attachment disturbances in infants born subsequent to perinatal loss: a pilot study

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INFANT MENTAL HEALTH JOURNAL, Vol. 20(2), 188–199 (1999)Q 1999 Michigan Association for Infant Mental Health CCC 0163-9641/99/020188-12

A R T I C L E

ATTACHMENT DISTURBANCES IN INFANTS

BORN SUBSEQUENT TO PERINATAL LOSS:

A PILOT STUDY

SHERRYL S. HELLERCHARLES H. ZEANAH

From the Section of Child and Adolescent Psychiatry, Tulane University School of Medicine,New Orleans, Louisiana

ABSTRACT: Mothers who have lost a baby in the perinatal period may experience relationship disturbanceswith infants born subsequently. This study involved mothers who had delivered a child within 19 monthsof losing a baby in the perinatal period. Mothers were assessed 2 months after the loss with a clinicalinterview. When the child born subsequent to the loss was 12 months old, the mother–child attachmentrelationship was assessed, and 45% of the infants had disorganized attachments to their mothers. Thiswas significantly higher than the expected rate of 15% disorganized attachments in other middle-classsamples. Based on narrative descriptions of the loss experience, measures of mothers’ resolution of lossand experience of support were not related to infant attachment. Mothers who accepted more responsibilityfor their own grief were more likely to have subsequent infants with secure attachments to them.

RESUMEN: Las madres que han perdido a su nino en el perıodo perinatal pueden experimentar subsecuen-temente trastornos en la relacion con infantes nacidos posteriormente. Este estudio involucra a madresque han dado a luz un nino dentro de los 19 meses posteriores al momento en que perdieron su nino enel perıodo perinatal. Las madres fueron evaluadas despues de la perdida por medio de una entrevistaclınica. Cuando el nino nacindo con posterioridad a la peridida tenıa 12 meses, se evaluo la relacion deafectividad entre la madre y el nino, y 45% de los infantes presentaban una desorganizacion en cuanto ala union afectiva hacia sus madres. Esto fue significativamente mas alto con relacion al puntaje de 15%esperado en relaciones afectivas desorganizadas en otras muestras de clase media. Con base en las des-cripciones narrativas de la experiencia de la peridida, las medidas de las resoluciones de las madres sobrela perdida y la experiencia de apoyo, no se relacionaban con la union afectiva del infante. Las madresque aceptaron mas responsabilidad por su propia pena estaban mas propensas a tener subsecuentementeninos con una afectividad firme hacia ellas.

RESUME: Les meres ayant perdu un bebe dans la periode perinatale peuvent ensuite faire l’experience detroubles relationnels avec les bebes nes plus tard. Cette etude a fait participer des meres ayant accouched’un enfant dans les 19 mois apres avoir perdu un bebe dans la periode perinatale. Les meres ont eteevaluees deux mois apres la perte avec un entretien clinique. Quand l’enfant ne apres la perte avait 12mois, la relation d’attachement mere-enfant a ete evaluee, et 45% des bebes avaient des attachements

The authors gratefully acknowledge the assistance of Barbara Danis, Moira Brennan, and Laura Dietz with this project.They also appreciate the comments of Drs. Neil Boris and Julie Larrieu about an earlier version of the manuscript.Direct correspondence to: Charles H. Zeanah, M.D., Department of Psychiatry and Neurology, Tulane UniversitySchool of Medicine, 1440 Canal Street, New Orleans, Louisiana 70112.

Attachment Disturbances in Infants Born Subsequent to Perinatal Loss: A Pilot Study ● 189

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cap heightbase of textdesorganises a leurs meres. Ce taux etait considerablement plus eleve que le taux attendu de 15%

d’attachements desorganises dans d’autres echantillons issus de classe moyenne. Base sur les descriptionsnarratives de l’experience de la perte, les mesures de la resolution maternelle de la perte et l’experiencede soutien n’etaient pas liees a l’attachement du nourrisson. Les meres qui acceptaient plus de respon-sabilite pour leur propre deuil etaient plus a meme d’avoir des nourrissons avec des attachements positifs.

