Parent-child attachment and internalizing symptoms in childhood and adolescence: A review of empirical findings and future directions

Abstract

The purpose of this paper is to evaluate the theory and evidence for the links of parent-child attachment with internalizing problems in childhood and adolescence. We address three key questions: (a) how consistent is the evidence that attachment security or insecurity is linked to internalizing symptoms, anxiety, and depression? (b) How consistent is the evidence that specific forms of insecurity are more strongly related to internalizing symptoms, anxiety, and depression than are other forms of insecurity? (c) Are associations with internalizing symptoms, anxiety, and depression consistent for mother-child and father-child attachment? The current findings are consistent with the hypothesis that insecure attachment is associated with the development of internalizing problems. The links between specific insecure attachment patterns and internalizing problems are difficult to evaluate. Father-child and mother-child attachments have a comparable impact, although there are relatively few studies of father-child attachment. No moderators consistently affect these relations. We also propose two models of how attachment insecurity may combine with other factors to lead to anxiety or depression.

Full text

Parent–child attachment and internalizing symptoms in childhood
and adolescence: A review of empirical findings and
future directions
LAURA E. BRUMARIU AND KATHRYN A. KERNS
Kent State University
Abstract
The purpose of this paper is to evaluate the theory and evidence for the links of parent–child attachment with internalizing problems in childhood and
adolescence. We address three key questions: (a) how consistent is the evidence that attachment security or insecurity is linked to internalizing symptoms,
anxiety, and depression? (b) How consistent is the evidence that specific forms of insecurity are more strongly related to internalizing symptoms,
anxiety, and depression than are other forms of insecurity? (c) Are associations with internalizing symptoms, anxiety, and depression consistent for
mother–child and father–child attachment? The current findings are consistent with the hypothesisthat insecure attachment is associated with the development
of internalizing problems. The links between specific insecure attachment patterns and internalizing problems are difficult to evaluate. Father–child and
mother–child attachments have a comparable impact, although there are relatively few studies of father–child attachment. No moderators consistently affect
these relations. We also propose two models of how attachment insecurity may combine with other factors to lead to anxiety or depression.
Anxiety and depression, typically labeled as internalizing
symptoms/disorders, are among the most common forms of
psychopathology affecting children and adolescents (Costello
et al., 1996; Last, Perrin, Hersen, & Kazdin, 1996), and there-
fore, it is important to understand factors that may give rise to
these conditions. With origins in the study of clinical issues,
attachment theory provides one framework for understanding
the development of anxiety and depression (Bowlby, 1969,
1973). Although studies assessing these associations have be-
gun to emerge in the last decade, a comprehensive review of
empirical findings is missing from the literature. One review
focused exclusively on family factors in anxiety, but not de-
pression (Bo
¨gels & Brechman-Toussaint, 2006), and other
reviews (e.g., DeKlyen & Greenberg, 2008; Ranson & Uri-
chuk, 2008) have assessed the relations of attachment with
a broad range of symptomatology, all with a limited focus
on empirical evidence regarding the associations of parent–
child attachment with internalizing problems or, more specif-
ically, anxiety and depression. The purpose of this paper is to
review theoretical approaches and to evaluate the empirical
evidence for the links between attachment and the develop-
ment of internalizing problems in childhood and adolescence.
In addition, we propose two models that might explain how
attachment, in combination with other factors, may relate to
anxiety or depression.
Anxiety and Depression: Conceptual Definitions
Internalizing problems are characterized by covert, inner-di-
rected symptoms (e.g., distress) and overcontrolled behaviors
(Achenbach & McConaughy, 1992), and are operationalized
in the child and adult literatures as symptoms, syndromes, or
diagnoses (Compas, Ey, & Grant, 1993; Fonseca & Perrin,
2001). Anxiety disorders include: generalized anxiety disor-
der, social phobia, specific phobia, obsessive–compulsive
disorder (OCD), panic disorder, posttraumatic stress disorder,
and separation anxiety disorder, with the latter the only anx-
iety disorder specific to childhood (American Psychiatric As-
sociation [APA], 2000). The common denominator of anxi-
ety disorders is an intense fear or worry associated with
avoidant behavior (Kendall, Hedtke, & Aschenbrand, 2006).
The most common depressive disorders in children are major
depressive disorder and dysthymic disorder, marked by feel-
ings of sadness, diminished energy, and sleep and appetite
disturbances (APA, 2000). Diagnostic criteria for depres-
sion are similar for children and adults, with two exceptions:
irritability may substitute for depressed mood, and the re-
quired duration of dysthymic disorder is shorter in child-
hood. Bipolar disorders are also included among the depres-
sive disorders (APA, 2000), but given the rarity and
difficulty of these diagnoses in childhood (Hammen & Ru-
dolph, 2003), bipolar disorders are not discussed in the cur-
rent review. For simplicity, we will use the terms anxiety and
depression as reflecting symptoms and syndromes. How-
ever, when we address studies based on diagnoses, we use
the term disorder.
Address correspondence and reprint requests to: Laura E. Brumariu, De-
partment of Psychology, Kent State University, Kent, OH 44242; E-mail:
lbrumar1@kent.edu.
Development and Psychopathology 22 (2010), 177–203
Copyright #Cambridge University Press, 2010
doi:10.1017/S0954579409990344
177

Internalizing problems are linked to children’s healthy
adaptation. High levels of anxiety are associated withmaladap-
tive outcomes such as avoidance of developmentally appropri-
ate activities, higher risk for comorbid conditions such as an-
other type of anxiety disorder, depression, or disruptive
behaviors, and difficulties in social adjustment (Albano, Chor-
pita, & Barlow, 2003; Fonseca & Perrin 2001; Ollendick,
Shortt, & Sander, 2005). High levels of depression are associ-
ated with psychosocial disturbances such as academic difficul-
ties and impaired interpersonal relationships, subsequent epi-
sodes of depression, increased risk for thoughts of death or
suicidal behaviors, and substance abuse during later adoles-
cence (Birmaher et al., 1996; Hammen & Rudolph, 2003).
Attachment Theory: Theoretical Links With Anxiety
and Depression
Given the cognitive, emotional, and behavioral impairments
associated with anxiety and depression, as well as the high
costs associated with their treatment (Greenberg et al.,
1999), it is important to develop and test theories addressing
their etiology. Bowlby (1969) suggested that the quality of at-
tachment between parents and children sets the stage for later
personality development. Attachment (in children) is typi-
cally defined as an emotional long-lasting bond that a child
forms with an attachment figure (Ainsworth, 1989). Children
feel secure in their relationships with attachment figures to the
extent that they perceive those figures as consistently avail-
able, sensitive, and responsive to their needs. Securely at-
tached children use their caregivers as a secure base from which
to explore and as a haven of safety in times of need. The attach-
ment figures’ sensitive responses soothe their distress,allowing
them to return to their routine. When there is a lack of re-
sponsivenessand sensitive care, children form insecure relation-
ships with their attachment figures and, consequently, are less
able to use them as a secure base and safe haven.
Ainsworth further expanded Bowlby’s tenets and identified
two types of insecure relationships: ambivalent (C type) and
avoidant (A type; Ainsworth, Blehar, Waters, & Wall, 1978).
Ambivalently attached children exhibit fearful and excessive
attachment behavior (i.e., heightening of negative emotions)
and increased dependence on the attachment figure reflecting
attempts to gain the attention of their inconsistently available
caregiver (Cassidy & Berlin, 1994; Main & Solomon, 1986).
Their attachment figure is thought to have difficulty setting
limits on children’s behavior, to undermine children’s auton-
omy and exploration, and to be inconsistent in responding to
the child’s distress (Cassidy, 1994; Cassidy & Berlin, 1994).
Avoidantly attached children tend to mask negative affect, to
engage in affectively neutral interactions with their attachment
figure, and to minimize his or her importance as a source of
comfort (Cassidy, 1994; Main & Solomon, 1986). This self-
reliance strategy, developed as a consequence of consistent
rejection by their attachment figure, particularly in times of
distress, serves children by allowing them to avoid further re-
jection that might be triggered by their attempts for contact.
For example, the attachment figures of avoidantly attached chil-
dren are thought to use a controlling interactional style and to
withdraw from interactions when children display negative
affect (Belsky & Fearon, 2008; Cassidy, 1994). The child
then learns that expressing negative affect is inappropriate.
Main and Solomon (1986) documented a third type of inse-
cure relationship, disorganized attachment. Infants with disorga-
nized attachments do not have a coherent and organized strategy
to cope with distress in the presence of their caregiver. These chil-
dren show contradictory, bizarre, and incoherent behaviors as an
expression of experiencing a paradoxical situation: the caregiver
is at the same time a source of apprehension and the secure base
(Lyons-Ruth & Spielman, 2004; Main & Solomon, 1986; van
IJzendoorn, Schuengel, & Bakermans-Kraneburg, 1999). Three
subgroups of disorganized attachment have been identified,
two of which manifest role reversal with the caregiver: control-
ling–caregiving, including children who focus on guiding and
entertaining the parent; controlling–punitive, including chil-
dren who manifest hostile behaviors toward the parent; and in-
secure–other or atypical, encompassing children who do not
show a clear A or C pattern (Main & Cassidy, 1986, cited in
Moss, Cyr, & Dubois-Comtois, 2004). Disorganized attachment
is thought to arise if children experience a psychologically una-
vailable attachment figure, extremely hostile or abusive caregiv-
ing, or actual or symbolic loss of the attachment figure (Lyons-
Ruth & Jacobvitz, 2008; Moss, Cyr, et al., 2004).
Although acknowledging the role played by temperament
and genetic factors, Bowlby (1973) emphasized that chil-
dren’s concerns about attachment figures’ availability consti-
tute the basis of anxiety. Based on their experiential history
with caregivers, children learn to predict the attachment fig-
ures’ availability. If children’s attempts to forecast the care-
givers’ availability fail, particularly when separated from the at-
tachment figures or when experiencing disturbing situations,
they respond with fearand anxiety. Further, Bowlby (1980) as-
serted that uncontrollable and prolonged loss, perceived or ac-
tual, increases vulnerability to depression. Broadly defined,
loss encompasses a wide range of situations such as physical
separation, death, and divorce, or conditions other than phys-
ical separation that lead to systematic unavailability of the
caregiver (e.g., parent suffers a traumatic event). The lack
of caregivers’ availability that contributes to attachment inse-
curity promotes perceptions of the self as a failure, percep-
tions that will be carried out and further reinforced throughout
subsequent losses that fuel depressive symptomatology. In
sum, Bowlby provided a theoretical basis for speculating
that insecure attachment relates to both anxiety and depres-
sion in children and adolescents.
With the advent of developmental psychopathology, the
investigation of behavioral maladaptation in the context of
the study of normal development (Cicchetti, 1984; Sroufe &
Rutter, 1984), theorists further refined Bowlby’s ideas while
underscoring the complexities of the association between at-
tachment and internalizing symptoms in general and anxiety
or depression in particular. Perry and colleagues (Finnegan,
Hodges, & Perry, 1996; Hodges, Finnegan, & Perry, 1999)
L. E. Brumariu and K. A. Kerns178

