NIH Public Access

Author Manuscript
Dev Psychopathol. Author manuscript; available in PMC 2007 April 26.
Published in final edited form as:
NIH-PA Author Manuscript

Dev Psychopathol. 2005 ; 17(1): 1–23.

Expanding the concept of unresolved mental states: Hostile/

Helpless states of mind on the Adult Attachment Interview are
associated with disrupted mother–infant communication and
infant disorganization

KARLEN LYONS–RUTHa, CLAUDIA YELLINb, SHARON MELNICKa, and GWENDOLYN

ATWOODa
aHarvard Medical School
bBoston University

Abstract
NIH-PA Author Manuscript

In a recent meta-analysis, only 53% of disorganized infants were predicted by parental Unresolved
states of mind on the Adult Attachment Interview (AAI). The goal of this study was to identify
additional predictors of infant disorganization on the AAI by developing and validating an interview-
wide coding system for Hostile/Helpless (H/H) parental states of mind with respect to attachment.
Maternal AAIs were collected from 45 low-income mothers with high rates of childhood trauma
when their children were age 7; Strange Situation assessments had been collected at 18 months of
age. AAIs were independently coded using both the Main and Goldwyn coding system and newly
developed codes for H/H states of mind. Results indicated that the H/H coding system displayed
discriminant validity in that it did not overlap substantially with the Unresolved, Cannot Classify, or
Fearfully Preoccupied by Traumatic Events categories in the Main and Goldwyn coding system.
Second, H/H states of mind accounted for variance in disorganized infant behavior not associated
with the Unresolved classification. Third, H/H states of mind were significantly related to maternal
disrupted affective communication as coded by the Atypical Maternal Behavior Instrument for
Assessment and Classification coding system, and maternal disrupted communication mediated the
relations between H/H states of mind and infant disorganization.

One current frontier of attachment research lies in the extension of adult attachment constructs
NIH-PA Author Manuscript

and assessments to at-risk or clinical populations. The importance of validating attachment

assessments in high- and low-risk family environments was demonstrated first in relation to
attachment assessments in infancy. When high-risk infants were studied using the three-
category attachment classification system developed for low-risk samples, unpredicted results
were obtained, and anomalous organizations of infant attachment behaviors began to be
described that did not fit any of the three attachment categories well (Crittenden, 1985; Lyons–
Ruth, Connell, Zoll, & Stahl, 1987; Radke–Yarrow, Cummings, Kuczynski, & Chapman,
1985). This led Main and Solomon (1990) to the development of criteria for a fourth attachment
category in infancy—the disorganized/disoriented group.

More recently, the assessment of adult attachment patterns using the Adult Attachment
Interview (AAI; Main & Goldwyn, 1998) has been extended to a variety of clinical populations.
Similar to the early studies of infant attachment patterns, the pattern of results has been
inconsistent and, at times, counter to clinical and theoretical predictions. Hypotheses based on

Adress correspondence and reprint requests to: K. Lyons–Ruth, Department of Psychiatry, Harvard Medical School at Cambridge
Hospital, 1493 Cambridge Street, Cambridge, MA 02139; E-mail: [email protected]..
 LYONS–RUTH et al. Page 2

attachment theory (Main & Hesse, 1990) suggest that clinical populations with high rates of
childhood loss or trauma should exhibit high rates of states of mind classified Unresolved (U)
with respect to loss or trauma. This prediction has been born out in some studies (Allen, Hauser,
NIH-PA Author Manuscript

& Borman–Spurrell, 1996; Patrick, Hobson, Castle, Howard, & Maughan, 1994) but not in
others. For example, few maritally violent men were judged U and only 33% were considered
Cannot Classify (CC; Holtzworth–Monroe, Stuart, & Hutchinson, 1997); only 53% of
personality-disordered violent criminal offenders in institutions were judged either U or CC
(van IJzendoorn, Feldbrugge, Derks, & deRuiter, 1997). Results with women patients who
were victims of abuse were somewhat stronger, with 60% of female psychiatric inpatients with
sexual abuse histories classified U. From a clinical perspective, these rates are unusually low
given the difficulties that clinical offenders or hospitalized abused women often experience
functioning in day to day relationships. Finally, only 36% of mothers followed by protective
services for grossly negligent parenting were classified U despite their chronically neglectful
parenting and their histories of childhood abuse and current depression and substance abuse
(Ethier, Lacharite, & St-Laurent, 2002).

