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Unresolved loss due tomiscarriage: an addition to theAdult Attachment InterviewMarian J. Bakermans-Kranenburg , Carlo Schuengel &Marinus H. Van IjzendoornPublished online: 28 Jul 2006.

To cite this article: Marian J. Bakermans-Kranenburg , Carlo Schuengel & MarinusH. Van Ijzendoorn (1999) Unresolved loss due to miscarriage: an addition to theAdult Attachment Interview, Attachment & Human Development, 1:2, 157-170, DOI:10.1080/14616739900134211

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Unresolved loss due to miscarriage: an addition to the Adult Attachment Interview

M A R I A N J. B A K E R M A N S - K R A N E N B U R G , CARLO S C H U E N G E L and MARINUS H. VAN

I J Z E N D O O R N

ABSTRACT Parental unresolved loss as assessed in the Adult Attachment Interview (AAI; George, Kaplan, & Main, 1985) is significantly associated with infant disorganized attachment. Lapses in the monitoring of both reasoning and discourse and reports of extreme behavioural reactions are evidence of the continuing presence of unresolved responses to loss. (Main, DeMoss, & Hesse, 1994). The original format of the AAI does not include a separate question concerning the experience of miscarriage. We added questions on this subject because, for many parents, miscarriage represents a significant loss. The questions and follow-up probes closely followed the format of the questions in the AAI about loss and were asked immediately after these questions. Answers to the questions about miscarriage were rated with the current classification system for unresolved loss. In a sample of 85 middle-class, non-clinical mothers of I-year-old infants, thirty mothers (35%) reported that they had experienced a miscarriage. Scores on the 9-point rating scale for unresolved loss due to miscarriage were related to infant disorganized attachment behaviour, r(30) = .30,p = .05. Mothers' unresolved loss was not related to the amount of time that had passed since they had a miscarriage. Unresolved loss due to miscarriage was, however, related to the duration of the pregnancy before miscarriage, r(30) = .56, p = .004. Thus, including a question on miscarriage in the AAI may yield theoretically and clinically important information.

KEYWOP, DS: Adult Attachment Interview - miscarriage - unresolved loss - infant disorganized attachment

Miscarriage, or the spontaneous abortion of pregnancy during the first twenty weeks of gestation, is a common occurrence affecting from 15% (Frost & Condon, 1996) to 20% (Lee & Slade, 1996) of diagnosed pregnan- cies. The experience of miscarriage may lead to emotional consequences such as depression and anxiety. Feelings of emptiness, shame, helplessness and low

O Attachment & Human Development Vol 1 No 2 September 1999 157-170 Copyright © Taylor & Francis Ltd 1999 ISSN 146t-6734

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self-esteem are commonly expressed (NicoI, 1989; Rosenfeld, 1991; Stack, 1984). Some authors state that the lack of an object about which to mourn is fundamental to the understanding of the psychological impact of miscarriage. Without the object, the process of mourning is potentially more complex and difficult (Parkes, 1972; Raphael, 1984). Moreover, miscarriage is usually sudden, leaving no time for anticipatory grieving (Stack, 1980). This also increases the risk of pathological grief (Parkes, 1972; Raphael, 1984).

One in five women is unable to accept pregnancy loss after approximately two years (Janssen, Cuisinier, & Hoogduin, 1996). Duration of the pregnancy before miscarriage, pre-loss neurotic personality and pre-loss psychiatric symptoms seem to be risk factors for stronger grief responses in women following a pregnancy loss (Janssen, Cuisinier, De Graauw, & Hoogduin, 1997). Some studies suggest that conceiving again and the birth of a living child lessened grief (e.g. Cuisinier, Janssen, De Graauw, Bakker, & Hoogduin, 1996), but others state that pregnancy itself inhibits mourning, so that the woman's ability to resolve her previous loss may be diminished, predisposing her to pathological grief (Lewis, 1979a). As has been described after stillbirth, many mothers report being overprotective towards the surviving children after miscarriage (Cornwelt, Nurcombe, & Stevens, 1977). Paradoxically, an association between miscarriage and subsequent child abuse has also been documented (Benedict, White, & Connelly, 1985). This parallels the associ- ation between child abuse and stillbirth (Lewis, 1979b). On the whole, mis- carriage seems to be a significant experience, potentially affecting maternal behaviour and the mother's attachment relationship with subsequent children.