ZUSAMMENFASSUNG: Mutter, die ein Kind rund um die Geburt verloren haben, erleben bisweilen Bezie-hungsstorungen mit dem nachsten Kind. In dieser Studie wurden Mutter erfaßt, die in den letzten 19Monaten ein Kind rund um die Geburt verloren hatten. Die Mutter wurden 2 Monate nach dem Verlustinterviewt. Wenn das nachste Kind 12 Monate war, wurde die Mutter—Kind Beziehung untersucht,wobei 45% der Kinder einen desorganisierten Beziehungstyp zeigten. Das war signifikant mehr als jene15% desorganisierter Beziehungstyp, den man in mittelklassigen Stichproben erwartet. Bei der Auswer-tung der Erzahlungen des Verlusterlebnisses waren die Werte fur die Bearbeitung des Verlusts und dieErfahrung der Unterstutzung, nichtn im Zusammenhang mit der Bindung des Kindes. Mutter, die ihreVerantwortung fur ihre Trauer eher akzeptierten, hatten eher nachfolgende Kinder mit einer sicherenBindung zu ihnen. Schlusselworte: Bindung, Verlust rund um die Geburt, Mutter—Kind Beziehungen.

* * *

Perinatal losses unnaturally interrupt mothers’ joyful anticipations of birth. For a numberof reasons, the mourning that follows perinatal losses is distinct from mourning following otherlosses (Benfield, Leib, & Vollman, 1978; Kirkley-Best & Kellner, 1982; Leon 1992; Parkes,1965; Theut, Pedersen, Zaslow, & Rabinovich, 1988; Theut, Zaslow, Rabinovich, Bartko, &Morihisa, 1990; Toedter, Lasker, & Alhadeff, 1988; Zeanah, 1989). First, perinatal loss notonly violates a mother’s expectations, it also effects her perception of her own reproductiveefficacy and ability to parent (Lewis & Page, 1978; Leon, 1992). Second, many potentiallysupportive people may regard perinatal loss as less important or less meaningful than lossesof other kinds (Danis & Zeanah, 1991). Third, is has been found that healthy resolution ofmourning following perinatal loss is more difficult than that following other losses because ofthe paucity of memories available to adults whose infant dies (Kennell & Trause, 1978; Lewis,1979; Lewis & Page, 1978). Memories facilitate the process of mourning, but following thedeath of a newborn, there is so little for mothers to remember that it may be difficult for themto resolve the loss.

Mourning, which describes a series of psychobiological processes set in motion by a loss,proceeds ordinarily from relatively unresolved to relatively resolved. Healthy mourning in-volves the ability to resume other relationships and to engage in new ones unimpeded by theloss. There are several reasons to expect that healthy mourning following perinatal loss mayat times be impeded.

It has been demonstrated, for example, that mothers who become pregnant again quickly—

190 ● S.S. Heller and C.H. Zeanah


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are at increased risk for problems (Bowlby, 1980; Lewis, 1979). In fact, in some studies,disordered mourning has been associated with conceiving a child within 5 months of a perinatalloss (Rowe et al., 1978), although other studies have demonstrated no clear association (Davis,Stewart, & Harmon, 1989; Phipps, 1985).

Lewis (1979) has argued that pregnancy impedes mourning because mothers may find itdifficult to attach to a new baby and detach from the lost baby simultaneously. Theut, Moss,Zaslow, Rabinovich, Levin, and Bartko (1992) reported that during a pregnancy followingperinatal loss, mothers often were preoccupied with the child they lost, were unable to focuson the new child, and frequently were unsure about their own ability to care for the new child.Mothers also have reported withholding their attachment to the subsequent child during preg-nancy and for a period of time after birth for fear of losing the new baby (Leon, 1992). If amother’s mourning is suspended during pregnancy and then resumes after the subsequentchild’s birth, relationship problems may occur between the mother and the new baby (Daviset al., 1989; Zeanah, 1989).