proposed that ambivalent attachment, rather then avoidant
attachment, is relevant for the development of internalizing
symptoms. Their reasoning stems from the fact that ambiva-
lent attachment is characterized by inhibition of autonomy
and exploration and difficulty in regulating emotions during
minor stressors, which in turn, promote fear responses and
self-perceptions of weakness and helplessness; these charac-
teristics are often associated with internalizing symptoms.
Perry and colleagues did not discuss disorganized attach-
ment. Some researchers argue that, because disorganized
children perceive themselves as helpless and vulnerable in
the face of frightening situations and attachment figures as
unable to protect them, disorganization may be the attach-
ment pattern most likely to be associated with the develop-
ment of internalizing symptoms (e.g., Moss, Rousseau,
Parent, St-Laurent, & Saintonge, 1998).
Other researchers made more specific predictions regarding
the associations between different insecure attachment patterns
and anxiety or depression. Carlson and Sroufe (1995) sug-
gested that both avoidantly and ambivalently attached children
may be vulnerable to develop internalizing symptoms, butonly
the latter are at greater risk for anxiety. Their prediction is based
on Bowlby’s (1973) observations that anxiety symptoms (i.e.,
phobias) are often associated with family patterns in which
children worry about the availability or well-being of attach-
ment figures. By the nature of their relationship, ambivalently
attached children have concerns about the availabilityof attach-
ment figures; thus, they are likely to experience fears about
leaving home and other related fears. By contrast, Manassis
(2001) suggested that ambivalent, avoidant, and disorganized
attachments may all predispose a child to develop anxiety,
but that specific insecure attachment patterns may be associ-
ated with specific anxiety disorders/symptoms. Because am-
bivalently attached children become preoccupied with bidding
for the caregivers’ attention and are less involved in explora-
tory behaviors, they may develop separation anxiety. The care-
givers of these children may express frustration at children’s
contact attempts or when the children try to reduce anxiety
by being near caregivers,further increasing rather than alleviat-
ing separation anxiety. Manassis also speculated that the self-
reliance strategy used by avoidantly attached children, along
with their perceptions of being rejected by their caregivers,
may result in decreased desire for social contact. In tempera-
mentally vulnerable individuals, this desire may lead to social
phobia. Alternatively, the restriction and avoidance of the ex-
pression of negative emotions may lead to defenses charac-
teristic of obsessive–compulsive symptomatology or to physi-
cal expression of distress as somatic complaints. In disorganized
attachment, the child sometimes has to look after a psychologi-
cally unavailable parent and may become excessively con-
cerned with the caregiver’s well-being, which may result in
school phobia associated with separation anxiety.
Children with different forms of insecure attachments may
all be susceptible to develop depression. For both avoidantly
and ambivalently attached children, symbolic or actual loss of
attachment figures (i.e., lackof a supportive relationship) may
confirm their expectations about the psychological unavail-
ability of attachment figures and may lead to depression
(Carlson & Sroufe, 1995). In a more recent paper, Egeland
and Carlson (2004) further refined the theoretical link be-
tween insecure attachment and depression and postulated,
based on Bowlby’s (1969) observations, that each insecure at-
tachment pattern is related to depression for different reasons.
Ambivalently attached children, who cannot fulfill the care-
giver’s demands despite repeated attempts, may perceive later
difficulties or loss as another failure and develop depression,
experienced mainly as helplessness. Avoidantly attached chil-
dren, who learn through their interactions with attachment
figures that they are unlovable or inadequate, may perceive
others as hostile rather than supportive, and develop depres-
sion experienced as alienation and hopelessness. Children
with disorganized attachments, some of whom experience in-
tense traumas, may interpret later difficulties as overwhelm-
ing and the self as incapable in the face of challenges, sche-
mas that ultimately would lead to depression.
Literature Review
With the revived interest in the clinical implications of attach-
ment theory, a focal question arises: is attachment indeed re-
lated to internalizing symptoms? One major purpose of this
paper is to evaluate the empirical evidence for the links be-
tween attachment and internalizing symptoms in childhood
and adolescence. Specifically, we address several key issues:
(a) how consistent is the evidence that attachment security or
insecurity is linked to internalizing symptoms, anxiety, and
depression? (b) How consistent is the evidence that specific
forms of insecurity are more strongly related to internalizing
symptoms, anxiety, and depression than are other forms of in-
security? (c) Are associations with internalizing symptoms,
anxiety, and depression consistent for mother–child and
father–child attachment?
Study selection
Studies included in this review have met the following criteria:
(a) included a measure of attachment to mother, father, or both
parents in childhood and/or adolescence; (b) included a measure
of internalizing symptoms,1anxiety, or depression; and (c) re-
ported a mean age of 18 years or younger for participants. Stud-
ies examining solely the associations of parenting, attachment to
peers or romantic partner, and other family aspects (e.g., family
environment, other dimensions of the child–parent relationship)
or grouping attachment to parents and peers in the same cate-
gory were excluded. Because temperament is one of the most
1. Studies investigating internalizing symptoms often analyzed the total in-
ternalizing symptom score as well as subscales (e.g., anxiety/depression,
somatic complaints). In the section on internalizing symptoms, we present
the main results for the total internalizing scale score. When the total in-
ternalizing score was not available, we present the main results for the
combined anxiety/depression score.
Parent–child attachment and internalizing symptoms 179

widely accepted precursors of internalizing problems, but not a
symptom of internalizing problems (Kagan, Snidman, Arcus, &
Reznick, 1994), measures of the anxious style of temperament
(also referred to as inhibition, withdrawal, shyness, and ap-
proach/avoidance) were not treated as measures of anxiety or de-
pression. Studies that referred to affective disorders were also
excluded if they did not differentiate between depression and
schizoaffective disorder.
We conducted a literature search for studies presenting quan-
titative data by (a) crossing different key words from the attach-
ment domain (attachment, secure-, insecure-, ambivalence, dis-
org-, avoid-) and internalizing symptoms domain (e.g., anxi-,
OCD, obsessive, depress-, internalize-) using the 1967 to pre-
sent PsychInfo database; and (b) tracing some studies based
on the references provided by relevant theoretical papers (e.g.,
Cummings & Cicchetti, 1990; DeKlyen & Greenberg, 2008).
We perused the titles, abstracts, and method and result sections,
and retained the studies corresponding to theaims of this review.
Thus, the literature search resulted in a final pool of 55 studies
covering the published research between 1984 and 2008.
Attachment measures
There are different assessment approaches and measures of at-
tachment from infancy to adulthood. The most common proce-
dure for identifying attachment patterns (secure, ambivalent,
avoidant, and disorganized) in infancy is the Strange Situation
procedure (Ainsworth et al., 1978), which consists of a series
of separation and reunion episodes with a caregiver in the labo-
ratory. Adaptations of the Strange Situation procedure are widely
used at preschool and early school age (Solomon & George,
2008). The Attachment Q-Set assesses the quality of a young
child’s secure base behavior in the home (Waters, 1995). Semi-
projective techniques such as story-stem narratives and picture
response procedures assess children’s internal representations
of attachment, and have been developed for preschoolers and
older school age children (e.g., Attachment Story Completion
Task; Bretherton, Ridgeway, & Cassidy, 1990; Separation Anx-
iety Test [SAT]; Slough & Greenberg, 1990; for reviews, see
Kerns, Schlegelmilch, Morgan, & Abraham, 2005; Solomon
& George, 2008). The Adult Attachment Interview (AAI;
George, Kaplan, & Main, 1996) is a narrative discourse measure
often used in adolescence and adulthood to assess a person’s
“state of mind” toward attachment. Based on experiences with
attachment figures and the meaning currently assigned to past
attachment-related experiences, the adolescent is classified into
categories that parallel the infant classifications: autonomous
(secure), dismissing (avoidant), preoccupied (ambivalent), or
unresolved (disorganized). In addition, a variety of question-
naires, assessing children’s and adolescents’ perceptions of
attachment, have been proposed (e.g., the Security Scale; Kerns,
Aspelmeier, Gentzler, & Grabill, 2001; the Inventory of Parent
and Peer Attachment [IPPA]; Armsden & Greenberg, 1987).
Although most attachment measures are intended to cap-
ture the secure base and safe haven constructs, a variety of
terms are used to conceptualize security (i.e., greater attach-
ment, attachment beliefs) or insecurity in childhood and ado-
lescence (i.e., angry distress and unavailability, anxiety and
avoidance, etc.), as well as to refer to the attachment patterns
(e.g., secure, ambivalent, avoidant, and disorganized; Main &
Solomon, 1986; secure, preoccupied, dismissive, and fearful;
Bartholomew & Harowitz, 1991). To avoid confusion, through-
out this paper we will use the terms secure, ambivalent, avoid-
ant, and disorganized to refer to the attachment categories or
dimensions assessed. However, when the terms are not con-
ceptually equivalent with the infant classification, we will use
the terms proposed by the authors.
In addition, it is important to note that different measures
vary in how they conceptualize attachment. Some measures
assess attachment behaviors, some assess representations,
and others assess perceptions of attachment. Some measures
have been designed for use only in infancy and early child-
hood (e.g., behavioral observation measures), some have
been used both in preschool years and early adolescence
(e.g., the SAT), and others have been designed specifically
for older adolescents or adults (e.g., the AAI). Early child-
hood assessments, such as those based on coding of child’s
attachment behaviors, are considered relationship-specific as-
sessments, whereas measures for older adolescents (e.g., the
AAI) are considered measures of an individual’s general style
across attachment relationships (Crowell, Fraley, & Shaver,
2008; Kerns et al., 2005; Solomon & George, 2008). Finally,
there are variations within and across measures of attachment
in terms of psychometric properties. Ainsworth’s classifica-
tion measure has been extensively validated on US and West-
ern European populations. The observational measures for
preschoolers also have relative good reliability and validity
(Moss, Bureau, Cyr, Mongeau, & St-Laurent, 2004; Solomon
& George, 2008). Similarly, the relative stability, reliability,
and predictive validity of the AAI are well established (Hesse,
2008). Representational measures (e.g., the story-stem tech-
nique) seem a promising approach, but have not been vali-
dated as extensively (Kerns et al., 2005). Although attach-
ment questionnaires have adequate internal consistency,
validity data are sparse for some measures (Kerns, 2008).
Based on theory and previous reviews (Crowell et al., 2008;
Kerns et al., 2005; Solomon & George, 2008), we grouped the
attachment measures used in the reviewed studies into three
categories: (a) behavioral observation measures including the
Strange Situation procedure (Ainsworth et al., 1978), the
Main and Cassidy extension of the Strange Situation to pre-
school and early school age (Cassidy & Marvin, 1992; Main
& Cassidy, 1986), and the Attachment Q-set (Waters, 1995);
(b) measures of attachment representations involving storytell-
ing, semistructured autobiographical interviews or family
drawings (the Attachment Story Completion Task, Bretherton
et al., 1990;the SAT, Slough & Greenberg, 1990; the Manches-
ter Child Attachment Story Task, Goldwyn, Stanley, Smith, &
Green, 2000; the AAI and Q-Set; George et al., 1996; Kobak,
Cole, Ferenz-Gillies, Fleming, & Gamble, 1993; analysis of
drawings, Fury, Carlson, & Sroufe, 1987); and (c) question-
naires (the SecurityScale, Kerns et al., 2001; Coping Strategies
L. E. Brumariu and K. A. Kerns180