Attachment theory provides a useful framework for research into the influ- ence of miscarriage on parent-child relationships, because of its attention to the effects of toss and other trauma on parenting and developmental out- comes in the child. It is acknowledged that parents' experiences of loss increase the risk of depression and difficulties in parenting, thereby affecting the attachment relationship with the child (e.g. Bowlby, 1980). However, it seems to be the lack of resolution of loss, rather than the loss itself, that is associated with subsequent problems in the infant-parent relationship (Ainsworth & Eichberg, 1991; Main, Kaplan, & Cassidy, 1985; Van IJzen- doom, 1995). A central hypothesis in attachment theory is that parental behaviour and the quality of the attachment relationship are strongly influ- enced by the parent's mental representation of childhood attachment experi- ences (Main et al., 1985), and their resolution of any loss or other traumatic experience (Main & Hesse, 1990). This mental representation of attachment can be assessed with the Adult Attachment Interview (AAI; George et al., 1985), an interview in which adults are asked to retrieve and evaluate attach- ment-related autobiographical memories. Avoidantly attached infants have parents who minimize the importance of attachment experiences for their own lives or idealize their parents, securely attached infants have parents who are able to report coherently about their childhood attachment experiences (whether these experiences were positive or not), and resistant infants tend

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to have parents who are still very preoccupied with their childhood attach- ment experiences and the current relationship with their own parents (Ainsworth & Eichberg, 1991; Benoit & Parker, 1994; Fonagy, Steele, & Steele, 1991; Kobak, Cole, Ferenz-Gillies, Fleming, & Gamble, 1993; Main, 1990; Main & Goldwyn, in press). A meta-analysis showed a correspondence of 75% between parents" mental representation of attachment and infants' attachment security, although it is not yet clear which mechanisms are responsible for this correspondence. Maternal sensitivity as currently measured does not seem to explain a large amount of variance in attachment security (Van IJzendoorn, 1995).

Some children, however, show disorganization of attachment, that is the (temporary) absence of an organized strategy of attachment behaviour. When placed in a stressful situation, these children lack a consistent pattern of attachment behaviour, and/or display conflicting, sometimes bizarre behav- iours. For example, a disorganized infant might cry and approach the parent, but before contact is achieved turn his back on the parent and walk away to huddle in a corner (Main & Solomon, 1990). Main and Solomon (1986) first described disorganized attachment in infants whose behaviour could not easily be classified using the traditional classification system. Since then, a substantial percentage of infants of maltreating parents have been assessed as disorganized (Barnett, Ganiban, & Cicchetti, in press; Lyons-Ruth, Repa- choli, McLeod, & Silva, 1991). Other studies found marital discord (Owen & Cox, 1997) and clinical depression of the parent (Teti, Messinger, Gelfand, & Isabella, 1995) to be associated with infant disorganized attachment (see van IJzendoorn, Schuengel, & Bakermans-Kranenburg, in press, for a review). In low-risk samples disorganized attachment appears to be associ- ated with unresolved parental trauma as assessed with the AAI, most often concerning the death of a loved one (e.g. Ainsworth & Eichberg, 1991; Main & Hesse, 1990; see van IJzendoorn, 1995, for a review). However, Schuengel, Bakermans-Kranenburg, and van IJzendoorn (i999) found that disorganized attachment was associated with unresolved loss only when the mothers had an otherwise insecure (that is, dismissing or preoccupied) representation of attachment. Behavioural descriptions of mothers of disorganized children are sparse. Childlike and helpless maternal behaviour (Solomon, George, & Ivins, 1987), extreme non-responsiveness (Lyons-Ruth & Block, 1996) and disrupted affective communication (Lyons-Ruth, Bronfman, & Atwood, in press) have been reported. Schuenget et al. (1999) found evidence for Main and Hesse's (1990) model in which parental frightening (i.e. threatening, frightened/deferential, and dissociative) behaviour explains why infants of parents with unresolved loss develop disorganized attachment relationships.