None of the clinical studies have had converging infant data or parent–infant interaction data
available to assess the validity of the AAI results. Therefore, it has been unclear whether the
results are accurate indicators that some clinical populations have higher rates of organized
states of mind (autonomous, dismissing, preoccupied) than expected or whether the
classification criteria developed for low-risk samples are not yet adequately developed to
NIH-PA Author Manuscript

capture the range of states of mind seen among clinical groups. The goal of the present study
was to identify additional pathways toward infant disorganization by developing an interview-
wide coding system for an underlying “hostile–helpless” parental state of mind with respect
to attachment and assessing its validity in relation to infant disorganization and deviations in
parental caregiving.

Classification as U With Respect to Loss or Trauma

According to the etiological model of the genesis of disorganized attachment strategies in
infancy initially proposed by Main and Hesse (1990), parental experiences of loss or abuse
may lead to unintegrated states of mind that generate lapses in reasoning or discourse when
interviewed on the AAI. This is termed a U state of mind, and it is the adult representational
measure of a disorganized working model of attachment. This U adult state of mind, in turn,
is predicted to be associated with frightened or frightening (FR) parental behavior toward the
infant, due to the lack of mental and behavioral integration of the fearful affect associated with
the loss or abuse experience. The parent's FR behavior, in turn, is seen as placing the infant in
an unresolvable conflict because the parent becomes a source of fear for the infant as well as
the primary source of comfort. This conflict is viewed as leading to the contradictory and
NIH-PA Author Manuscript

unintegrated behaviors toward the caregiver that are the hallmark of attachment disorganization
(Main & Solomon, 1990).

Classification as U with respect to loss or trauma refers to the lack of full integration into
consciousness of the occurrence and immediate implications of a traumatic event. This may
be seen, for example, in extreme attention to the details of the loss or trauma or in indications
that the interviewee felt unrealistically responsible for the loss or trauma, such as in believing
that they killed the person with their thoughts (Main & Goldwyn, 1998). Hesse and Main
(1999) view these slippages as brief and isolated and generally as occurring in the presence of
an otherwise organized interview.

The infant attachment classification corresponding to the adult U classification is the

Disorganized/Disoriented (D) classification, which refers to the category of infant attachment
in which the infant displays a range of atypical behaviors in the presence of the caregiver that

Dev Psychopathol. Author manuscript; available in PMC 2007 April 26.

 LYONS–RUTH et al. Page 3

indicate fear, conflict, or disorientation (Main & Solomon, 1990). Behaviors such as freezing,
showing apprehension, or approaching and moving away from the caregiver in rapid alternation
suggest a collapse of an organized behavioral strategy for dealing with the stress of separation
NIH-PA Author Manuscript

from and reunion with the caregiver (Main & Solomon, 1990).

A number of studies have demonstrated a relationship between the adult U and infant
Disorganized classifications (van IJzendoorn, Schuengel, & Bakermans–Kranenburg, 1999).
Most of those studies have involved low-risk samples; none have involved clinically referred
parents. In addition, as van IJzendoorn (1995) points out in a meta-analysis of nine attachment
studies, a weaker relationship exists between the U and Disorganized classifications than
between most other adult categories of attachment and their infant counterparts. In his meta-
analysis the correlations between parent and infant attachment classifications for the combined
studies were secure–autonomous (r = .48), avoidant–dismissing (r = .42), ambivalent–
preoccupied (r = .19), and U–disorganized (r = .31). For 53% of disorganized infants, the parent
was also classified U; this leaves 47% of disorganized infants unaccounted for by parental U
states of mind. Thus, there is clearly a great deal of variance in infant disorganization that
remains to be accounted for by other factors. Although Spangler and Grossman (1999) have
suggested that infant temperamental factors also account for variance in disorganization, here
we evaluate the possibility that methodological issues related to the current AAI coding system
may lead to underestimates of the influence of parental state of mind on infant disorganization.
Specifically, some parental states of mind described in the clinical literature and likely to be
NIH-PA Author Manuscript

related to infant disorganization are not yet captured by coding criteria for U states of mind,
as discussed below.