In fact, several types of attachment relationship disturbances have been described in theclinical literature regarding the loss or feared loss of a child. For example, references to thereplacement child syndrome and its relationship to the birth of a subsequent child are commonin the perinatal loss literature (Davis et al., 1989; Theut et al., 1992; Wilson, Fenton, Stevens,& Soule, 1982; Zeanah, 1989). Replacement children are reported to be overprotected byanxious parents who fear that the new child also will be taken from them unexpectedly (Cain& Cain, 1964; Pozanski, 1972). Another clinical pattern is the vulnerable child syndrome,which involves separation problems, overprotectiveness, hypervigilance, and extreme concernsin mothers whose child have suffered serious illness and then recovered (Green & Solnit, 1964).Anecdotal reports of mothers’ idealization, rejection, overprotectiveness, and hypervigilancein regard to the health and safety of the child born subsequent to perinatal loss are similar tothe symptoms described originally in the vulnerable child syndrome (Davis et al., 1989; Phipps,1985; Theut et al., 1992; Zeanah, 1989).

These kinds of relationship disturbances suggest that mothers who are mourning the lossof a previous baby may be at increased risk for attachment disturbances with the baby bornsubsequently. Nevertheless, no previous studies have examined this question. In this investi-gation, we examined the effects of perinatal loss on the attachment relationship between moth-ers and their subsequent born infants, and we related infant attachment classifications to indi-vidual differences in patterns of mothers’ grief and mourning.

Several variables evident in mothers’ narrative descriptions of the loss seem relevant toconsider. First, research on attachment in adults and infants has demonstrated an associationbetween unresolved mourning in parents and an insecure/disorganized attachment in infants(Ainsworth & Eichberg, 1992; Benoit & Parker, 1994). In these studies, lack of resolution ofmourning was measured by lapses in the coherence and emotional integration of narrativedescriptions of the losses. For example, descriptions of losses may reveal evidence of unre-solved feelings of guilt or fear related to loss, or inconsistences about the time or circumstancessurrounding a loss. Many of these same features, such as irrational fear and guilt, hypervigil-ance, and overprotectiveness toward the subsequent baby have been noted in mother followingperinatal loss (Leon, 1992; Twomey, 1995). Therefore, we hypothesized that mothers whoreveal lack of resolution of mourning following the loss of a baby might be at increased riskfor having attachment disturbances with their infants born subsequently.

Other variables reflected in narrative descriptions of the loss also might be important toexamine. Mothers’ sense of feeling supported has been importantly related to differences inmothers’ mourning following perinatal loss (Zeanah, 1989). Therefore, we examined mothers’



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health-care professionals, other family members). Also, in a related line of research, external-izing defensive tendencies in mothers have been linked with insecure attachments in theirchildren. Specifically, in narrative descriptions of their relationships with their children, motherswho externalized responsibility for their children’s difficulties and who looked to others toresolve their problems with their children had children who were more likely to be insecurelyattached to them (Zeanah, Benoit, Hirshberg, Barton, & Regan 1994; Benoit, Zeanah, Parker,Nicholson, & Coolbear, 1997). These findings led us to examine mothers’ tendency to exter-nalize responsibility for their grief onto others.

In this preliminary study, we hypothesized specifically that infants born subsequent to aperinatal loss would be at increased risk for insecure/disorganized attachments to their mothers.Infants are classified insecure/disorganized by displaying anomalous attachment behaviors thatseem to lack a readily observable goal, intention, or explanation (Main & Solomon, 1990).Although an insecure/disorganized attachment relationship with one’s mother is not necessarilyindicative of psychopathology, it is considered to be a risk factor for later maladaptation (seeZeanah & Emde, 1994). We also predicted that mothers who had problematic adaptations toloss of their infants as revealed in narrative characteristics would be at increased risk fordisordered mourning as reflected in having infants with insecure/disorganized attachment clas-sifications. Specifically, mothers who were judged in interviews about their experiences oflosing a baby to be dissatisfied with their support, to externalize responsibility for resolvingtheir own grief, or to exhibit lack of resolution of mourning, were expected to be at increasedrisk for attachment relationship disturbances with their infants born subsequent to the loss.

