 1992). When this behavior
primary care setting are on the front lines and in occurs (for example, when the clinician enters the
a position to identify, assess, and enhance the room or begins the physical examination), the clinician
attachment relationship. Ideally, pediatric clinicians can explain to the mother that the infant is looking
can begin working with young mothers and their around to make sure his or her mother is still present
infants immediately after birth when the attachment and that he or she feels safe with her in the room.
relationship is first being established. When the child is removed from the mother’s presence,
To begin, clinicians can simply explain the attach- perhaps simply by stepping out of the room with the in-
ment relationship as a reflection of how the infant and fant, he or she may begin crying and looking for the
mother respond to one another. Additionally, the clini- mother (Slade & Aber, 1992). A simple means to assess
cian can explain the infant’s attachment behaviors, such gross motor skills and understand the infant’s attach-
as smiling, crying, reaching, and resisting separations ment security simultaneously is to bring the infant out
from the mother. Attachment behaviors ought to be of the examination room and out of the mother’s sight
met with a maternal response that will promote a feeling and let him or her crawl or walk back to the mother. It
of security in the child. Clinicians can look for attach- is important for the adolescent mother to understand
ment behaviors in the visit, such as when the infant that the crying infant is a strong indicator as to the secu-
cries, follows (or tracks the mother), or how the child rity the child feels with respect to his or her mother.
references the mother during greetings and reunions Finally, when the infant reunites with the mother, the
after short separations. During the visit, clinicians can infant often allows the mother to pick him or her up
model caregiver-infant relationships or coach and and provide comfort before returning to play (Slade &
encourage young mothers to assume some of the Aber, 1992). This can be a very powerful message for
behaviors that favor more secure attachment outcomes. a young teen mother who may not understand the ex-
Adolescent mothers may need help reinterpreting the tent of her role as a secure figure in her infant’s life. In
infant’s behaviors as cues to the parent about the contrast to the secure infant, insecurely attached infants
infant’s state and needs. For example, when an infant may show little wariness around strangers, often make
cries, a young mother may become frustrated with no protest when removed from their mother’s sight, and
what can be a disrupting physical state and either offer little attention to their mother when reunited
ignore the infant or rush the pick the infant up for a feed- (Slade & Aber, 1992). It can be very striking to observe
ing. Rather, the clinician can guide the mother to appre- infant behavior, particularly as it relates to the mother’s
ciate that the infant is crying to express an emotional presence, and it can offer the clinician insight into the
state, ask the mother how she feels (with an ‘‘I won- existing attachment relationship and provide teachable
der.’’ statement) when the infant cries, and how she moments during the visit to enhance the relationship.
thinks the baby might be feeling. It is with recognition Observation of attachment behaviors is not limited to
of maternal and infant emotional and physical states the primary care setting; pediatric clinicians in acute

118 Volume 25  Number 2 Journal of Pediatric Health Care

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