One methodological issue that may weaken the prediction from the U category is that coding
for U status depends on the reporting of a specific loss or abuse experience. If no death or abuse
is identified by the participant, then adult state of mind cannot be coded U.

In addition, in a departure from the practice established for other states of mind, only aspects
of the interview that can be tied to the participant's state of mind regarding the loss or abuse
experience are relevant to the coding of a U state of mind; aspects of the interview unrelated
to the mental processing of loss or abuse do not enter into the coding. In contrast, autonomous,
dismissing, or preoccupied states of mind are viewed as pervasive mental models for organizing
discourse regarding attachment-related affects; therefore, indicators of those states of mind are
viewed as pervading the interview rather than as appearing in circumscribed lapses.

A related conceptual issue is also associated with the methodological dependence on

experiences of loss or abuse. Adults are viewed as developing U states of mind in relation to
experiences of loss or abuse that often occur later than the first few years of life. In contrast,
NIH-PA Author Manuscript

infants are viewed as developing disorganized attachment strategies through exposure to the
caregiver's unintegrated fear related to past loss or abuse (Main & Hesse, 1990). Thus, different
etiological mechanisms are proposed to account for disorganization in early development and
disorganization in adulthood. This leads to the conundrum that if a disorganized infant grows
up without a specific experience of loss or abuse then the disorganized attachment strategy
would not be expected to persist into adulthood, and methodologically he or she could not be
judged as U on the AAI. Lyons–Ruth, Yellin, Melnick, and Atwood (2003) have termed this
a “transmission block” in the conceptual model for how disorganized attachment is transmitted
to the third generation.

However, existing data are at least congruent with the possibility that infant disorganization
may lead to continued unintegrated states of mind in the absence of specific incidents of loss
or abuse (Ogawa, Sroufe, Weinfield, Carlson, & Egeland, 1997). Infant disorganization has
been shown to predict controlling attachment strategies at least through age 6 in low-risk

Dev Psychopathol. Author manuscript; available in PMC 2007 April 26.

 LYONS–RUTH et al. Page 4

samples in which neither parental death nor abuse were reported to be associated with the
infant's continued deviance (Main, Kaplan, & Cassidy, 1985; Wartner, Grossmann, Fremmer–
Bombik, & Suess, 1994). One theoretical issue that emerges, then, is how to conceptualize the
NIH-PA Author Manuscript

etiological mechanisms that contribute to the maintenance of disorganized–controlling

attachment strategies into adolescence and adulthood in the absence of specific incidents of
loss or abuse. The corresponding methodological issue that emerges is how to assess such
disorganized–controlling strategies in adolescence or adulthood when there has been no serious
loss or abuse about which to inquire.

In one approach to this dilemma, Hesse (1999) has developed criteria for designating an AAI
as CC if both a dismissing and a preoccupied strategy are evident in different parts of the
interview (i.e., in discussing mother vs. father or present vs. past). Due to the rarity of these
protocols, however, there are as yet no reliability data available for this classification and no
validity data available to tie these adult characteristics to the developmental pathways involving
disorganized attachments. Therefore, more work is needed to identify indices of atypical states
of mind on the AAI that can predict infant disorganization independent of unresolved loss or
abuse.

Attachment, Relational Trauma, and Pervasively Unintegrated States of Mind

In the Main and Goldwyn coding system, an AAI participant may be coded U with respect to
NIH-PA Author Manuscript

either loss or abuse. Most empirical work that has demonstrated a relationship between the U
classification of the parent and the D classification of the infant has involved U parents who
were classified U with respect to loss. Few studies have contained enough cases of unresolved
abuse to look specifically at parental discourse about abuse and its relation to infant attachment
classification. In addition, the parent's discourse about abuse events per se may constitute too
narrow a window for indexing the range of relational events in early development that lead to
disregulation of fearful arousal, symptom formation, and intergenerational transmission of
disorganized attachment.

The Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric
Association (APA, 1994) describes a traumatic event as “direct personal experience of an event
that threatens death, serious injury, or other threat to the physical integrity of the self or other,
or learning about unexpected or violent death or injury or threat of death or injury experienced
by a family member or other close associate” (APA, 1994, p. 424). Others have described
trauma from a psychological perspective as what occurs “… when neither resistance nor escape
is possible, [and] the human system of self defense becomes overwhelmed and
disorganized” (Herman, 1992, p. 34). Herman (1992) and Terr (1991) further distinguish acute
trauma, involving a single overwhelming event, from chronic trauma, in which the trauma is
NIH-PA Author Manuscript

prolonged and/or repeated. Van der Kolk and Fisler (1994) also distinguish the effects of
isolated incidents of trauma which result in “… rather discrete conditioned biological and
behavioral responses to reminders of the trauma” from chronic abuse and neglect, which are
likely to have a more pervasive effect on psychological and behavioral regulatory processes” (p.
147). These authors describe the inability of some people exposed to interpersonal trauma at
an early age to regulate their affective states and behavioral responses. When ongoing and
occurring at an early age, such experiences affect not only current functioning but “… the
totality of personality development” (p. 147), “resulting in a syndrome of complex PTSD which
includes problems regulating affective arousal, dissociation, somaticization, changes in
perception of self and other, and changes in systems of meaning” (see also Herman, 1992).
The crystallization of such a personality style includes psychological constriction, massive
numbing, rage, and, in some cases, identification with an aggressive perpetrator.

Dev Psychopathol. Author manuscript; available in PMC 2007 April 26.

 LYONS–RUTH et al. Page 5

Whether trauma is defined by event characteristics or by psychological and physiological

response, one problem with the above account is that the attachment context of traumatic events
is not typically integrated into the theory of symptom formation. The symptomatic impact of
NIH-PA Author Manuscript

traumatic events has largely been considered outside the context of the attachment relationships
that buffer or augment the fear-arousing potential of the event itself. It is important to note that
physical or sexual abuse by a family member in childhood most often involves two distinct
processes that are confounded: (a) occurrence of a physically threatening event and (b) failure
in the ongoing protective function of attachment figures. These intertwined processes have not
always been clearly distinguished in conceptualizing the etiological context of trauma
symptoms. For example, trauma symptoms, such as dissociation, have generally been viewed
as precipitated by the nature and severity of the threatening event. However, recent prospective
longitudinal studies from infancy indicate that chronic impairment in caregiver responsiveness
may be more central to the etiology of dissociative symptoms then abusive events per se
(Ogawa et al., 1997).

An additional problem with the objective specification of what constitutes a traumatic event
(APA, 1994) is that trauma is defined from an adult point of view, with no adjustments for
how infants and young children evaluate threats to the integrity of the self. The central focus
of Bowlby's work was the demonstration that infants and young children experience threats to
the integrity of the self as a function of the availability of a familiar protective caregiver, not
as a function of “objective” adult-defined physical danger. Hence, Bowlby observed that
NIH-PA Author Manuscript

children with their caregivers in war-time London threatened by bombing experienced

themselves as safer and were less symptomatic than children separated from their caregivers
and sent to objectively safer residential care in the countryside (Bowlby, 1973). We would
further argue that the relative contributions of attachment security and physically dangerous
or threatening events to the etiology of trauma symptoms will shift from infancy to adulthood,
with symptom formation from infancy to age 6 influenced much more heavily by the lack of
responsive availability of primary attachment figures and symptom formation from 6 to
adulthood gradually becoming increasingly related to adult criteria for physical threat.
Therefore, phenomena usually discussed as symptoms of childhood trauma or abuse are likely
to be related not only to the occurrence of threatening events but also, more broadly, to
uncertainty regarding the responsive availability of caregivers.