METHODS

Subjects

For purposes of this study, 19 mothers and their 20 infants were recruited following theirparticipation in a larger longitudinal investigation on perinatal loss that included a final visit15 months after the baby’s death. A total of 23 mothers of the 82 who participated in theoriginal sample (Zeanah, Danis, Hirshberg, & Dietz, 1995) were invited to participate (the first23 who were pregnant or already had another baby at the 15-month visit). The four motherswho had participated in the original study of perinatal loss but who declined to participate inthe follow-up study of the baby born subsequently cited time pressures as the reason fordeclining. The 4 who declined did not differ from the 19 who agreed to participate in thecurrent investigation on demographic variables. Details about the larger sample, includingsample to population comparisons, have been described elsewhere (Zeanah et al., 1995).

The sample of 19 mothers in the current investigation was middle class, with 94% Holl-ingshead levels I to III. These 19 mothers ranged in age from 25 to 40 years (mean age 31years). Ninety percent of the mothers completed high school, and the mean education levelwas two years of college. With regard to ethnicity, 89% of the subjects were Caucasian and11% were African-American. At the time of the loss, 78% of the sample were married, 31%had no other children, and 36% had suffered a pregnancy loss previous to this perinatal loss.In this sample, 52% of the infants did not live more than 24 hours (range of 0 hours to 22weeks). With regards to the others, 21% (n 5 4) lived up to 1 week, 10% (n 5 2) lived 1 to3 weeks, and, 10% (n 5 2) over 1 month, these data were missing on one subject. The averagegestational age at delivery was 30 weeks, with a range of 20 to 41 weeks.

The subsequent babies, who were the subjects of the current investigation, were bornbetween 12 and 19 months after the loss, with the exception of two infants who were both



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pose of this study since previous research has demonstrated that grief reactions in parents wholose one twin are comparable in intensity to those who lose a singleton baby (Wilson et al.,1982). Thus, these two mothers were believed to have had to struggle with many of the sameissues as mothers who delivered another baby subsequent to their loss, and they were includedin the investigation.

In order to delineate any differences between the current sample to the larger sample fromwhich they were drawn, we compared demographic variables of the 19 mothers in the currentsample to those of the 63 other mothers who also participated in the original study of perinatalloss. There were no significant differences on any of the following variables: race, maritalstatus, whether the birth was live or a stillbirth, infant gender, whether the deceased baby wassurvived by a twin, whether there were any medical complications, or whether there was aprevious maternal medical history. The only significant difference was maternal age. The meanage for the current sample was 31 years (SD 5 4.12) and the mean age for the larger samplewas 28 years (SD 5 5.52, F 5 3.89, p , .05).

Measures

The Perinatal Loss Interview. This semistructured clinical interview was administered 2months following the death of the mothers’ infants. The interview was designed to elicit anarrative account of the parents’ experiences before, during, and after the loss of their infant(Danis & Zeanah, 1991). The interviews were coded by several different scales designed todetermine content and especially qualitative features of mothers’ narrative accounts of theirloss. Two coders, blind to the attachment classifications of the infants, scored all of the inter-views.

The first scale coded the clarity and coherence with which the mothers described their loss.It was a slightly modified version of the Resolution of Mourning scale developed by Main,DeMoss, and Hesse (1989), adapted for perinatal losses. Mothers who reported feeling over-whelmed or confused by the loss and whose interviews were incoherent and difficult to followreceived high scores on the Resolution of Loss scale. We predicted that mothers scoring highwould be more likely to have infants with an insecure/disorganized attachment. Conversely,we predicted that mothers who reported being strongly affected by the loss yet who describedtheir experiences clearly and coherently would be more likely to have infants with secureattachments. This scale initially consisted of four categories, however, after classifying theinterviews, the numbers of mothers in each of the four categories were too small to analyze.After reviewing the scores, we collapsed the two groups of mothers who were incoherent andeither confused or overwhelmed into one group and the mothers who were clear and coherentbut either influenced or unaffected into one group. Interrater reliability for this scale (fourgroups) was .80 (Cohen’s Kappa).