In the AAI the participant is asked about the experience of loss of loved ones, either during childhood or more recently. Evidence for the continuing presence of unresolved responses to loss are lapses in the monitoring of both reasoning and discourse and reports of extreme behavioural reaction (Main et al., 1994). Even autonomous individuals may be classified as unresolved

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because of their answers to questions about loss experiences, in the context of an otherwise coherent interview. The original format of the AAI does not include a separate question concerning miscan'iages. Nevertheless, for many parents miscarriage represents a significant loss (Lee & Slade, 1996). With the fact that miscarriage occurs in 15% to 20% of the diagnosed pregnancies in the back of our mind, we were thus puzzled by the fact that in one of our first studies with the AAI, where the interview was administered to 83 mothers of a normal sample (Bakermans-Kranenburg & Van IJzendoorn, 1993), only one mother reported that she had experienced a miscarriage. Of course, mothers could have talked about this experience spontaneously in response to the general AAI question about loss, but it appeared that this did not happen. Because of the potential importance for the development of the parent-infant attachment relationship, we decided to add a question about miscarriage to the standard AAI, and to rate the answers according to Main et al.'s (1994) guidelines to assess unresolved state of mind.

The purpose of the present study is twofold. First, we want to test whether mothers" answers to this additional question concerning miscarriage, as rated according to Main et al.'s (1994) guidelines to assess unresolved state of mind, are associated with infant disorganization, and whether the additional scores for unresolved state of mind due to miscarriage lead to an improvement of the prediction of infant disorganization. As Schuengel et al. (1999) found a link between unresolved loss and infant disorganization only in mothers with an otherwise insecure representation of attachment, we wilt explore whether results on the association between unresolved loss due to miscarriage and infant disorganization are different for secure and insecure mothers. Second, we want to examine whether scores for unresolved state of mind due to mis- carriage are related to the amount of time that passed since the event or to the duration of the pregnancy before miscarriage.

M E T H O D

Participants Using the town-hall records of three cities in the western part of the Nether- lands we identified mothers who had babies of about 6 months old and invited them to participate in our study about the influence of everyday as well as major life events on parenthood. By telephone we asked them about their education, hospitalization of the child, and hours spent away from home in employment. Mothers who had a minimum of 12 years of education, who worked away from home less than 33 hours per week, and whose child had not been hospitalized for long periods of time or for serious illnesses were identified as potential participants. As one of our other research ques- tions concerned the mechanism linking unresolved loss and disorganized attachment (see Schuengel et al., 1999), we selected 85 mothers who had

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BAKERMANS-KRANENBURG e t aI: UNRESOLVED LOSS & MISCARRIAGE 161

experienced an important loss through death (other than a miscarriage) before the birth of their child. For more detailed information about the sam- pling procedure, see Schuengel et al. (1999). The mean age of the mothers at their infant's birth was 31.4 years (SD = 3.6). Of the infants, 39 (46%) were girls. Of the mothers, 34 (40%) did not work away from home, the others worked away from home for 22.5 hours on average. There were 53 infants (62%) who had older siblings (1.3 on average). No neurological abnormali- ties among the babies were reported at 8 months.

Instruments

Adult Attachment Interview (AAI) We conducted the AAI (George et al., 1985) with the mothers when their infants were about 12 months old. The mothers were unknown to their interviewer. The AAI is a semi-structured interview that probes alternately for descriptions of the past relationship with parents, specific supportive or contradictory memories, and the current relationship with the parents. About two-thirds of the way through the inter- view, questions are asked about the participant's experiences of loss through death of important figures, both as a child and as an adult. After the ques- tions on loss, we added questions and follow-up probes on miscarriage, which closely followed the format of the questions in the AAI about loss. We asked the mother whether she had ever experienced a miscarriage, and if so,

asked her how long ago this happened to her, how many weeks or months she had been pregnant, and whether the miscarriage was sudden or somehow expected. We rephrased the AAI question about attending the funeral or cre- mation and included the final follow-up questions, about the influence on one's personality and parental approach to one's own child, with small adap- tations (see Appendix A).