Questionnaire, Finnegan et al., 1996; the IPPA, Armsden &
Greenberg, 1987; the Adolescent Attachment Questionnaire,
West, Rose, Spreng, Sheldon-Keller, & Adam, 1998; the Rela-
tionship Questionnaire, Bartholomew & Horowitz, 1991;
Parental Attachment Questionnaire, Kenny, 1987). When
possible, we grouped studies within a measurement category
based on the instrument used (e.g., studies based on the IPPA).
Review format
To facilitate evaluating hypotheses regarding specificity of rela-
tions between attachment patterns and particular internalizing
problems, we separately summarized the literature for internal-
izing symptoms (in general), anxiety, and depression. There
are some variations in the manifestation of internalizing symp-
toms between childhood and adolescence, and in the correlates
of anxiety and depression (APA, 2000). Our initial intention
was to group studies based on the outcome and the age of devel-
opment (childhood, middle childhood, preadolescence, adoles-
cence). There are, however, very few studies assessing internal-
izing symptoms in early childhood (age 6 or younger). In
addition, many symptoms do not become prevalent until later
middle childhood (10–12 years of age). Therefore, for each
type of symptom (internalizing symptoms, anxiety, and depres-
sion) we summarized separately the datafor studies in childhood
(up to age 10 years) and preadolescence/adolescence (age 10
years or older). For studies with a large age range, a decision
was made based on the mean and/or median age of assessment.
When enough information was provided (i.e., means and stan-
dard deviations, correlations, etc.), we used standard formulas
to compute Cohen’s (1988) effect size.2We used Cohen’s (1988)
conventions for effect sizes; thus, d¼0.2 was considered
a small effect, d¼0.5 was a medium effect, and d¼0.8 was
a large effect. A correction factor was applied, when computing
effect sizes based on means, to account for the differences in
sample sizes and small samples, according to the suggestions
of Hedges (1981). Details about the studies are presented in
Tables 1–6. It should be noted that the majority of the samples
were predominantly Caucasian (for exceptions, see Anan &
Barnett, 1999; Constantine, 2006) and were drawn from the
Untied States, Canada, or Europe. Although a significant num-
ber of studies employed a longitudinal design (23 studies),
cross-sectional designs were commonly used (32 studies).
Attachment and Internalizing Symptoms
Childhood internalizing symptoms
The 19 studies reporting associations between attachment and
internalizing symptoms in childhood, and the corresponding
effect sizes, are presented in Table 1.
Behavioral observation studies. All 16 studies assessed at-
tachment to mother. Ten of these studies used the Strange
Situation procedure, four of which assessed only secure,
ambivalent, and avoidant attachments, but did not assess
the disorganized attachment. Specifically, Lewis, Feiring,
McGuffog, and Jaskir (1984) found that, at age 6 years, se-
curely attached boys were rated the lowest by mothers and
ambivalently attached boys the highest on an internalizing
scale. No significant results were reported for girls. Although
Pierrehumbert, Miljkovitch, Plancherel, Halfon, and Anser-
met (2000) did not perform statistical analyses to assess dif-
ferences among attachment patterns, effect sizes indicated
that insecure infants showed more internalizing symptoms
at age 5 years than did secure infants, and that avoidant infants
showed more internalizing symptoms than nonavoidant in-
fants. No differences were found between ambivalent and
nonambivalent children. Two other studies reported no asso-
ciations between ABC attachment classifications in infancy
and internalizing symptoms in the preschool years (Bates &
Bayles, 1988; Bates, Maslin, & Frankel, 1985; Burgess, Mar-
shall, Rubin, & Fox, 2003). It is interesting that the effect
sizes based on the results of Bates and colleagues’ study sug-
gest that, at the age of 5 and 6 years, securely attached boys
showed more internalizing problems than ambivalently at-
tached boys, and securely attached girls showed more inter-
nalizing problems that avoidantly attached girls.
Six studies based on the Strange Situation assessed disor-
ganization, although not all studies included all four attach-
ment patterns. In a mixed sample of healthy and chronically
ill children (Goldberg, Gotowiec, & Simmons, 1995), se-
curely attached children in infancy received lower ratings of
internalizing symptoms at ages 2–3 years than did insecurely
attached children. The secure–avoidant contrast was also sig-
nificant. In the Lyons-Ruth, Easterbrooks, and Cibelli (1997)
study of a low-income sample, infants classified avoidant as
opposed to secure displayed more internalizing symptoms at
the age of 7 as rated by teachers, but not by mothers, when
continuous but not clinical scores of the internalizing scale
were used. Disorganized status, as opposed to organized sta-
tus, was not consistently related to internalizing symptoms as
rated by mothers or teachers. This sample did not contain in-
fants in the ambivalent category. In the National Institute of
Child Health and Human Development (NICHD) Study of
Early Child Care, secure and disorganized attachments in in-
fancy did not relate to mothers’ or caregivers’ reported inter-
nalizing symptoms at the age of 3 years (McCartney, Owen,
Booth, Clarke-Stewart, & Vandell, 2004). McCartney et al.
(2004) did not include ambivalent and avoidant attachments
in the analyses. ABCD attachment classifications were not
significantly related to mother ratings of internalizing prob-
lems when children were between 4.5 years and first grade
(NICHD Early Child Care Research Network, 2006), al-
though teachers rated first graders with secure attachments
in infancy lower on internalizing symptoms than avoidant
or disorganized children. Two studies based on samples
at economic risk reported a positive association between
2. The most common reason why effect sizes could not be computed wasthat
control variables were included in the published analyses. We contacted au-
thors to request the appropriate statistics, many of whom were able to pro-
vide the necessary information. We thank these authors for their assistance.
Parent–child attachment and internalizing symptoms 181

Table 1. Studies of attachment and childhood internalizing symptoms
Study Country/
Symptoms
Study Type NEthnicity AF Age Informant Comparison/Association Effect Size
Behavioral measures
1. Anan & Barnett (1999) L 56 US, 3 M 4.5 C, M Security 0.17, 0.39
2. Bates et al. (1985), L 74 US M 3, 5–6 M Security NA
Bates & Boyles (1988) NA B vs. A (boys) 0.02
B vs. C (boys) 0.44
B vs. A (girls) 0.57
B vs. C (girls) 0.03
3. Booth et al. (1994) CS 79 US, 1 M 4.3 P þO Security 0.06
L 8 Security** 0.70
4. Burgess et al. (2003) L 144 US, 1 M 4 M A vs. B, B vs. C 0.11, 0.14
5. Carlson (1998) L 157 US, 1 M 6–12 T Disorganization* 0.39
6. Easterbrooks et al. (1993)aCS 45 US, 1 M 7.66 M Security,* avoidance* 0.70, 0.70
T Security,** avoidance** 0.90, 0.82
Lyons-Ruth et al. (1997)aL 50 US, 1 M 7 M A vs. B, D vs. nonD NA
TA.B,** D .nonD† NA
M A vs. B, D vs. nonD NA
TA.B,†D.nonD NA
7. Goldberg et al. (1995) L 145 US, 1 M 2 þ3MþFB,AþBþC* 0.39
B,AþBþCþD* 0.34
B,A** 0.68, 0.59
8. Lewis et al. (1984) L 113 US, NA M 6 M B ,A,C** (boys) NA
B vs. A vs. C (girls) NA
9. Manassis et al. (1995) CS 20 Canada, 1 M 3.25 M B ,nonB* 1.10
10. McCartney et al. (2004) CS 1015 US, 2 M 3 M, Cg Security***;** 0.24, 0.24
Disorganization*;ns 0.12, 0.04
L M, Cg Security 0.02, 0.08
Disorganization 0.10, 0.02
Q-Set security***;*** 0.37, 0.30
NICHD (2006) L 1069 US, 2 M 4.5–6 M A, B, C, D NA
TB,(A, D)** NA
11. Moss et al. (1996, 1998) CS 77 Canada M 5–7 T B vs. A, C, D NA
182

CS 121 NA 5–7 D .AþBþC* NA
B vs. A, C; B ,D† NA, NA
L 103 7–9 D .AþBþC* NA
B vs. A, C; B ,D* NA, NA
12. Moss, Cyr, et al. (2004) CS 242 Canada M 5–7 T B vs. A, C, D punitive NA
NA B ,D caregiving* NA
13. Moss et al. (2006) L 96 Canada M 7–9 C B ,D,** B vs. A, B vs. C 0.59, 0.03, 0.15
NA 8.5 T þMB,D,* B ,A,† B vs. C 0.50, 0.36, 0.18
14. Pierrehumbert et al. (2000) L 40 France, M 5 M B vs. A þC 0.51
NA A vs. B þC, C vs. B þC 0.60, 0
15. Shaw & Vondra (1995) L 80 US, 2 M 3 M B vs. nonB 0.07
72 B vs. nonB 0.60**
Shaw et al. (1997) L 86 5 M Security 0.02
Disorganization* 0.43
Vondra et al. (2001) L 223 US, 2 M 3.5 M A, B, C, D infancy NA
Atypical score,*** A, C 0.57, NA, NA
16. Stams et al. (2002) L 146 Holland, 1 M 7 M þT Security, disorganization 0.12, 0.04
Representational measures
1. Easterbrooks & Abeles (2000)aCS 85 US, 1 M 8 M, T Security** 0.82
Security†;b0.58
2. Goldwyn et al. (2000) CS 30 UK, NA M 5–7 P Security*;bNA
Disorganization** 0.80
T Disorganization** 0.80
3. Miljkovitch et al. (2007) CS 71 France, NA P 3.10 M, F Security 0.35, 0.37
Deactivation 0.28, 0.37
Hyperactivation 0.26, 0.06
Disorganization†;ns 0.43, 0
Questionnaires
1. El-Sheik & Buckhalt (2003) CS 216 US, 2 M 9.44, M, T Security 0.08, 0.14
F 9.51 Security*;† 0.28, 0.35
Note: For study type: L, longitudinal; CS, cross-sectional. For ethnicity: 1, predominantly Caucasian; 2, majority Caucasian, but some other ethnicities are relatively well represented; 3, predominantly African American.
AF, attachment figure. For attachment figure: M, mother, P, parent. For internalizing symptoms, age is reported in years (range or mean). For symptoms informant: C, child; Cg, caregiver; F, father; M, mother; O, ob-
servation; P, parent; T, teacher. For comparison: A, avoidant; B, secure; C, ambivalent; D, disorganized.
aOverlapping samples.
bPositive association.
†p,.10. *p,.05. **p,.01. ***p,.001.
183

Table 2. Studies of attachment and preadolescent or adolescent internalizing symptoms
Study Country/
Symptoms
Comparison/
Study Type NEthnicity AF Age Informant Association Effect Size
Behavioral measures
1. Carlson (1998) L 157 US, 1 M .10 T Disorganization* 0.37
Representational measures
1. Allen et al. (1998)
CS 131 US, 2 P 14–18 C Security
Ambivalence***
0.20
16 0.82
2. Brown et al. (2003) CS 30 UK,1 P 17 C C .A¼B* 1.26, 1.44
3. Granot & Mayseless (2001)aCS 113 Israel, 1 M 10.5 T B ,D,*** B ,A*** 0.93, 0.90
B vs. C 0.22
Questionnaires
1. Buist et al. (2004) CS 288 Holland, P 13.5 C Security** 0.43–0.77
NA 14.5 Security** 0.56–1.42
15.5 Security** 0.72–1.35
L 14.5 C Security** 0.47–0.75
15.5 Security** 0.49–1.15
2. Davis et al. (2002) CS 173 US, 1 P 12.58 C SecurityNA 0.70
3. Doyle & Markiewicz (2005) CS 175 Canada, 1 P 17 C Anxiety, avoidance† 0.14, 0.28
LAnxiety,* avoidance* 0.39, 0.32
4. Finnegan et al. (1996), CS, L 173 US, 1 M 12.3 Peer Ambivalence* NA
Hodges et al. (1999) Avoidance NA
5. Granot & Mayseless (2001)aCS 113 Israel, 1 M 10.5 T Security** 0.52
6. Harold et al. (2004) CS 181 UK, 1 P 11.65 C Availability** 0.72
Dependability** 0.61
7. Noom et al. (1999) CS 400 Holland, NA M 15.0 C Security** 0.45
F Security** 0.68
8. Williams & Kelly (2005) CS 116 US, 2 M, F 11–14 T Security 0.22, 0.16
9. Yunger et al. (2005) CS 502 US, 2 M 9–11 Peer Ambivalence* NA
Avoidance NA
Note: For study type: L, longitudinal; CS, cross-sectional. For ethnicity: 1, predominantly Caucasian, 2, majority Caucasian, but some other ethnicities are relatively well represented. AF, attachment figure. For
attachment figure: M, mother; F, father; P, parent. For internalizing symptoms, age is reported in years (range or mean). For symptoms informant: C, child; T, teacher. For comparison: A, avoidant; B, secure;
C, ambivalent; D, disorganized.
aStudies included in more than one category.
†p,.10. *p,.05 **p,.01. ***p,.001.
184

Table 3. Studies of attachment and childhood anxiety
Study Country/
Anxiety
Comparison/
Study Type NEthnicity AF Age Informant Type Association Effect Size
Behavioral measures
1. Bohlin et al. (2000)aL 96 Sweden M 8.75 C S B ,A† 0.34
NA B ,C* 0.41
2. Bosquet & Egeland (2006) L 155 US, 2 M 5–6 M þT S Insecurity 0.24
3. Dallaire & Weinraub (2007) L 1364 US, 1 M 3 M S Security 0.08
6–7 M, F, T Securityns;ns;†0.08, 0.02, 0.14
M 3 M Security** 0.22
6–7 M, F, T Security†;†;ns 0.12, 0.12, 0.02
Dallaire & Weinraub (2005) L 99 US, 1 M 6 I S B ,AþC* 0.50
B,C* 0.47
C vs. A, B vs. A 0.21, 0.39
4. Moss et al. (2006) L 96 Canada M 7–9 C S B ,D* 0.47
NA B ,D, B ,D 0.38, 0.16
5. Shamir-Essakow et al. (2005) CS 104 Australia, 1 M 4.7 Dx. Int. D Security* 0.44
6. Wood (2007) L 31 US, 2 M 4–5 T S Security* 0.82
Representational measures
1. Bohlin et al. (2000)aCS 96 Sweden, NA M 8.75 C S Security† 0.45
Note: For study type: L, longitudinal; CS, cross-sectional. Forethnicity: 1, predominantly Caucasian; 2, majority Caucasian, but some other ethnicities are relatively well represented. AF, attachment figure. For attachment
figure: M, mother. For anxiety, age is reported in years (range ormean). For anxiety informant: M, mother; F, father; C, child; T, teacher; I, interview; Dx. Int., diagnostic interview. For anxiety type: S, symptoms/syndrome;
D, disorder. For comparison: A, avoidant; B, secure; C, ambivalent.
aStudies included in more than one category.
†p,.10. *p,.05.
185