After reviewing the Perinatal Loss Interviews from the participants in the larger sample(who had not experienced a subsequent pregnancy) four areas appeared to reflect specificcategories and individual differences in mothers’ response to the loss of their infants. Theseareas were similar to some that other investigators noted in their work with adolescent mothersand their mothers (see Dean, 1998). They included Perceived Support from Husband, PerceivedSupport from Mother, Experience of Support, and Responsibility for Grief. Two of these scales,involving the mother’s perception of the support she received from her husband and from hermother, were not included in subsequent analyses. Too few mothers spoke enough about theirown mothers for the Support from Mother scale to be coded. Interrater reliability for the Supportfrom Husband scale was unacceptably low (Cohen’s Kappa 5 0.40).



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cap heightbase of textThe Experience of Support scale that we used was developed to measure the mothers’

relationship conflicts or relationship distance from potential sources of support. We predictedthat mothers who were more dissatisfied with their support, because they felt others were notavailable or were intrusive/unhelpful in their support (relationship conflicted), as well as thosewho chose to go through the event alone (relationship distant), were expected to be more likelyto have infants with insecure/disorganized attachments. Mothers who felt that others werehelpful and supportive were expected to be more likely to have infants with secure attachments.The interviews were originally classified into one of four group, however, because of numbersin each group, the three groups involving relationship dissatisfaction were collapsed into onegroup. Interrater reliability for this scale (four groups) was .57 (Cohen’s Kappa).

The Responsibility for Grief scale involved ratings of how accountable the mother heldherself or others for the resolution of her grief. We predicted that those mothers who exter-nalized responsibility for their grief by feeling unable to control themselves, by depending onothers to resolve their grief, or by being preoccupied by other people’s opinions about theappropriateness of their grieving were more likely to have infants with insecure/disorganizedattachments. On the other hand, we predicted that mothers who took responsibility for resolvingtheir grief would be more likely to have secure attachment relationship with their subsequentchild. As with the previous scales, interviews were originally classified into one of four groups.Given the low numbers in each of the four groups the three groups who held others responsiblefor their grief resolution were collapsed into one group. Interrater reliability for this scale (fourgroups) was .78 (Cohen’s Kappa).

Strange Situation Procedure. The Strange Situation Procedure is a widely used and well-validated measure for classifying infant–caregiver attachment (Ainsworth, Blehar, Waters, &Wall, 1978). This procedure lasts 22 minutes, and consists of a series of episodes involvinginteractions with a caregiver and an unfamiliar adult. Based on the organization of the infants’attachment and exploratory behaviors, especially during reunions with the caregiver, the in-fants’ attachment to that caregiver is classified into one of four categories: secure, insecure/avoidant, insecure/resistant, or insecure/disorganized.

The primary coder, who was certified as reliable by Alan Sroufe’s laboratory in codingthe Strange Situation, was blind to the hypotheses of the study and the nature of the sample.The primary coder coded tapes from two different samples of infants who were seen in thesame laboratory pooled together and was unaware of any details about either sample or eventhat two different samples were being coded. A secondary coder, who also was trained bySroufe, coded all the tapes for reliability. This coder was aware of the nature of the sample butunaware of interview responses of mothers at the time the tapes were coded. Interrater reliabilityfor Strange Situation classifications was 90% (Cohen’s Kappa 5 .78). The coders were trainedby Sue Spieker and Mary Main in coding disorganized/disoriented attachments, respectively.Differences were resolved by conferencing.