The interviews were transcribed verbatim and coded with Main and Goldwyn's (1994) coding system to assess state of mind with regard to attachment and attachment experiences. On the basis of this system, inter- views are considered autonomous when attachment-related experiences are described coherently, whether these experiences were negative (e.g. parental rejection or over-involvement) or positive. Participants are classified as dis- missing when they devalue the importance of attachment relationships for their own lives or idealize their parents without being able to illustrate their positive evaluations with concrete events demonstrating secure interaction. Participants who are still very much involved and preoccupied with their past attachment experiences and who are therefore not able to describe them coherently are classified as preoccupied. They may express anger when dis- cussing current relationships with their parents. Evidence for the continuing presence of unresolved responses to loss or abuse are lapses in the monitor- ing of both reasoning and discourse and reports of extreme behavioural reac- tions. These participants receive the additional classification unresolved (Main et al., 1994). The classification system for unresolved loss or trauma

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identifies only positive markers for an unresolved state of mind. Markers for successful resolution of loss are not evaluated, so the classification system does not include a 'resolved' category. Each toss is rated on a 9-point rating scale for unresolved state of mind. Where ratings above a 5 are assigned, an interview will be considered unresolved as a primary classification. Tran- scripts receiving ratings of 4 and less are not assigned a classification as unre- solved, and with a rating of 5 the coder has to make a choice. Several studies report satisfactory reliability and discriminant validity for the AAI (Baker- mans-Kranenburg & Van IJzendoorn, 1993; Crowell et al., 1996; Sagi et al., 1994). The questions concerning miscarriage closely followed the format of the questions in the AAI about loss and experiences of miscarriage were con- ceived as losses. The answers were rated according to the current guidelines to assess unresolved state of mind (Main et al., 1994). Intercoder agreement between the three coders was determined in 13 cases, and agreement on the four classifications was obtained in 82% of the cases on average (range 77% to 92%), the mean kappa being .73 (range .65 to .89). The mean Spearman correlation concerning their scale scores for unresolved state of mind was .83 (range .80 to .86). Coders assigned separate scores for unresolved state of mind due to loss, miscarriage and abuse. They were kept blind by deleting all identifying information from the transcripts. In the subsequent analyses sub- jects were reclassified as either secure (autonomous) or insecure (dismissing or preoccupied) in order to increase the cell counts.

Strange Situation Procedure We observed the infants within the Strange Situation Procedure (Ainsworth, Blehar, Waters, & Wall, 1978) when they were between 14 and 15 months old (M = 14.7 months, SD = 0.6). Children were classified as secure, insecure avoidant, or insecure resistant. We used the scoring system of Main and Solomon (1990) to code disorganized behaviour. Disorganized behaviour is a momentary interruption of an organized attach- ment strategy in the parent's presence (e.g. stereotypical movements, anomal- ous postures, or the freezing of all movement with a disorganized expression on the infant's face). A score for disorganization is assigned on a 9-point rating scale and a child is classified as disorganized (together with a best-fitting, alternative insecure-avoidant, secure, or insecure-resistant classification) if a rating of above 5 for disorganization is assigned. Main and Solomon (1990) indicate that infants differ in the intensity, context and frequency of their display of disorganized behaviours, and that disorganization operates as a cat- egory only in extreme cases; whereas in other cases it operates as a dimension (Main & Cassidy, 1988). Therefore, a classification as either disorganized or not disorganized is assigned as well as a score on the 9-point rating scale. In rare cases, when the pattern of infant behaviour is incompatible with these categories, infants are rated as 'cannot classify' (Main & Solomon, 1990). In order to increase the cell counts, these cases (n = 3) were combined with the disorganized category (this strategy has been used more often, e.g. Main & Cassidy, 1988; Vondra, Shaw, & Kevenides, 1995). The two coders (MJBK and

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MHvlJ) were blind to all other information about the dyads. Intercoder reli- ability on 20 cases was adequate, with 100% agreement on the three-way classification, and 85% agreement on the D/non-D distinction. The Spear- man correlation between the scale scores for disorganization was .88. There were 26 infants who were classified as disorganized. Disregarding disorgani- zation, 54 infants were classified as secure, and 31 infants were classified as insecure (9 were insecure avoidant, 22 insecure resistant).