Both in the attachment literature and in the trauma literature, particular incidents of abuse (i.e.,
traumatic experiences) have not been clearly conceptually or empirically separated from the
ongoing context of parent–child interaction in which such incidents occur. The ongoing context
of interaction is significantly different among maltreating families than among
socioeconomically matched controls, even when assessed in relatively brief (40-min)
assessments (e.g., Lyons–Ruth et al., 1987; Madigan, Pederson, & Moran, 2003). We have
NIH-PA Author Manuscript

long argued that because of this confound, the impact of ongoing deviant regulation in the
relationship needs to be empirically separated from the impact of abusive incidents per se.
Many of the psychological correlates of abuse described in both the trauma and attachment
literatures are likely to be effects not of trauma per se but of traumatic events occurring in the
context of serious relationship deviance or even of sustained relationship deviance itself (e.g.,
Ogawa et al., 1997). For example, a large majority of dissociative disorders and borderline
disorders occur in the context of chronic abusive or neglecting family relationships in which
the ongoing interaction with the primary caregiver is likely to be deviant (Putnam, 1991;
Zanarini, Williams, Lewis, Reich, Vera, & Marino, 1997). To the extent that the caregiver is
markedly hostile or unavailable to the child, the child may experience excessive fearful arousal
and associated symptom formation whether or not an adult-defined physically threatening
event occurs. Animal models have contributed clear support for this model of the foundational
nature of early care for the regulation of fearful responses in infancy and early childhood
(Coplan, Andrews, Rosenblum, Owens, Friedman, Gorman, & Nemeroff, 1996; Francis,

Dev Psychopathol. Author manuscript; available in PMC 2007 April 26.

 LYONS–RUTH et al. Page 6

Diorio, Liu, & Meaney, 1999). In addition, congruent with animal models, human neuroscience
research is demonstrating that enduring psychophysiological effects on brain organization and
stress physiology may result not only from overt physical or sexual abuse but also from self-
NIH-PA Author Manuscript

reported emotional abuse, such as repeatedly hostile or emotionally unprotective responses

from central caregivers (Teicher, 2002; Yehuda, Hallig, & Grossman, 2001).

This converging evidence from animal models, adult neuroscience, and developmental studies
suggests that disorganized attachment behaviors and states of mind are likely to be related to
a broader range of caregiving responses than abusive behaviors alone. Infant studies have
established clear links between hostile or unavailable caregiving and infant disorganized
attachment behaviors (Goldberg, Benoit, Blokland, & Madigan, 2003; Grienenberger & Kelly,
2001; Kelly, Ueng–McHale, Grienenberger, & Slade, 2003; Lyons–Ruth, Bronfman, &
Parsons, 1999; Madigan & Hawkins, 2003; Madigan, Pederson, & Moran, 2003). Therefore,
we expected that hostile, conflictual, or unprotective responses from caregivers would also be
associated with atypical states of mind in adulthood on the AAI, even in the absence of specific
incidents of abuse.

Despite the noted confound between specific threatening events and the ongoing quality of
caregiving regulation, the clinical trauma literature has provided the most consistent, in depth
descriptions of states of mind associated with very deviant caregiving relationships. Therefore,
we turned to those descriptions to inform the development of the coding system. However, we
NIH-PA Author Manuscript

remain agnostic about the relative causal contributions of physically threatening incidents per
se versus ongoing features of the caregiving interaction in the genesis of these states of mind.
Further work will be needed to differentiate empirically the effects of threatening events from
the effects of ongoing caregiver hostility, withdrawal, role reversal, or helplessness to protect.