Procedures

Mothers were interviewed 2 months after the death of their baby. When the child born sub-sequent to the loss reached 12 months of age each of the dyads was videotaped in the StrangeSituation. The range of time between the perinatal loss and the administration of the StrangeSituation Procedure was 12 to 31 months, with 14 of 19 dyads falling between 24 and 31months. Three interviews were not available for coding due to equipment failure, leaving 16mothers who completed the perinatal loss interview and the Strange Situation.



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TABLE 1. Mother’s Responsibility for Grief and StrangeSituation Procedure Attachment Classification

Nondisorganizedin SSP

Disorganizedin SSP

Autonomous 6 1Dependent 2 7

RESULTS

Distribution of Attachment Classifications

Using the Strange Situation procedure, 55% of the infants (11 of 20) were classified securelyattached to their mother and 45% (9 of 20) were classified insecure/disorganized. None of theinfants’ primary attachment classifications were insecure/avoidant nor insecure/resistant. Anal-yses computed demonstrated that the disorganized group was not statistically different fromthe nondisorgainized group on any of the various demographic variables (this included: ma-ternal age, maternal education, Hollingshead, ethnicity, marital status, maternal medical history,medical complications, number of previous losses, infant gender, whether the infant was sur-vived by a twin, whether the birth was live or a stillbirth, the length of time the child survived,and the gestational age of the deceased infant).

A one-sample Chi-square analysis indicated that the percentage of infants who displayedinsecure/disorganized attachment in this sample (45%) was significantly greater (x 5 14.12,2

p , .01) than the 15% proportion found in other middle-class samples (van IJzendoorn, 1995).Thus, the first hypothesis was supported: a significantly higher proportion of insecure/disor-ganized attachment classifications was found in the perinatal loss sample than has been foundin middle-class samples unselected for loss.

Perinatal Loss Interview and Infant Attachment

Using the Responsibility for Grief scale, we classified mothers into two groups, autonomous(n 5 7) or dependent (n 5 9), as shown in Table 1. These two groups were significantlydifferent for the two attachment groups (x 5 6.3, p , .01). Mothers of infants who were2

securely attached to them were more likely to be classified as autonomous and the insecure/disorganized mothers were more likely to be classified as dependent. Analyses computed dem-onstrated that the autonomous group was not statistically different from the dependent groupon any of the various demographic variables (this included: maternal age, maternal education,Hollingshead, ethnicity, marital status, maternal medical history, medical complications, num-ber of previous losses, infant gender, whether the infant was survived by a twin, whether thebirth was live or a stillbirth, the length of time the child survived, and the gestational age ofthe deceased infant).

On the other hand, there were no significant differences between infant attachment tomothers based on mothers’ descriptions of their experience of support (x 5 .25, p . .10).2

Seven mothers were classified as satisfied with their level of support and nine as unsatisfied orstoic. In regards to the Resolution of Loss scale, there were no differences in attachmentclassifications between mothers rated as more (n 5 9) or less resolved (n 5 7) based on theclarity and coherence of their descriptions of their experience of loss (x 5 2.3, p . .10).2

Excluding the dyads that included a surviving twin did not change any of the results.



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This is the first prospective study of infant–parent attachment in infants born subsequent toperinatal loss. The most important finding of the study is that infants born subsequent to aperinatal loss were significantly more likely to develop disorganized attachment relationshipswith their mothers than infants in other demographically comparable samples.

The disorganized classification represents lack of an organized strategy in the infant forobtaining felt security from a caregiver (Main & Solomon, 1990). Previous research has dem-onstrated that the disorganized classification is highly prevalent in high-risk samples (Carlson,Cicchetti, Barnett, & Braunwald, 1989; Lyons-Ruth, Connell, Grunebaum, & Botein, 1990;Speiker & Booth, 1988), and predictive of role-reversed relationships between school-agedchildren and their mothers (Main & Cassidy, 1988; Solomon, George, & De Jong, 1995). It isalso the classification believed to be most closely related to clinical disorders of attachment(Zeanah & Emde, 1994).