Table 4. Studies of attachment and preadolescent or adolescent anxiety
Study Country/
Anxiety
Comparison/
Study Type NEthnicity AF Age Informant Type Association Effect Size
Behavioral measures
1. Bosquet & Egeland (2006) L 155 US, 2 M 11–12 T, M þTþC S Insecurity 0.22
16 Insecurity** 0.47
17.5 Dx. Int. Insecurity 0.12
Warren et al. (1997) L 172 US, 1 M 17.5 Dx. Int. D C,* A, B 0.41, NA, NA
2. Bar-Haim et al. (2007) L 136 Israel, NA M 11.5 M þCSB,C,* B vs. C 0.33, 0.0–0.27
Representational measures
1. Marsh et al. (2003) CS 123 US, 2 P 15.9 C S Ambivalence† 0.33
Questionnaires
1. Brumariu & Kerns (2008) CS, L 74 US, 1 M 12 C S Security;ns 0.47, 0.14
Ambivalence**;* 0.80, 0.60
Avoidance 0.39, 0.16
2. Costa & Weems (2005) CS 88 US, 2 M 11 M þC S Security*** 0.58
3. Laible et al. (2000) CS 89 US, 2 P 16 C S Security 0.02
4. Larose & Boivin (1997) CS 459 Canada, NA M 17 C S Security 0.18
F Security** 0.39
5. Papini et al. (1991) CS 231 US, 1 M, F 12.8 C S Security NA, NA
6. Papini & Roggman (1992) CS 47 US, 1 M 12.6 C S Securityns;*** 0.58–1.82
F Securityns;*** 0.42 – 1.32
7. Roelofs et al. (2006) CS 237 Holland, 1 M 10.5 C S B ,nonB** NA
FB,nonB*** NA
Note: For study type: L, longitudinal; CS, cross-sectional. Forethnicity: 1, predominantly Caucasian; 2, majority Caucasian, but some other ethnicities are relatively well represented. AF, attachment figure. For attachment
figure: M, mother; F, father; P, parent. For anxiety, age is reported in years (range or mean). For anxiety informant: M, mother; C, child; T, teacher; Dx. Int., diagnostic interview. For anxiety type: S, symptom/syndromes; D,
disorder. For comparison: A, avoidant; B, secure; C, ambivalent.
†p,.10. *p,.05.**p,.01. ***p,.001.
186

Table 5. Studies of attachment and childhood depression
Study Country/
Depression
Comparison/
Study Type NEthnicity AF Age Informant Type Association Effect Size
Behavioral measures
1. Bureau et al. (2009) L 45 US, 1 M 8 C S B vs. nonB 0.01
Disorganization* 0.27
Graham & Easterbrooks (2000) CS 85 US, 1 M 7–9 C S B ,AþCþD** 0.59
A, B, C ,D* NA
B vs. A, B ,C†, B ,D* NA
A,C†, A ,D* NA
2. Moss et al. (2006) L 96 Canada, NA M 7–9 C S B ,D* 0.67
Representational measures
1. Gullone et al. (2006) CS 326 Australia, NZ, NA P 8–10 C S Insecurity*** 0.52
Questionnaires
1. de Minzi (2001) CS 1019 Argentina, NA M, F 8–12 C S Avail.,*** reliance NA
Avail.,*** reliance*** NA
Note: For study type: L, longitudinal; CS, cross-sectional. For ethnicity: 1, predominantly Caucasian. AF, attachment figure. For attachment figure: M, mother, F, father; P, parent. For depression, age is reported in years
(range or mean). For depression informant: C, child. For depression type: S, symptoms/syndromes. For comparison: A, avoidant; B, secure; C, ambivalent; D, disorganized.
†p,.10. *p,.05.**p,.01. ***p,.001.
187

Table 6. Studies of attachment and preadolescent or adolescent depression
Study Country/
Depression
Comparison/
Study Type NEthnicity AF Age Informant Type Association Effect Size
Representational measure
1. Allen et al. (2007) L 167 US, 2 P 13.36, C S Security*** 0.54
14.29, Security** 0.47
15.22 Security*** 0.54
2. Kobak et al. (1991) CS 48 US P 14–18 C S Secure/anx.*** NA
NA 15.7 Rep./preocc.* NA
3. Marsh et al. (2003) CS 123 US, 2 P 15.9 C S Ambivalence** 0.47
Questionnaires
1. Abela et al. (2005) CS 140 US, 1 P 6–14 C, Dx. Int. S Insecurity*** 1
D Insecurity***;** 0.56, 0.60
2. Armsden et al. (1990) CS 97 US, 1 P 10–17 C, Dx. Int. S Security*** 1.25
S Security**;*** 0.80–1.35
3. Cawthorpe et al. (2004) CS 73 Canada, NA P NA Dx. Int. D Angry distress, unavailabilityNA NA
4. Constantine (2006) CS 283 US, 3 P 16–18 C S Security* 0.68–0.77
5. DiFilippo & Overholser
(2000) CS 59 US, 2 M, 15.6 C S Security* NA
F Security NA
6. Essau (2004) CS 1035 Germany, NA P 14.3 Dx. Int. D Security*** NA
7. Harold et al. (2004) CS 181 UK, 1 P 11.65 C S Availability** 1.35
Dependability** 1.32
8. Kenny et al. (1993) CS 207 US, 1 P NA C S Security** 0.85–1.19
9. Laible et al. (2000) CS 89 US, 2 P 16 C S Security* 0.54
10. Papini et al. (1991) CS 231 US, 1 M, 12.8 C S Security*** NA
F Security* NA
11. Papini & Roggman (1992) CS 47 US, 1 M, 12.6 C S Security**;*** 0.82–1.76
F Securityns;*** 0.58–1.71
12. Roelofs et al. (2006) CS 237 Holland, 1 M, 9–12 C S B vs. nonB NA
F 10.5 B ,nonB*** NA
13. Sund & Wichstrøm (2002) L 2360 Norway, NA P 14.9 C S Most secure/least secure**** NA
14. Margolese et al. (2005) CS 134 Canada, 2 M, 16.95 C S Self,* other** NA, NA
F Self, other
15. Wilkinson (2004) CS 2006 Norway, NA P 15.27 C S Security** 0.72
CS 329 Australia, NA P 16.84 C S Security** 0.36
CS 347 Australia, NA P 17.14 C S Security** 0.95
Note: For study type: L, longitudinal; CS, cross-sectional. For ethnicity: 1, predominantly Caucasian; 2, majority Caucasian, but some other ethnicities are relatively well represented; 3, predominantly African American.
AF, attachmentfigure. For attachment figure: M, mother; F, father; P, parent. For depression, age is reported in years (range or mean). For depression informant: C, child, Dx. Int., diagnostic interview. For depression type: S,
symptoms/syndrome; D, disorder. For comparison: B, secure.
*p,.05. **p,.01. ***p,.001.
188

disorganization in infancy and childhood internalizing symp-
toms (Carlson, 1998; Shaw, Keenan, Vondra, Delliquadri, &
Giovannelli, 1997). Carlson (1998) focused exclusively on
disorganization and Shaw et al. (1997) included also secure
attachment, which was not related to internalizing scores at
the age of 5. Based on the same sample, Shaw and Vondra
(1995) reported that insecurity at 18 months, but not at 12
months, was associated with higher rates of internalizing
symptoms at the age of 3. Based on an overlapping sample
but including all four attachment patterns, Vondra, Shaw,
Swearingen, Cohen, and Owens (2001) reported that attach-
ment patterns in infancy were not associated with later inter-
nalizing symptoms. Similar results were reported in the
Stams, Juffer, and van IJzendoorn (2002) longitudinal study.
Some studies based on the Main and Cassidy system or an
equivalent system for preschool and school age children
yielded significant results for attachment. The Booth, Rose-
Krasnor, McKinnon, and Rubin (1994) study showed that at-
tachment security at age 4 years was not related concurrently
with internalizing symptoms, but was negatively associated
with internalizing symptoms at 8 years. The McCartney
et al. (2004) study discussed above showed that concurrent
secure attachment was negatively associated with maternal
and caregiver ratings of internalizing symptoms. Disorga-
nized status was positively related to maternal report but
not caregiver report of internalizing symptoms. Anan and
Barnett (1999) reported that attachment security at the age
4 was not significantly associated with self-reported or
mother-reported internalizing symptoms approximately 2
years later. In the Easterbrooks, Davidson, and Chazan (1993)
article, based on overlapping sample with Lyons-Ruth et al.
(1997), attachment security and avoidance correlated in the
expected directions with concurrent ratings of internalizing
symptoms provided by mothers and teachers. Unfortunately,
the authors did not report any results based on the four attach-
ment classifications, although they were used in other analy-
ses. In Vondra et al. (2001), insecure–other classification at
24 months, but not ambivalent or avoidant classifications,
measured with the Crittenden (1994) scoring system, pre-
dicted internalizing symptoms at the age of 4.
A series of three studies conducted by Moss’ research group
included all four attachment classifications. Attachment pat-
terns, measured between 5 and 7 years, did not relate to chil-
dren’s levels of internalizing symptoms assessed concurrently
(Moss, Parent, Gosselin, Rousseau, & St-Laurent, 1996). Based
on approximately the same sample, Moss et al. (1998) reported
that disorganized children showed more internalizing symptoms
concurrently and 2 years later than the combined A, B, and C
groups and B group alone. Also, avoidant boys had significantly
higher internalizing scores than avoidant girls at the age of 5–7.
In a different study, children with (disorganized) controlling
attachments at ages 5–7 years had significantly higher scores
on internalizing symptoms at the age of 7–9 years than the se-
cure group (Moss et al., 2006). Differences among other attach-
ment groups were not found consistently. In another study that
included all three subcategories reflecting disorganization, con-
trolling–caregiving children showed more internalizing symp-
toms than did the secure children (Moss et al., 2004). No other
contrasts were significant.
In a sample of children aged 18 to 59 months whose
mother received an anxiety disorder diagnosis, the Strange
Situation was coded either with the infant scoring system or
with the preschool scoring system, depending on the age of
the child (Manassis, Bradley, Goldberg, Hood, & Swinson,
1995). Mothers of insecurely attached children reported more
internalizing symptoms shown by their children than did
mothers of securely attached children. Finally, the McCartney
et al. (2004) study was the only one to assess security with the
Attachment Q-Set. Attachment security at age 2 years was
negatively associated with mothers’ and caregivers’ reports
of internalizing symptoms 1 year later.
Attachment representation studies. We identified three stud-
ies using representational measures. One study showed that
security with mother measured with the SAT was negatively
related to mother’s report of children’s internalizing symp-
toms, and marginally, positively related to teacher’s reports
(Easterbrooks & Abeles, 2000). It should be noted that the
sample of this study overlaps with the sample of the Lyons-
Ruth et al. (1997) and Easterbrooks et al. (1993) articles. An-
other study (Miljkovitch, Pierrehumbert, & Halfon, 2007)
showed that none of the four attachment patterns, measured
with the attachment story completion task, was concurrently
associated with mother’s or father’s reports of child’s inter-
nalizing symptoms. Surprisingly, another study, based on
the Manchester Attachment Story Task, showed that more se-
cure children were rated higher on an internalizing scale by
their mothers (Goldwyn et al., 2000). Disorganization was
also associated positively with internalizing symptoms.
Questionnaire studies. El-Sheikh and Buckhalt (2003) re-
ported that attachment to father, but not to mother, measured
with the IPPA, was related to elementary school-age chil-
dren’s internalizing symptoms.
Preadolescent/adolescent internalizing symptoms
The 12 studies of attachment and internalizing symptoms in
preadolescence or adolescence, and the corresponding effects
sizes, are shown in Table 2.
Behavioral observation studies. Carlson (1998) reported that
infants receiving higher disorganization ratings were rated
higher by their teachers on an internalizing scale when they
were in high school.
Attachment representation studies. We identified three stud-
ies in this category. Allen, Moore, Kuperminc, and Bell
(1998) measured attachment using the AAI, and found that
ambivalence, but not security, was related to internalizing
symptoms. Dismissing and hyperactivating scales were not
used in the analyses. This study also included the IPPA. Al-
Parent–child attachment and internalizing symptoms 189