RESULTS

Of the 85 mothers, 30 (35%) reported that they had experienced a miscar- riage. Their mean score on the 9-point rating scale for unresolved state of mind due to miscarriage was 2.4 (SD -- 1.46, Min. 1, Max. 6). Fourteen mothers who reported a miscarriage were insecure (47%). This percentage is somewhat higher than the percentage of insecure mothers in our sample (38%), but the difference is not significant 0C ~ = 1.6, p = .20). Two mothers had scores above 5 and would be classified as unresolved on the basis of their answers to the questions about miscarriage (one of them was secure, the other insecure). One of them had a disorganized child (score 5.5), the other's child had a score of 4.5 for disorganization. Because of the small number of mothers with a primary classification as unresolved due to miscarriage, and because disorganization operates both as a dimension and as a category, associations between parental unresolved state of mind and infant disorgan- ized attachment behaviour will be described on the basis of the dimensional measures.

Scores on the 9-point rating scale for unresolved loss due to miscarriage were related to the children's scores on the rating scale for disorganized attachment behaviour, r(30) -- .30,1 p = .05. 2 In the group of mothers who had experienced a miscarriage, scores for unresolved state of mind on the basis of the standard AAI question on loss were not significantly related to their infant's disorganization, r(30) = .24, p = .11. When the highest U-score was taken into account, whether it had been assigned on the basis of the mother's discussion of her miscarriage or of other losses, the correlation with infant disorganization was r(30) -- .28, p = .07. The correlation between unresolved loss on the basis of the standard AAI and unresolved state of mind due to miscarriage was .19 (p = .16). Controlling for unresolved loss on the basis of the standard AAI, the partial correlation of unresolved loss due to miscar- riage with infant disorganization was .28 (p = .08). Analyses of the whole sample (N = 85) paralleled these results; the partial correlation of unresolved loss due to miscarriage with infant disorganization, controlling for unre- solved loss on the basis of the standard AAI, was .14 (p = .10). 3

In the subgroup of secure mothers who had experienced a miscarriage (n = 16) the association between unresolved loss due to miscarriage and infant dis- organization was not significant, rs(16) = .11, p =.34. Results for the secure

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mothers from the whole sample (n = 53) were analogous: there was no sig- nificant association between unresolved state of mind due to miscarriage and infant disorganization. In the subgroup of insecure (dismissing or preoccu- pied) mothers who had experienced a miscarriage (n = 14), however, unre- solved loss due to miscarriage was significantly related to infant disorganization, rs(14) = .53, p -- .03. The association between their scores for unresolved state of mind on the basis of the general AAI question on loss and their infant's disorganization was rs(14) = .39, p = .08. When the highest U- score was taken into account, whether it had been assigned on the basis of the mother's discussion of her miscarriage or of other losses, the correlation with infant disorganization was rs(14) = .58, p = .02. Controlling for unre- solved loss on the basis of the standard AAI, the partial correlation of unre- solved loss due to miscarriage wkh infant disorganization was .47 (p = .05). Results for insecure mothers from the whole sample (n = 32) paralleled these associations. Controlling for unresolved loss on the basis of the standard AAI yielded a partial correlation of unresolved loss due to miscarriage with infant disorganization of .36 (p -- .03).

Mothers' scores for unresolved loss due to miscarriage were not related to the amount of time that had passed since they had a miscarriage, r(30) = .02, p = .94. Their scores were, however, related to the duration of the pregnancy before miscarriage, r(30) = .56, p -- .004.

We repeated all analyses excluding the two mothers with high scores for unresolved state of mind due to miscarriage. Results were comparable to those reported, indicating that the correlations reflect a truly linear association and were not inflated by these two cases. Analyses without the three infants who were rated as 'cannot classify' did not yield different results either.