It is notable that in this middle-class sample, as in some other middle-class samples (e.g.,Frodi & Thompson, 1985; Owen, Easterbrooks, Chase-Lansdale, & Goldberg, 1984), there areso few avoidant and resistant infant classifications. The results of this investigation underscorethe importance of the disorganized/disoriented classification in identifying dyads whose rela-tionship might otherwise be classified secure.

We had predicted that mothers who were judged to be unresolved about the loss of theirinfants would be more likely to have infants with disorganized attachments. In contrast toprevious findings from attachment research (van IJzendoorn, 1995), mothers’ lack of resolutionof mourning, as measured by the Resolution of Loss scales, was not related to disorganizedattachment in this sample. Several possibilities may explain the difference. Healthy mourningmay be difficult to detect accurately from narrative descriptions of the loss so soon after itoccurs. Recent losses described during the Adult Attachment Interview (George, Kaplan, &Main, 1985; Main & Goldwyn, 1991), for example, often are not coded because they are notexpected to be resolved (Main et al., 1989). Devoting an hour-long interview to discussion ofthe loss may lead to differences in the narrative qualities revealed in the Perinatal Loss Interviewcompared to the more abbreviated treatment of loss in the Adult Attachment Interview. Alter-natively, special qualities of perinatal loss itself may mean that other aspects of descriptionsof the loss other than clarity, coherence, and emotional integration may be more important.More research will be necessary to determine which if any of these possibilities explains thispotentially important negative finding.

The Responsibility for Grief Scale discriminated significantly between mothers of secureand mothers of disorganized infants. This scale measured the extent to which the mother usedher relationships with others to avoid or to assume emotional responsibility for her grief.Mothers who had infants classified as disorganized reported feeling overwhelmed by their griefand felt that it was largely out of their control. Some of these mothers reported being extremelyconcerned with other people’s approval of their grieving. Conversely, mothers whose grievingwas well integrated in their search for meaning following the loss and who viewed the expe-rience as their own struggle, even if others could impact on it, were more likely to have infantsclassified secure.

To portray the differences between the two grief groups more clearly, we selected excerptsfrom two interviews as illustrations of these two classifications. The following excepts are froman interview with a mother who was rated as having assumed responsibility for her own griefresolution.

Mother: The first few weeks after it happened, to have so much family support andfriends being around, you know, especially for the first couple of weeks that it doesn’t, um,



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cap heightbase of textyou don’t feel the loss as much until after that time. Then, all of the sudden it hits you . . . at

first, ah, after it happened, I didn’t feel the need for it {a support group}. Agh, you know,I though I was in that category that could handle any situation, until after a couple of months,and friends weren’t talking about it as much, you feel the need to talk to someone about itand the support group’s been the answer for that . . . and I’ve learned through the supportgroup . . . plus I’ve done alot of reading too on the subject, so that’s been a big help tome as well. . . It’s something that we can’t change. We’ll never be able to change it andwe have to get on with our lives. We’ll never forget her, but it’s ah, but it’s something thatum, it happened. It was out of our control. . . I don’t take things for granted anymore.Having a baby was truly a miracle. It’s ah, you know, an amazing thing to happen. And youreally can’t take something like that for granted because it’s one of the most important thingsin life. . . .

Interviewer: How has this loss affected you as a person?Mother: I know I’m ah, I know I’m a changed person as a result of it. I’ll never, ahh,

I don’t think I’ll ever be the same, not that it’s a bad way to be. But I’m just ah, I’m differentas a result of it. It’s ummm. I’m more compassionate . . . even though I still get angrywith my son, I’m so thankful to have him. And I appreciate children, I think, alot more.Um, when I look at other mothers who were complaining about their children, I just, I feelthat it’s so sad that they have to be that way, because they don’t realize how lucky they areto have as many children. . . . Ah, you know, I want to help other people in this situationget through things like this. . . I’m at the point where I want to help other people get throughthis because I feel I had so much support and help myself.