though the authors did not conceptualize the IPPA as measur-
ing attachment, the total score of the IPPA predicted the inter-
nalizing scores in the regression analysis at a trend level.
Granot and Mayseless (2001) measured attachment to mother
with the Doll Story Interview, a version of the Attachment
Story Completion Task (Bretherton et al., 1990) for preado-
lescents. The secure group had fewer teacher-reported inter-
nalizing symptoms compared with the disorganized and
avoidant groups. Brown and Wright (2003), using a version
of the SAT in a mixed clinical and nonclinical sample, found
that adolescents ambivalently attached with parents reported
higher levels of internalizing symptoms than did avoidantly
or securely attached adolescents.
Questionnaire studies. We identified nine questionnaire-
based studies, three of which were based on the Security
Scale. Security with mother (Granot & Mayseless, 2001) or
with parent (Harold, Shelton, Goeke-Morey, & Cummings,
2004) was correlated negatively with adolescents’ internaliz-
ing symptoms. One study found that attachment security with
each parent was not related to sixth to eighth graders’ internal-
izing symptoms (Williams & Kelly, 2005). Two studied were
based on the IPPA questionnaire. Buist, Dekovic
´, Meeus, and
van Aken (2004) reported significant correlations between at-
tachment security and internalizing symptoms at three time
points. Noom, Dekovic
´, and Meeus (1999) reported that at-
tachment security with both mother and father was negatively
associated with adolescents’ internalizing symptoms. Using a
questionnaire developed for their study, Davies, Harold,
Goeke-Morey, and Cummings (2002) found that attachment
security was negatively related to internalizing symptoms.
In the Doyle and Markiewicz (2005) study, two dimen-
sions of attachment to parents, anxiety and avoidance, were
assessed with the Relationship Questionnaire when the partic-
ipants were 13 years old and 3 years later. The attachment di-
mensions were longitudinally but not concurrently related to
adolescents’ internalizing symptoms. Two studies employed
the Coping Strategies Questionnaire to assess the differential
outcomes of ambivalence and avoidance. Controlling for age
and other variables, higher ambivalence but not higher avoid-
ance with mother was related to more peer-reported internal-
izing symptoms both concurrently (for boys only, Finnegan
et al., 1996) and longitudinally (Hodges et al., 1999). Yunger,
Corby, and Perry (2005) replicated the former results in a
larger sample of fifth and sixth graders.
Summary of studies assessing attachment and
internalizing symptoms
Evidence for a relation between attachment and internalizing
symptoms in childhood was mixed. Two of 13 longitudinal
studies (15.38%) indicated significant results, five studies
(38.47%) reported nonsignificant results, and six studies
(46.15%) yielded mixed results (e.g., security was related to
internalizing symptoms when contrasted with only one inse-
cure pattern; security was related to internalizing symptoms
as reported by one informant, but not another, or to internal-
izing symptoms assessed at one age but not another). Three of
nine concurrent studies (33.33%) reported significant results,
two studies reported mixed results (22.22%), three studies
reported nonsignificant results (33.33%), and one study
(11.11%) reported a positive association between security
and internalizing problems. Effect sizes ranged between
low and high regardless of the type of study. The results re-
garding the associations of security with internalizing symp-
toms in preadolescence/adolescence were more consistent,
with the one longitudinal study (100%) and six of eight con-
current studies (75%) yielding significant results, and most
effect sizes ranging from moderate to very high. Because
questionnaires are the most common form of attachment as-
sessment in preadolescence/adolescence, shared method var-
iance may partially account for these results.
Studies that assessed avoidance or ambivalence showed that
neither was consistently associated with internalizing symptoms
in childhood. Of 11 studies that included A and C classifications,
one longitudinal study (9.09%) showed a significant Aversus B
contrast, one longitudinal study (9.09%) yielded mixed results
regarding A versus B contrast, and one longitudinal study
(9.09%) showed that ambivalently attached adolescent boys
but not girls have higher levels of internalizing symptoms
than avoidantly attached boys. One other study yielded mixed
results for avoidance and did not include the C classification.
Although clear patterns did not emerge in childhood, in pre-
adolescence/adolescence one of five studies (20%) reported
a significant concurrent A versus B contrast, and one study
(20%) indicated that avoidance is longitudinally but not con-
currently related to depression. Four of five studies (80%)
found that ambivalence bears a significant relation to internal-
izing symptoms. Note that most of the results regarding am-
bivalence are based on concurrent studies and none of the pre-
adolescent/adolescent studies supporting an association
between ambivalence and internalizing symptoms assessed
disorganization. In those studies where it was assessed, there
was some evidence that disorganization entails a greater risk
for developing internalizing symptoms than other attachment
patterns (6 of 11 studies [54.55%] of childhood yielded signif-
icant results and two studies reported mixed results [18.18%];
two of two studies [100%] of preadolescence/adolescence
found significant results for disorganization).
The role of fathers in the development of internalizing
symptoms has been neglected as most studies focused on
attachment to mothers only (for exceptions, see El-Sheik
& Buckhalt, 2003; Noom et al., 1999; Williams & Kelly,
2005). Few studies of internalizing problems included a
representational measure to assess attachment. Future
studies should incorporate multiple measures, assessing
different aspects of attachment (attachment behavior,
representations, and perceptions of attachment) to evaluate
the consistency of the results. Null effects of internalizing
symptoms in childhood are difficult to explain as they were
reported in both concurrent and longitudinal studies, small
and large samples, and preschool or elementary school age.
L. E. Brumariu and K. A. Kerns190

The inconsistent findings may be partially due to the diversity
of symptoms assessed with global measures of internalizing
symptoms. In the following sections, we evaluate whether
attachment relates specifically to anxiety or depression.
Studies of the Associations Between Attachment
and Anxiety
Childhood anxiety
The six studies investigating attachment to mother and anxi-
ety in children under age 10, and the corresponding study ef-
fect sizes, are included in Table 3.
Behavioral observation studies. AsshowninTable3,sixstud-
ies in childhood included observational assessments of attach-
ment, five of which are longitudinal. Two studies used the
Strange Situation procedure for infants, two employed its pre-
school version, one used both measures, and one used the At-
tachment Q-Set. Bohlin, Hagekull, and Rydell (2000) found
that children who were secure as infants, compared to those
who had been insecure (ambivalent or avoidant), reported lower
levels of social anxiety symptoms at the age of 9 years old. Dal-
laire and Weinraub (2005), based on a subsample from the
NICHD Study of Early Child Care, reported that insecurely at-
tached children showed more separation anxiety at the age of 6
than did securely attached children. In a larger sample of partic-
ipants from the same study, attachment security in infancy or at
the age 3 was not related to a general measure of child anxiety
symptoms at first grade (Dallaire & Weinraub, 2007). Based on
an economically high-risk sample, Bosquet and Egeland (2006)
also found no direct association between an insecure attachment
history in infancy and an aggregate score of anxiety measured in
kindergarten and first grade. Moss et al. (2006) reported that
children with (disorganized) controlling attachments rated
themselves higher on separation anxiety, but not on overanxiety
or simple phobia, than did securely attached children. The Sha-
mir-Essakov, Ungerer, and Rapee (2005) study of preschoolers
drawn from a behavioral inhibition prevention program is the
only study that assessed the presence of an anxiety disorder. In-
secure attachment was associated with the sum of the number of
anxiety disorders for which a child met criteria. Wood (2007)
reported that security assessed with the Attachment Q-Set at
age 3 was associated with preschool anxiety.
Attachment representation studies. The Bohlin et al. (2000)
study also measured concurrent attachment security with
the SAT when children reached the age of 9 years old and re-
ported that overall security was marginally associated with
social anxiety.
Preadolescent/adolescent anxiety
The 10 studies investigating the relation between attachment
and anxiety in children 10–18 years, as well as the corre-
sponding effect sizes, are included in Table 4.
Behavioral observation studies. The two longitudinal studies
in this category assessed attachment to mother with the
Strange Situation. Two articles are based on the same Minne-
sota Longitudinal Study of Parents and Children. Attachment
insecurity in infancy was not directly related to anxiety symp-
toms at sixth grade or at age 17.5 years, but was associated with
anxiety at age 16 (Bosquet & Egeland, 2006). Ambivalence,
but not security or avoidance, was positively and longitudi-
nally related to the number of anxiety disorder diagnoses (War-
ren, Huston, Egeland, & Sroufe, 1997). The Bar-Haim, Dan,
Eshel, and Sagi-Schwartz (2007) study included only partic-
ipants who were securely or ambivalently attached in infancy.
At 11 years, children who were ambivalently attached in in-
fancy had higher scores on school phobia, but not on the total
anxiety score or other types of anxiety symptoms, compared
with children who were securely attached.
Attachment representation studies. Marsh, McFarland, Allen,
McElhaney, and Land (2003) used only scores of ambiva-
lence with parents derived from the AAI in a sample of ado-
lescents experiencing academic difficulties. There was a sta-
tistical trend for the relation between ambivalence and
anxiety symptoms, which became nonsignificant after ac-
counting for the effect of demographic factors.
Questionnaire studies. Seven studies that used questionnaires
to assess attachment were identified, five of which relied on
the IPPA and assessed the relations concurrently. Costa and
Weem (2003) reported that attachment security with mother
was negatively associated with anxiety. Three studies as-
sessed security with mother and father separately using the
IPPA (Larose & Boivin, 1997; Papini & Rogman, 1992; Pa-
pini, Roggman, & Anderson; 1991). The results for attach-
ment to mother and father were similar, with effect sizes rang-
ing from small to very high. One other study based on the
IPPA assessed attachment security with the parent who has
the most influence on the child and found no significant rela-
tion with self-reported anxiety (Laible, Carlo, & Raffaelli,
2000). In one study, the Relationship Questionnaire for Chil-
dren was used to assess attachment security (Roelofs, Mee-
ster, ter Huurne, Bamelis, & Muris, 2006). Preadolescents
insecurely attached to mother or father reported higher anxi-
ety than did securely attached preadolescents. In one study,
using the Security Scale and the Coping Strategies Question-
naire to assess the relations of past and concurrent security,
ambivalence, and avoidance with social anxiety, ambivalence
was the attachment pattern most consistently associated with
social anxiety (Brumariu & Kerns, 2008).
Summary of studies assessing attachment and anxiety
Overall, these results provided some support for the hypothesis
that attachment security is associated with lower levels of anx-
iety in childhood and preadolescence/adolescence. As shown
in Table 3, two of five longitudinal studies (40%) of childhood
anxiety indicated marginallysignificant or significant findings,
Parent–child attachment and internalizing symptoms 191