D I S C U S S I O N

The addition of a question concerning miscarriages to the original format of the AAI, and scoring the answers according to Main et al.'s (1994) system for unresolved loss, appeared to yield relevant information about associations with infant disorganized attachment behaviour. Our sample was not selected on the experience of miscarriage. Nevertheless, 30 mothers reported that they had experienced a miscarriage. As the 85 mothers in our sample had 154 living children in total, this number of miscarriages seems to reflect closely the prevalence of miscarriage (15-20%) in normal populations (Frost &Condon, 1996; Lee & Slade, 1996).

Two of the mothers (7%) had scores above 5 and would be classified as unresolved on the basis of their answers to the questions about miscarriage. One mother, for instance, reported extreme behavioural reaction: 'I thought I would bleed dry; and I went through the house crying and weeping for weeks - on and on crying, weeping, crying a terrible lot', and she showed unsuccessful denial of the loss of a hoped-for baby: 'I don't know, it was not

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like, I've lost a child, but I had the feeling of being pregnant and having a child, so I did not have feelings like here it is, the child, but I did feel - bearing something living within me, something living now disappearing.' The other mother showed disoriented speech: 'It was very sudden. We went to the hos- pital for an ultra-sound scan and I said: "John, we are going to look at our second child." And then I was told, your son [sic], eh, the assistant house- man, that it was an empty, eh, well that the embryo did not beat any more. And I didn't believe it and I started laughing and, yes, look again, you are a student and blah-blah-blah . . . . And then we went to another hospital for a second opinion for we didn't believe it, like that doesn't happen to us . . . . And then I said I want to have that child removed immediately, I cannot live with it. Death inside me. I was very frightened then, I couldn't, I was so frightened . . . . And every year on the 5th of May, commemoration of the dead, I think, no, that is a feast-day, that is for me, I have been curetted on the 5th of May.' (This is a remarkable association, as in the Netherlands the memorial day for the war victims, comparable to Armistice Day, is the 4th rather than the 5th of May. The 5th of May is Liberation Day.)

Although the mothers in our sample had been selected on the basis of their experience of an important loss through death (other than a miscarriage), this does not seem to have biased our results in the direction of more unresolved loss due to miscarriage than would be expected in other samples. On the con- trary, the percentage of mothers with unresolved miscarriages (7%) seemed rather tow. Janssen et al. (1996) reported that one in five women was unable to accept pregnancy loss after approximately two years, but this may reflect a broader definition of 'unresolved' in their study (behavioural changes, psychological and somatic complaints). Moreover, all mothers in our study had given birth to a healthy child in the period between the miscarriage and the assessment of unresolved loss. This may have contributed to the low per- centage of mothers with unresolved miscarriages, although Lewis (197%) suggested that a new pregnancy might also inhibit resolution of a previous pregnancy loss.

Mothers' scores for unresolved loss due to miscarriage were not related to the amount of time that had passed since they had a miscarriage. It should be noted, however, that none of them had miscarried very recently. It has been mentioned elsewhere that the rating of unresolved loss might be less reliable in the case of recent loss (Bakermans-Kranenburg & Van IJzendoorn, 1993; Main & Goldwyn, 1988). It is conceivable that in the first year after a mis- carriage or other loss most subjects are involved in a process of coming to terms with this recent experience. Our results are in line with findings of Pianta, Marvin, Britner, and Borowitz (1996), who developed an interview to assess parents' resolution regarding their child's diagnosis of cerebral palsy or epilepsy. They found no association between resolution status and the amount of time that had elapsed between receiving the diagnosis and the administration of the interview (Pianta et al., 1996; Marvin & Pianta, 1996).

We found that unresolved state of mind due to miscarriage was related to

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the duration of the pregnancy before miscarriage. An association between grief and the duration of the pregnancy has also been reported by others (Janssen et al., 1997) and is comprehensible, as the reality of the pregnancy and the unborn child probably become more meaningful to the mother as the pregnancy progresses. As our participants were recruited some time after the experience of a miscarriage, we have no information regarding pre-loss personality or any pre-loss psychiatric symptoms. Therefore, we cannot report on risk factors for unresolved state of mind in women following a pregnancy loss.