This mother monitored her own reactions and adjusted her behavior accordingly. Initially,she said that she did not see a need for a support group because of support available from herfamily and friends, but later she found that she did need a support group and sought thatresource. She looked to others for help, but implicitly she conveyed that it was her responsibilityto evaluate her options and to find what she needed.

The following excerpts are from a mother who was coded as having externalized respon-sibility for her grief and whose infant had a disorganized attachment to her.

Mother: . . . he’s {the baby} forgotten now. And {husband} doesn’t want to talkabout it. The kids don’t talk about him. It’s something we don’t talk about, it’s over anddone with. And if, if I do, I feel guilty. You know because they don’t want to see it. Theydon’t want to hear it. Sometimes I’ll just get up and go in my room. And if, if I do cry,{husband} seems to get mad. It’s like, I mean it’s been long enough now, just forget it. Youknow, it shouldn’t be bothering you anymore. . . I think I’m the only one that ever knewhim. I’m probably the only one that ever misses him {crying}. You know when it {funeral}was done I couldn’t leave . . . I kept thinking he’s gonna be cold . . . I mean it was socold that day . . . You, you just don’t want to leave . . . and of course the funeral directorand the priest won’t leave until you do. So it was like, well, I can’t keep these people standinghere in the cold, so I am going to have to get in the car and leave. Because they want toleave . . . I don’t know how I am suppose to be doing. I don’t know if I am suppose tobe over this . . . every now and than I can face a box of pampers and sometimes Ican’t . . . I go and pick up a box of cereal and turn around and see the baby food. And Icry . . . maybe I’m not suppose to be doing that. I don’t know. But if I don’t cry I feelguilty. It’s like how could I have forgotten my child. If I do remember everyone else isuncomfortable, so it’s like I really shouldn’t cry because they don’t like it. It makes themuncomfortable. But somebody’s got to remember him.



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cap heightbase of textThis mother, in contrast to the previous one, experienced intense feelings of grief that

threatened to overwhelm her. She did not indicate, however, that she was seeking help activelyfor her distress. She was coded as having externalized responsibility for her own grief becauseshe felt overwhelmed, was unsure as to whether she was handling her grief appropriately, andexpressed concern about others’ reactions to her. Implicitly, she seemed to be reading cuesfrom others about what was and what was not appropriate rather than seeking the assistanceshe needed on her own accord.

In summary, we found that at 2 months after a perinatal loss, whether or not mothers tookresponsibility for their own emotional well-being in regard to grief resolution predicted dis-organized attachment in the infant born subsequently. The question is what accounts for sucha finding? One possibility is that those women who expected others to take responsibility fortheir emotional well-being might have expected the same from the child born soon after thisloss. Having suffered the loss of a baby, these mothers might have entered the subsequentpregnancy with a pattern of hoping or expecting that others (including the next child) wouldresolve any feelings of anger, inadequacy, or grief associated with their previous loss. This isone scenario in which a bereaved mother might attempt to induce caregiving from a childbecause the child fears for the mother’s emotional well-being. This type of helpless and de-pendent caregiving has been associated both with disorganized attachment (Main & Hesse,1990) and with clinical role-reversal (Zeanah & Klitzke, 1991). This explanation is in keepingwith the findings of George and Solomon (1996) regarding an association between mothers’self-evaluations as helpless and disorganized caregiving. If replicated, this might suggest an-other pathway linking frightening/frightened maternal behavior to disorganized infant attach-ment.

The relationship between maternal variables involved in perinatal loss and the attachmentrelationship with a subsequent child has not been studied previously and needs further explo-ration. This is underscored by the prevalence of disorganized attachment in this sample, ascompared to other middles-class, low-risk samples. Nevertheless, there are significant limita-tions to this study, including the small sample size and new scales developed in this study forcoding the Perinatal Loss Interviews. These methods may need refinement and clearly needreplication before our tentative findings can be considered conclusive.

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attachment disturbances in infants born subsequent to perinatal loss: a pilot study

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