two longitudinal studies (40%) provided mixed results, and
one study (20%) reported nonsignificant results. Two concur-
rent studies (100%) reported marginally significant or signifi-
cant findings. Regarding preadolescent/adolescent anxiety,
two of three longitudinal studies (66.66%) yielded mixed re-
sults and one (33.33%) yielded nonsignificant results. Four
of seven concurrent studies (57.15%) yielded consistently sig-
nificant results, one study (14.28%) reported mixed results,
and two studies (28.57%) reported nonsignificant results.
The majority of significant effect sizes fell between the lower
range of a medium effect size and a high effect size.
For the specific insecure patterns, two longitudinal studies
(100%) of childhood anxiety found a significant B versus C
contrast. For ambivalence, two of three longitudinal studies
(66.66%) of preadolescent/adolescent anxiety reported sig-
nificant results and one study (33.33%) provided mixed
results. Two concurrent studies (100%) of preadolescent/
adolescent anxiety reported significant or marginally signifi-
cant results. For avoidance, one of two longitudinal studies of
childhood anxiety (50%) yielded marginally significant
results, and one study (50%) reported nonsignificant results,
whereas two longitudinal studies of preadolescent/adolescent
anxiety (100%) reported nonsignificant results. For disorga-
nization, the one study of childhood anxiety provided mixed
results. Because none of the studies of preadolescence/
adolescence included a measure of disorganization, studies
assessing this attachment pattern are desirable. Studies
assessing attachment to father are also needed.
Notably, research assessing the links between attachment
and childhood anxiety relies on behavioral observation mea-
sures of attachment. Given that observational measures of at-
tachment have not been validated for children over the age of
7, studies including other attachment measurement approaches
are needed to provide a comprehensive picture of the relation
between attachment and childhood anxiety. A limitation of
findings regarding preadolescent/adolescent anxiety is that
most studies utilized adolescent self-reports for both attach-
ment and anxiety, which increases the risk of inflated correla-
tions. There is a critical need for studies assessing anxiety and
children’s attachment representations in adolescence.
Studies of the Associations Between Attachment
and Depression
Childhood depression
The four studies of attachment and depression in childhood,
and the corresponding effect sizes, are described in Table 5.
Behavioral observation studies. Two papers are based on the
same sample at economic risk, which also overlaps with the
sample of the Lyons-Ruth et al. (1997), Easterbrooks et al.
(1993), and Easterbrooks and Abeles (2000) articles. Disor-
ganization, but not secure/insecure classification in infancy,
was related to depression at early school age (Bureau, Easter-
brooks, & Lyons-Ruth, 2009). At ages 7–9 years, securely at-
tached children reported concurrently fewer symptoms of de-
pression than did insecurely attached children, when the three
insecure classifications were combined (Graham & Easter-
brooks, 2000). When analyzed separately, differences were
found between children with secure and children with am-
bivalent or disorganized attachment, but not between children
with secure or avoidant attachments. In addition, controlling
(disorganized) preschoolers reported the highest levels of de-
pression. Similarly, Moss et al. (2006) reported that control-
ling children reported higher levels of depression than did se-
cure children. No other attachment groups were included in
the analyses.
Attachment representation studies. The only study in the lit-
erature, based on family drawings, indicated that attachment
insecurity with parent was positively correlated with self-re-
ported depression (Gullone, Ollendick, & King, 2006).
Questionnaire studies. De Minzi (2006) found that father’s
availability and reliance, and mother’s availability, measured
with the Security Scale, were associated with children’s de-
pression.
Preadolescent/adolescent depression
The 18 studies of attachment and depression in adolescence
and the corresponding effect sizes are included in Table 6.
Attachment representation studies. The three studies in this
category used the AAI to assess attachment. In a study of ado-
lescents assessed at three time points at the ages of 13, 14, and
15, attachment security, measured between Waves 2 and 3,
correlated negatively with self-reported depression at all three
time periods (Allen, Porter, McFarland, McElhaney, &
Marsh, 2007). Marsh and colleagues (2003) reported that
adolescent ambivalence was related to self-reported symp-
toms of depression. In a sample selected for elevated depres-
sive symptoms, the secure/anxiety attachment dimension was
associated with depression concurrently and 10 months prior
to the AAI Q-Set assessment (i.e., higher security related to
lower depression), whereas the repression/preoccupation
dimension was associated positively with concurrent depres-
sion only (Kobak, Sudler, & Gamble, 1991).
Questionnaire studies. We found 15 studies using question-
naires, nine of which relied on the IPPA to assess attachment.
Three studies separately assessed attachment to mothers or fa-
thers using the IPPA. Whereas two studies indicated that se-
curity with mother and father was negatively related to de-
pression (Papini et al., 1991, 1992), one study found that
security with mother, but not with father, was related to
self-reported depression in a sample of adolescent psychiatric
inpatients (DiFilippo & Overholser, 2000).
Six of the IPPA-based studies did not differentiate be-
tween attachment to mother and attachment to father, but as-
sessed attachment to parents in general or to the parent who
L. E. Brumariu and K. A. Kerns192

most influenced the child, or reported the composite sum of
attachment to mother and father. Two of these studies re-
ported a significant negative relation between attachment se-
curity and depression (Constantine, 2006; Laible et al., 2000).
In another study, when attachment scores were divided in four
quartiles varying from most secure to least secure, each quar-
tile increment in insecure attachment increased the odds of re-
porting more severe depression by 36% (Sund & Wichstrøm,
2002). Notably, three studies based on the IPPA examined the
presence of a diagnosis. Abela et al. (2005) reported signifi-
cant associations between attachment insecurity with parents
and current self-reported levels of depression, a current diag-
nosis of depression, and current severity of depression, in a
sample of offspring of parents with a history of depression.
No relations were found between attachment insecurity and
past diagnosis of depression or past severity of depression.
In the Armsden, McCauley, Greenberg, Burke, and Mitchell
(1990) study, depressed adolescents reported less secure at-
tachment than did children with other psychiatric conditions
and children without a psychiatric condition. The level of
attachment security of adolescents with resolved depression
was similar to that of the nonpsychiatric control group.
Among all psychiatric patients, security scores correlated
negatively with ratings of the severity of children’s depres-
sion based on parent and child interview as well as with chil-
dren’s self-reported depression, with higher associations for
the week of evaluation than for the depressive episode as a
whole. Similarly, Essau (2004) reported that attachment se-
curity was lower among depressed ( pure or comorbid) adoles-
cents than among adolescents without a psychiatric disorder.
One study employed the Adolescent Attachment Question-
naire to assess security with parents in a sample of inpatient fe-
males (Cawthorpe, West, & Wilkes, 2004). The attachment in-
security variables (angry distress and unavailability) had higher
scores for the group with a depressive disorder than for the
group with other disorders. Two studies used the Relationship
Questionnaire. Whereas one study reported that higher levels of
insecure attachment (i.e., more negative models of self and
others) in relation with mother, but not with father, was related
to greater depression (Margolese, Markiewicz, & Doyle,
2005), the other study found that children insecurely attached
to father, but not to mother, displayed higher levels of depres-
sion than securelyattached children (Roelofs et al., 2006). One
study employed the Security Scale and reported a negative
relation between attachment security and self-reported depres-
sion (Harold et al., 2004). Kenny, Moilanen, Lomax, and
Brabeck (1993) reported a negative relation between the three
subscales of the Parental Attachment Questionnaire and de-
pression. Finally, Wilkinson (2004) found that attachment
security, measured with a scale designed for this study, was neg-
atively associated with depressive symptoms in adolescence.
Summary of studies assessing attachment and depression
Collectively, the results provide evidence that attachment se-
curity relates to childhood depression, with three of four
available effect sizes in the medium range. Nonetheless,
this evidence is based on a total of only four studies, with
one of two longitudinal studies (50%) and two concurrent
studies (100%) yielding significant results. The lack of stud-
ies assessing the links between attachment and childhood
depression may be due to the rarity of depression (as a diag-
nosis) in young children (Hammen & Rudolph, 2003). How-
ever, some children do receive a diagnosis of depression in
childhood or experience symptoms of depression, which in-
crease the risk for future diagnosis of depression (Hammen
& Rudolph, 2003). Further, studies assessing a relation be-
tween other risk or protective factors and childhood depres-
sion exist in the literature (e.g., parenting, negative cogni-
tions, stress; see Garber & Hilsman, 1992; Rapee, 1997),
suggesting that the low prevalence rate of depression at this
age is not a viable explanation for the scarcity of studies fo-
cusing on the links with attachment. All studies of preadoles-
cence/adolescence, 2 longitudinal and 16 concurrent, found a
consistent relation between attachment security and depres-
sion, at both symptom and diagnosis levels, with all available
effect sizes in the high and very high range. However, be-
cause both attachment and depression were assessed concur-
rently with questionnaires in several studies, some findings
regarding symptoms of depression may be inflated because
of shared method variance and the possible impact of de-
pressed mood on reports of parent–child attachment.
Further, two studies found that disorganization relates con-
currently and longitudinally to childhood depression, and one
study reported that ambivalence is concurrently associated
with preadolescent/adolescent depression. Overall, these
findings point to the need for more studies based on ap-
proaches that include assessments of all insecure attachment
patterns. Attachments to both parents have been assessed
only in preadolescence/adolescence, although it should be
noted that there are very few studies and they included ques-
tionnaires evaluating these associations. Studies are needed to
further explore the consistency of the relation between attach-
ment to both parents and depression. There are few longitu-
dinal studies that raise concerns about the causal link between
attachment and depression. Is depression a product of attach-
ment, or does depression color one’s perceptions of attachment
relationships (e.g., Roisman, Fortuna, & Holland, 2006)?
Future studies should clarify this issue.
General Discussion of Findings
How consistent is the evidence that attachment security or
insecurity is linked to internalizing symptoms, anxiety, and
depression?
The reviewed studies revealed that attachment security is
more consistently, although modestly, related to anxiety and
depression than to global internalizing symptoms. The asso-
ciations are stronger in preadolescence/adolescence than in
childhood. Although the current findings are to some extent
consistent with Bowlby’s (1973, 1980) hypothesis that inse-
Parent–child attachment and internalizing symptoms 193

curity is positively associated with internalizing problems,
particularly anxiety and depression, to conclude that attach-
ment is a causal factor for internalizing problems, strong lon-
gitudinal support is needed, and the available data provide
mixed support for this hypothesis. Most effect sizes were in
the medium to large range, which is not surprising, given
that this review is based on the published literature. As ex-
pected, the effect sizes are generally higher for the studies
based on questionnaires than for the studies based on behav-
ioral or representational measures of attachment.
There is variability in the use of attachment measurement
approaches across studies. For example, whereas behavioral
observation measures are relatively well represented among
studies of childhood anxiety and internalizing symptoms,
with few exceptions (e.g., Bosquet & Egeland, 2006), they
are almost nonexistent among studies of adolescent internal-
izing symptoms, adolescent anxiety, and childhood and ado-
lescent depression. Future literature could benefit from longi-
tudinal studies of the association between secure attachment
behavior in childhood and adolescent internalizing symp-
toms. Studies of children’s attachment representations are
rare, regardless of the type of internalizing symptoms as-
sessed. Attachment questionnaires are the most employed as-
sessment procedure in studies evaluating adolescents’ inter-
nalizing symptoms. There is a need for additional studies
using other methods of assessing attachment to avoid capital-
izing on shared method variance and response biases that in-
flate associations when questionnaires are used to measure
both attachment and internalizing symptoms. Finally, be-
cause mood can influence the recollection of attachment re-
lated events (Roisman et al., 2006), longitudinal studies that
control for initial levels of internalizing symptoms may disen-
tangle the possible bidirectional effects between attachment
and internalizing symptoms.
How consistent is the evidence that some specific forms
of insecurity are more strongly related than others
to internalizing symptoms, anxiety, and depression?
Although a definitive conclusion cannot be reached, two con-
sistent patterns have emerged, depending on how many at-
tachment patterns/dimensions were assessed in a particular
study (three vs. four). Studies that included A and C classifi-
cations or their corresponding dimensions, but not D classifi-
cation, found that ambivalence poses a higher risk for preado-
lescence/adolescence internalizing symptoms and anxiety
than do other patterns of attachment. There are too few studies
to evaluate these associations with depression. Avoidance
was not consistently associated with internalizing symptoms,
although it was related to internalizing symptoms in at risk
samples (e.g., Goldberg et al., 1995; Lyons-Ruth et al., 1997).
When disorganization was assessed, ambivalence was less
consistently associated with internalizing problems. Several
studies showed that disorganization was related to internalizing
symptoms (e.g., Carlson, 1998, Granot & Mayseless, 2001;
Moss, Cyr, et al., 2004; Moss et al., 1998, 2006; Shaw et al.,
1997) or depression (Bureau et al., 2009; Graham & Easter-
brooks, 2000), although there were some exceptions (Lyons-
Ruth et al., 1997; Stams et al., 2002). Comparing different
subtypes of disorganized attachment, it has been found that
controlling–caregiving children show more anxiety than con-
trolling–punitive or insecure–other children (Moss, Cyr, et al.,
2004). Overall, the results for disorganization indicate moderate
effect sizes.
However, caution is recommended when interpreting
these findings. As already noted, few studies assessed the in-
secure patterns, and most of these studies examined internal-
izing symptoms rather than specifically anxiety or depression.
For example, only one study evaluated the relation of disorga-
nization with anxiety (Moss et al., 2006), and only two stud-
ies examined the relation of disorganization with depression
in childhood (Graham & Easterbrooks, 2000; Moss et al.,
2006; see also Bureau et al., 2009). No study investigated
the relations of disorganization, compared with other attach-
ment patterns, to anxiety or depression in adolescence. This
review evaluates direct links between attachment and inter-
nalizing problems. It should be noted that few longitudinal
studies adjusted for the effects of earlier levels of internaliz-
ing problems (see Doyle & Markiewicz; 2005; Hodges
et al., 1999), and thus little is known about whether the inse-
cure attachment patterns predict changes in internalizing
problems across childhood. In addition, the question of how
changes in attachment predict changes in internalizing symp-
toms also has not been investigated.
Available research fails to validate Finnegan et al.’s (1996)
hypothesis that only ambivalence is consistently related to in-
ternalizing symptoms. The findings provide some support for
Carlson and Sroufe’s (1995) hypothesis that ambivalence ra-
ther than avoidance is related to anxiety, but only when the
ABC classifications are considered and when anxiety is as-
sessed in adolescence. The available data are insufficient to
draw a conclusion regarding Egeland and Carlson’s (2004)
proposal that all insecure attachment patterns are related to de-
pression. Manassis’ (2001) hypothesis that different attach-
ment patterns relate to specific anxiety symptoms/disorders
is especially difficult to evaluate as few studies assessed dif-
ferent types of anxiety, and they yielded mixed results. Future
research could investigate whether insecure attachment pat-
terns predict specific anxiety symptoms/disorders, especially
those that arise at each developmental stage (e.g., if attach-
ment is relevant to separation anxiety in childhood and to
panic or obsessive compulsive disorder in adolescence).
One of the biggest gaps in the literature is studies evaluating
whether different insecure attachment patterns are differen-
tially related to different internalizing problems.
Are associations with internalizing symptoms, anxiety,
and depression consistent for mother–child and father–
child attachment?
Although some attachment measures assess an individual’s
state of mind toward attachment and reflect experiences in
L. E. Brumariu and K. A. Kerns194