A mother's unresolved loss due to miscarriage was related to her infant's score on disorganized attachment behaviour. For mothers with an otherwise insecure (dismissing or preoccupied) representation of attachment, the addi- tional rating for unresolved toss due to miscarriage contributed uniquely to the prediction of infant disorganization, as was shown by the significant partial correlation coefficients. For secure mothers, the association between unresolved state of mind due to miscarriage and infant disorganization was not significant. This result parallels Schuengel et al.'s (1999) finding that unre- solved loss predicted infant disorganization only in the subgroup of mothers with an otherwise insecure representation of attachment. A secure attach- ment representation seems to function as a protective mechanism, blocking the intergenerationat transmission of unresolved loss (Hesse, 1999). Secure attachment does not prevent trauma and/or loss from occurring, and, more- over, secure mothers can be unresolved with respect to these experiences as well. Unresolved secure mothers seem, however, able to prevent their unre- solved states of mind impinging upon the evolving infant-mother attachment relationship. Schuengel et al. (1999) found that unresolved secure parents did not display frightening behaviour, and thereby averted the risk of their infants becoming disorganized. In the same vein, Jacobvitz, Hazen, and Riggs (1997) found a difference in maternal behaviour among unresolved mothers based on whether the secondary classification was secure or insecure, with unresolved insecure mothers showing more frightening behaviour. A secure mental representation may thus act as a protective mechanism, altering the exposure to the risk (Rutter, 1987) posed by unresolved loss. More research is needed to shed light on this issue; for example, it is unknown how this pro- tective mechanism in secure parents operates. Moreover, it leaves unanswered the question about the precursors of disorganized behaviour in otherwise secure children, who in some samples (Main & Solomon, 1990) are even the majority of those classified as disorganized.

If miscarriage is not separately asked about in the interview but is volun- teered by the participant, it can be probed, and coded along with the other losses. It should be noted, however, that the mothers in our sample did not mention the loss through miscarriage spontaneously in their answers to the more general questions about loss; that is, we would have missed these indi- cations of unresolved loss if we had not asked our supplementary questions. Thus, including questions on miscarriage in the AAI may yield theoretically

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and clinically important information; for example, leading to improved pre- diction of disorganized attachment in infants.

A P P E N D I X A

The additional AAI question about miscarriage has the following format: 1. Did you ever have a miscarriage? i f so: Some people don't look upon a miscarriage as a traumatic event, others experience it as the loss of a child. Therefore, I would like to ask you some questions about your miscarriage. a. H o w long ago did this happen to you? b. How many weeks or months had you been pregnant? c. Was your miscarriage sudden or somehow expected? d. Did you bid farewell in some way? e. Have your feelings regarding this miscarriage changed much over

time? f. Would you say this experience has had an effect on your adult per-

sonality? g. Does it affect your approach to (name child)?

A C K N O W L E D G M E N T S

This study was partially supported by a Pioneer award from the Netherlands Organisation for Scientific Research (NWO; PGS 59-256) and by a fellowship of the Netherlands Institute for Advanced Study in the Humanities and Social Sciences (NIAS) to the third author. We gratefully acknowledge the help of Abraham Sagi and Tirtsa Joels of Haifa University, and Marjolein Mosmans, Tessa Schmidt, Philomeen Breddels-van Baardewijk, Marjolijn Biota, Bart Bosman and Loes de Blok with data collection and coding.

Correspondence concerning this article should be addressed to Marian J. Bakermans-Kranenburg, Centre for Child and Family Studies, Leiden University, PO Box 9555, 2300 RB Leiden, the Netherlands. e-mail: bakermans@fsw.leidenuniv.nl

N O T E S

1 Pearson product-moment correlation coefficients will be reported when n = 30; Spearman's rank order coefficients did not yield different results.

2 Associations between unresolved state of mind and infant disorganization will be reported with one-sided p-values.

3 In cases that had not been given a score for unresolved loss due to miscarriage, a score of I was substituted.

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168 ATTACHMENT & HUMAN DEVELOPMENT VOL. 1 NO. 2

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