multiple relationships, others are designed to assess sepa-
rately attachment to mothers and fathers. Of those studies as-
sessing attachment to a specific parent, most assessed only at-
tachment to mother and indicated significant relations, as
noted above. Assessing attachment to both parents is the ex-
ception rather than the norm of available research. One study
showed that father–child attachment, but not mother–child at-
tachment, was related to childhood internalizing symptoms
(El-Sheikh & Buckhalt, 2003), one study showed that both at-
tachments to mother and father were associated with internal-
izing symptoms in adolescence (Noom et al., 1999), and one
study showed that attachments to mother or father were not re-
lated to internalizing symptoms in adolescence (Williams &
Kelly, 2005). Whereas no studies of childhood anxiety as-
sessed attachment security or insecurity to fathers, four stud-
ies of adolescent anxiety included assessments of attachment
to both father and mother. One showed that the effect sizes are
relatively small and similar (Larose & Boivin, 1997), another
study showed that the effect sizes are moderate to high for
both attachment to mother and father (Papini & Roggman,
1992), and two studies indicated that both attachment to
mother and father are associated with adolescent anxiety (Pa-
pini et al., 1991; Roelofs et al., 2006). The one study of child-
hood depression showed that attachment to both father
and mother was related to childhood depression (De Minzi,
2006). Studies assessing adolescent depression revealed
mixed results. Two studies of adolescent depression reported
no relation to father–child attachment, but significant rela-
tions to mother–child attachment (DiFilippo & Overholser,
2000; Margolese et al., 2005), one study showed a relation
to father–child attachment but not to mother–child attachment
(Roleofs et al., 2006), and two studies reported similar rela-
tions to attachment to both parents, with the influence of at-
tachment to father increasing overtime (Papini et al., 1991;
Papini & Roggman, 1992).
Overall, there has been little consideration of the role of at-
tachment to father, comparing to attachment to mothers, in
the development of internalizing symptoms. Almost all stud-
ies with fathers included adolescents, and therefore, we have
limited knowledge of the associations of father–child attach-
ment with childhood internalizing symptoms. In addition,
studies with fathers employed only questionnaires (child
self-report) to assess father–child attachment. Although evi-
dence is somewhat mixed and limited, these findings suggest
that attachments to fathers have a comparable impact to at-
tachments to mothers on the development of adolescent inter-
nalizing symptoms.
In many cultures, societal norms have emphasized the
caregiver roles of mothers and the breadwinner and playmate
roles of fathers. Given mothers’ greater involvement in their
children’s lives, one may expect that attachment to mother
may influence the development of internalizing symptoms
more strongly than does attachment to father. Indeed, theories
of familial influences on child development reflect this view
by emphasizing the importance of the quality of the mother–
child relationship and almost ignoring the role of fathers
(Lamb, 1997; Verschueren & Marcoen, 2005). Alternatively,
research has shown that fathers have a unique influence on
many areas of child development. For example, it has been
found that attachment to father affects children’s responses
to novel situations and peer acceptance (Lamb, 1982). Fur-
ther, father’s involvement in children’s lives has been associ-
ated with an internal locus of control and social competence
(Amato, 1994). Therefore, it is possible that attachment to fa-
ther, in addition to attachment to mother, may be relevant for
internalizing symptoms when children face changes in their
social life that require social competences to make successful
adjustments. For example, attachment to father may be espe-
cially relevant when children enter larger groups, or experi-
ence disruption in previous friendships and develop new
friendships, which can occur with the changing of schools
as children enter middle school or high-school (Hardy, Bu-
kowski, & Sippola, 2002). Future research has the task of
evaluating these hypotheses.
Moderators of the Relations Among Attachment and
Internalizing Symptoms, Anxiety, or Depression
The modest association between attachment and internalizing
problems is not surprising, given that insecure attachment, by
itself, will not invariably lead to anxiety or depression. In-
deed, from a developmental psychopathology perspective,
any factor may produce different effects depending on the cir-
cumstances under which it functions (the principle of multi-
finality, Cicchetti & Cohen, 1995). For example, Cummings
and Cicchetti (1990) proposed a transactional model of child-
hood/adolescent depression in which the effects of insecure
attachment depend on potentiators (“factors increasing the
probability of insecure attachment leading to depression”)
and compensators (“factors decreasing the chances of devel-
opment of depression”). Thus, attachment may be consis-
tently associated with internalizing problems only in the
presence of other risk factors.
A limited number of studies have assessed other factors (i.e.,
moderators) that might identify the conditions under which at-
tachment is related to internalizing symptoms, anxiety, and de-
pression. Alternatively, some researchers conceptualized attach-
ment as a moderator (Easterbrooks et al., 1993; El-Sheikh &
Buckhalt, 2003; Graham & Easterbrooks, 2000; Gullone et al.,
2006; NICHD, 2006). Researchers have proposed eight factors
that may moderate the relation of attachment with internalizing
symptoms. Specifically, it has been hypothesized that insecurely
attached children who also experience high levels of stress
(Dallaire & Weinraub, 2007), poor parenting (Marsh et al.,
2003; NICHD, 2006), low autonomy (Noom et al., 1999), eco-
nomic risk (Easterbrooks et al., 1993; Graham & Easterbrooks,
2000), behavioral inhibition, or other temperamental characteris-
tics (Burgess et al., 2003; Shamir-Essakov et al., 2005) or those
who exhibit excessive reassurance seeking (Abela et al., 2005)
would show greater internalizing symptoms, anxiety, or depres-
sion than those who do not experience these risk factors. In ad-
dition, it has been hypothesized that a secure parent–child attach-
Parent–child attachment and internalizing symptoms 195

ment would be a protective factor in the association between pa-
rental problem drinking and children’s internalizing symptoms
(El-Sheikh & Buckhalt, 2003), that the buffering effect of attach-
ment on anxiety or depression may be moderated by children’s
pubertal status (Papini et al., 1991), and that the relation between
attachment and depression would be stronger for girls than for
boys (DiFilippo & Overholser, 2000).
Evidence supporting these hypotheses is inconsistent, and
based on a limited number of studies. Although one study
showed that attachment security at 15 months but not at 36
months interacted with stress to predict mothers’ and teacher’s
reportsof child anxiety(Dallaire & Weinraub, 2007), two other
studies indicated that the interaction between attachment and
stress was not related to childhood internalizing symptoms
(Bates et al., 1985) or adolescent depression (Sund & Wich-
trøm, 2002). In the NICHD (2006) study, the mean of parenting
quality over the first years of life, but not changes in parenting
quality, interacted with attachment to predict mother reported
but not teacher reported internalizing problems in childhood.
Parenting quality was more strongly related to internalizing
symptoms for children with secure attachment than for children
with ambivalent or disorganized attachments. Marsh et al.
(2003) found that ambivalence was more strongly related to
anxietyand depression in adolescence when mothers displayed
low levels of autonomy in interactions with their adolescents,
whereas Noom et al. (1999) reported that adolescents’ attitudi-
nal autonomy did not moderate the relation between attachment
securityand internalizing symptoms. Easterbrooks et al. (1993)
found that economic risk did not moderate the relation of attach-
ment with internalizing symptoms in childhood. By contrast,
Graham and Easterbrooks (2000) found that insecure children
at higher economic risk had higher levels of depression than in-
secure children at lower economic risk. Four studies showed
that behavioral inhibition or difficult temperament failed to
moderate the relations of attachment to childhood internalizing
symptoms (Bates et al., 1985; Burgess et al., 2003; Stams et al.,
2002) and childhood anxiety (Shamir-Esakov et al., 2005), al-
though one study indicated that the interaction effect between
social withdrawal and attachment was associated with child-
hood depression (Gullone et al., 2006). Abela et al. (2005) re-
ported that children who exhibited high levels of both insecure
attachments and excessive reassurance seeking experienced
higher levels of depression than did children experiencing
only one or neitherof these risk factors. El-Sheikh and Buckhalt
(2003) reported that the interaction effect between security and
parental drinking problems did not predict children’s internaliz-
ing symptoms, and Papini et al. (1991) showed that pubertal
status did not moderate the relations of attachment with anxiety
or depression in adolescence.
Although many studies used gender as a covariate, very few
studies further investigated whether attachment was associated
with internalizing symptoms differently for boys and girls.
Some studies showed that the relations of attachment security/
insecurity (or insecure attachment patterns) with childhood in-
ternalizing symptoms (Anan & Barnet, 1999; Shaw et al.,
1997; see also Goldberg et al., 1995; Noom et al., 1999),
childhood anxiety (Bohlin et al., 2000), adolescent anxiety
(Bar-Haim et al., 2007; Larose, & Boivin, 1997), and adolescent
depression (DiFilippo & Overholser, 2000; Sund & Wichstrom,
2002) were similar for girls and boys (for an exception on social
anxiety see Bar-Haim et al., 2007). One study reported a relation
between attachment classification and childhood internalizing
symptoms for boys only, with securely attached boys scoring
the lowest and ambivalently attached boys scoring the highest
(Lewis et al., 1984), and one study showed a relation between
avoidant attachment and internalizing symptoms for boys only
(Moss et al., 1998). However, Moss and colleagues (1998)
also reported no significant effects for the interactions of am-
bivalence or disorganization with gender. One study indicated
a stronger relation of attachment security and adolescent depres-
sion for girls than for boys (Allen et al., 2007) and another study
showed a stronger relation for boys than for girls (Kenny et al.,
1993). Thus, gender did not consistently moderate associations
between attachment and internalizing symptoms.
Although no specific hypotheses were offered, a few other
studies have examined potential moderators (i.e., included the
interaction term in the statistical analyses). These studies ex-
amined child age (Hodges et al., 1999; Moss, Cyr, et al.,
2004; NICHD, 2006; Noom et al., 1999), health status (Gold-
berg et al., 1995), mental development (Lyons-Ruth et al.,
1997), or parental depression (Graham & Easterbrooks, 2003).
None of these factors showed moderation effects.
In sum, despite interest regarding how other risk factors
might increase the likelihood that insecure attachment will
be associated with internalizing problems, the available
data indicate that no moderator consistently affects the direc-
tion or strength of the relations between attachment and inter-
nalizing symptoms, anxiety, or depression. It may be that the
number of risk factors combined with insecure attachment is
more important than experiencing attachment insecurity in
combination with a specific risk factor.
Attachment and Internalizing Symptoms: Etiological
Models
Although secure attachment was associated with lower
levels of internalizing symptoms, our review was inconclu-
sive regarding a link between specific insecure attachment
patterns and internalizing problems. Thus, insecure attach-
ment may be a general risk factor for internalizing prob-
lems. In this last section, our goal is to embed attachment
within a broader framework to generate hypotheses regard-
ing how insecure attachment might, in combination with
other risk factors, be related to internalizing symptoms.
Considering other risk factors may allow for testing poten-
tial pathways from attachment to internalizing symptoms.
One possibility is that insecure attachment is a direct cause
of later internalizing symptoms (i.e., lack of a secure base
leads to feelings of depression and anxiety). Alternatively,
links between attachment and internalizing problems may
be indirect, in that these relations are mediated or explained
by other factors.
L. E. Brumariu and K. A. Kerns196

We were able to locate only six studies that tested specific
mediators. Two studies showed that perceived social support
explained the relations of attachment with internalizing symp-
toms (Anan & Barnett; 1999; Larose & Boivin, 2001). Note
that social support has a strong conceptual overlap with attach-
ment. Another study found that attachment security affects
childhood anxiety through effects on emotion regulation, and
adolescent anxiety through effects on competence and peer re-
lationships (Bosquet & Egeland, 2006). Regarding depression,
one study indicated that negative cognition but not ruminative
coping mediated the relation between attachment security and
depression (Margolese et al., 2005, for girls only), and two
studies showed that the view of the self or self-esteem explain
this relation (Kenny et al., 1993; Wilkinson, 2004). Although
small in number, these studies suggest that it may be important
to examine other factors that can account for links between at-
tachment and internalizing problems.
To advance research in this area, we propose two models of
how attachment may be related to, respectively, anxiety and de-
pression. In these models, we include other known risk factors
for anxiety and depression and propose specific mediators.
DeKlyen and Greenberg (2008) proposed that insecure attach-
ment may combine with high family adversity, ineffective par-
enting, and atypical child characteristics in predicting psychopa-
thology, including internalizing symptoms. Although general
models are important for identifying risk factors, they offer little
guidance regarding which specific factors may contribute to
one form of psychopathology rather than another. We elaborate
and expand on DeKlyen and Greenberg’s suggestions by iden-
tifying potential moderators and mediators of the relations be-
tween attachment and internalizing symptoms, and proposing
specific pathways from attachment to anxiety and depression.
For example, although ineffective parenting is linked to both
anxiety and depression, parental excessive control may be
more strongly related with anxiety, whereas parental rejection
may be more strongly related to depression (Rapee, 1997). Al-
though there are gender differences in the rates and prevalence
of internalizing problems by adolescence (Albano et al., 2003;
Hammen & Rudolph, 2003), we did not find consistent results
supporting the notion that gender may be a potential moderator
of associations between attachment and internalizing problems,
and therefore we did not include gender in these models.
Prior models of internalizing symptoms delineate common
risk factors for anxiety and depression, such as parenting prac-
tices (e.g., parental rejection or overcontrol), temperament (e.g.,
negative emotionality), parent’s psychopathology, and stressful
life events (e.g., Rapee, 1997; Seligman & Ollendick, 1998),
which may explain the comorbidity of anxiety and depression
and/or the presence of internalizing symptoms. Even when mod-
els of internalizing symptoms have included attachment as a risk
factor, they have rarely identified mechanisms that may explain
the relations of attachment with internalizing symptoms/disor-
ders. Our models extend earlier work by specifying three child
characteristics that may explain links between attachment and
child internalizing symptoms: cognitive biases, difficulty with
emotions, and self-concept. Cognitive biases refer to inaccurate
beliefs, interpretations, attributions, or expectancies in relation to
specific events. Emotional problems include impairments in
identifying and understanding emotional states and adoption
of less constructive coping strategies. Self-concept refers to
one’s perceived efficacy and self-worth. All three child charac-
teristics have been associated with both anxiety and depression
(e.g., Abela & Hankin, 2008; Compas, Connor-Smith, Saltz-
man, Thomsen, & Wadsworth, 2001; Durbin & Shafir, 2008;
Southam-Gerow & Kendall, 2002; Vasey & MacLeod, 2001),
and all three are shaped (in part) through early relationships
and interactions with parents (e.g., Dadds, Barrett, Rapee, &
Ryan, 1996; Thompson, 2001; Thompson & Meyer, 2007).
Pathways to anxiety are likely to start with dysfunctional
parent–child relationships (Figure 1). Specifically, transac-
tions between insecure attachment and overcontrolling and
overprotective parenting may lead to thoughts of physical
or psychological threat, perceived lack of control, and vigilant
attention to threat (Chorpita & Barlow, 1998; Thompson,
2001; Vasey & MacLeod, 2001; Weems & Silverman, 2006).
Lack of open communication regarding emotion and an
inability to rely on the parent for comfort may lead to the child
developing difficulties in monitoring, appropriately expres-
sing, or understanding emotions as well as the use of avoid-
ance rather than problem solving as a coping strategy (Barrett,
Rapee, Dadds, & Ryan, 1996; Suveg & Zeman, 2004;
Thompson, 2001). Minimal opportunities for exploration
may foster a reduced sense of autonomy, control, or self-effi-
cacy, as insecurely attached children lack opportunities to de-
velop new skills or to explore the environment as well as to
rely on the parent in times of need (Chorpita & Barlow,
1998; Chorpita, Brown, & Barlow 1998). Maladaptive cogni-
tions, emotion regulation processes, and self-concepts may
signal a risk for anxiety when children experience stress asso-
ciated with anticipated danger (Barlow, 2002). Parental anx-
iety may also play a role as children may model parents’ anx-
ious behavior and avoidant coping strategies (Barrett et al.,
1996; Dadds et al., 1996). Negative emotionality and behav-
ioral inhibition may have a direct influence on children’s anx-
iety, or may exacerbate the effect of coping strategies on chil-
dren’s anxiety (Lonigan & Phillips, 2001). For example,
avoidant coping strategies may be linked with anxiety only
for children who are temperamentally predisposed to experi-
encing high negative emotions or who have difficulty adjust-
ing to novel situations (e.g., Lonigan & Phillips, 2001).
Pathways to depression are also likely to stem from dys-
functional parent–child relationships, as shown in Figure 2.
Attachment insecurity, in combination with parental rejec-
tion, may predispose a child to infer that he or she is to blame
for such parental behaviors, to take responsibility for these
early disturbed interactions, and to develop a depressogenic
inferential style (e.g., to attribute negative outcomes to inter-
nal, global, and stable factors; Abela & Hankin, 2008; Hankin
& Abela, 2005). Because authentic expression of their feel-
ings is likely to trigger more parental rejection, these children
may learn to overregulate their display of emotions, may have
difficulty understanding their emotions, and may come to rely
Parent–child attachment and internalizing symptoms 197

on ineffective coping strategies such as passive or ruminative
coping and helplessness, denial of the negative experience, as
well as decrease assertiveness in the face of conflict or emotion-
ally challenging event (Casey, 1996; Ebata & Moss, 1991;
Kobak & Ferenz-Gillies, 1995; Silk, Steinberg, & Morris,
2003; Southam-Gerow & Kendall, 2002; see also Hammen &
Rudolph, 2003). Early disturbed parent–child relationships
may also fuel a negative self-view and diminished self-worth
(Hammen & Rudolph, 2003). Children already predisposed to
a depressogenic inferential style, with difficulties regulating their
emotions, and with a low self-worth, may develop depression
when encountering personal disappointment, achievement fail-
ure, and loss-related stressors (Goodyer, 2001; Lakdawalla, Han-
kin, & Mermelstein, 2007). Parental depression may exacerbate
these links as children may model the parent’s depressed cog-
nitive style and affect (Silk, Shaw, Skuban, Oland, & Kovacs,
2006; see also Berg-Nielsen, Vikan, & Dahl, 2002; Lovejoy,
Graczyk, O’Hare, & Neuman, 2000). Depression may be espe-
cially likely when the child is predisposed to high level of
negative emotions or low levels of positive emotions (Chorpita,
Albano, & Barlow, 1998).
Our review suggested that associations of attachment with
anxiety and depression may be stronger at older ages. Patterns
of information processing, emotion regulation, and self-views
may become more crystallized and automatic with age. Patterns
may also become more self-perpetuating over time. Thus, we
predict that models will be more strongly confirmed for older
children for whom mediating processes are less flexible.
The proposed models are speculative and are offered as a
framework to guide future research. In some ways, the models
Figure 1. Model of attachment influences on anxiety in the context of other factors. NE, negative emotionality; BI, behavioral inhibition.
Figure 2. Model of attachment influences on depression in the context of other factors. NE, negative emotionality; PE, positive emotionality.
L. E. Brumariu and K. A. Kerns198

are oversimplified. For example, there are likely to be interac-
tive and cumulative effects that play out over time. Longitu-
dinal studies are also needed to investigate the possibility that
feelings of anxiety or depression may further undermine chil-
dren’s sense of security with caregivers (Roisman et al., 2006).
In addition, it is still possible that specific patterns of insecure at-
tachment, rather than insecurity per se, are related to different
types of internalizing symptoms (i.e., anxiety and depression,
different types of anxiety symptoms) in the context of other
risk factors, but that the available research failed to capture these
differences. Finally, the models provide only a limited integra-
tion of biological factors. Although temperament and parent’s
psychopathology may in part capture genetic contributions, inse-
cure attachment may also affect the neurophysiological and
biochemical processes that serve as biological foundations for
internalizing symptoms. Our heuristic models focus mainly on
environmental factors and do not detail biological influences
on internalizing symptoms. Nonetheless, these pathways offer
a starting point in the process of disentangling the dynamic inter-
play between attachment and other factors in predicting anxiety
and depression in children and adolescents and lead to several
testable hypotheses.
Conclusion
In summary, this review documents that the links of insecure
attachment to anxiety and depression are stronger than the links
to internalizing symptoms. The associations of attachment are
also stronger in preadolescence/adolescence than in childhood.
Thus, attachment is one factor that may contribute to the devel-
opment of internalizing symptoms. Several questions remain to
be addressed in future research. First, given the focus in prior
literature on mother–child attachment, little is known about
how attachments to fathers may play a role in the development
of internalizing symptoms, especially in childhood. Second,
there is clearly variability in how well established is the link be-
tween attachment and internalizing symptoms. Relatively few
studies have investigated childhood depression, employed re-
presentational measures of attachment, assessed the presence
of disorders rather than symptoms, or used ethnically/racially
diverse samples. Third, it is not clear yet whether security op-
erates as a protective factor or whether specific forms of inse-
curity pose risks for specific forms of internalizing problems.
Thus, there is still the question of whether there is likely to
be specificity in the relations between specific forms of inse-
curity and anxiety and depression, as proposed by attachment
theorists. Available research does not show that only ambiva-
lence is consistently related to internalizing symptoms or anx-
iety, that different attachment patters relate to specific anxiety
symptoms/disorders, or that all insecure attachment patterns
are related to depression. However, it also needs to be acknowl-
edged that there are relatively few studies testing specific hy-
potheses. Thus, future studies should target further empirical
investigation of these proposed links. Fourth, it is not known
how pathways from attachment to internalizing symptoms
might differ from pathways to externalizing symptoms,
which also have been linked to insecure attachment (De-
Klyen & Greenberg, 2008). Thus, an additional question
is how the insecure attachment patterns may show differen-
tial risk for internalizing and externalizing problems. Fi-
nally, there is a need for research that will embed attachment
within a broader context. In addition to considering multiple
influences on internalizing symptoms, it is important to con-
sider factors that may moderate or mediate the relation of at-
tachment with internalizing problems. Research focusing on
such factors may also aid in identifying new targets for
the treatments of internalizing symptoms (e.g., child charac-
teristics).
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