Main and Goldwyn (1998) and Main and Solomon (1990) have described contradictory and
unintegrated behavioral and mental processes as a core phenomenon of disorganized
attachment relationships. Therefore one set of psychological phenomena that seemed
particularly relevant to intergenerational transmission of disorganization were the extreme
forms of segregated mental systems that have been described by students of trauma and
psychopathology under the labels of “dissociation” and “splitting.” These concepts, in
combination with the detailed examination of a small set of pilot AAI protocols, guided the
development of a set of additional interview-wide codes for indexing pervasively unintegrated
states of mind on the AAI. Dissociation is sometimes referred to as a “vertical split” because
disparate representations of both self and other are observed to be maintained in separate mental
“compartments” unintegrated with one another but available to consciousness in alternation
with one another (Horowitz, 1986; Kluft, 1991). Thus, traumatized individuals may dissociate,
or mentally segregate, affects that are too disorganizing of coping efforts to experience at the
NIH-PA Author Manuscript

time of fearful arousal or may dissociate self-schemas that are threatening to the maintenance
of positive identity, self-esteem, and motivation. The person is not generally simultaneously
aware of these mentally segregated contents; yet, they both remain mentally active and
available to consciousness and find expression in discourse and behavior at different times.

Splitting is a specific form of dissociation, defined as an unconscious process that actively

separates contradictory positive and negative affects and their related mental representations
of good and bad aspects of the other and the self. Splitting is viewed as a defense that allows
contradictory representations to alternate in consciousness without an integrating conscious
overview of the contradiction. Initially developed to capture the therapist's clinical experience
of being alternately globally idealized and globally devalued in the relationship between patient
and therapist, the mechanism of splitting has been central to understanding a variety of
phenomena associated with Axis II personality disorders and traumatic childhoods, in
particular, borderline psychopathology (e.g.,APA, 1994; Kernberg, 1975). Borderline

Dev Psychopathol. Author manuscript; available in PMC 2007 April 26.

 LYONS–RUTH et al. Page 7

personality disorder has also been consistently related to a history of trauma (e.g., Herman,
Perry, & Van der Kolk, 1989; Kernberg, 1975).
NIH-PA Author Manuscript

The global idealization that occurs in splitting is viewed as more extreme and less stable than
the stable idealization that occurs in dismissing stances. Stable idealization is viewed in clinical
writing as based on a repressive strategy, or “horizontal split,” through which negative affects
and related representations that generate conflict for the individual are consistently maintained
out of awareness, converging with the research evidence that dismissing attachment strategies
are best viewed as consistent and organized. In contrast, splitting is viewed as a form of mental
segregation in which alternations in states of consciousness may occur, so that even mild
disappointments in a relationship may activate representations of the “bad” caregiver expressed
as affectively intense devaluation and, at times, in a complete rupture of the relationship. When
the negative representation is not active, some individuals who present global idealization are
also clinically described as displaying “affect intolerance” or emotional constriction that
excludes involved anger, emotional pain, fear, and vulnerability from consciousness.
Relatively little controlled research has yet explored these clinically described phenomena.
However, Fischer and colleagues have documented experimentally the presence of such a core
devalued self among victims of childhood sexual abuse, in which attributes rated more central
to the self concept are also evaluated as negative (Calverley, Fischer, & Ayoub, 1994).

The Hostile/Helpless (H/H) Coding System for Pervasively Unintegrated

NIH-PA Author Manuscript

States of Mind
To operationalize the states of mind that might present on the AAI secondary to chronic
relational trauma, including but not limited to sexual, physical, or emotional abuse, the
development of an additional set of codes for theAAI was undertaken. The indicators for coding
H/H states of mind were derived theoretically from concepts in the trauma and attachment
literatures, as reviewed above. They were also derived empirically through close examination
of the AAI's of mothers in a development sample, as described under Methods.

In the resulting coding system, an H/H state of mind describes the overall psychological
organization of an adult who displays explicit contradictory but unintegrated emotional
evaluations of a central caregiver across the transcript, often including evidence of an
unexamined identification with that caregiver. These contradictory evaluations are typically
accompanied by evidence of globally negative devaluing mental representations of self and/
or caregiver. Another common presentation is for the participant to make recurrent references
to fearful affect that may or may not have an identified source in a traumatic experience. A
more elaborated description of the H/H classification, as well as the ways in which it differs
from the established Main and Goldwyn classifications, is included in the Methods section.
NIH-PA Author Manuscript

Descriptively, a number of H/H protocols were characterized by devaluation of caregivers,

identification with those caregivers, and laughter at pain. These protocols often featured a
concise, nontangential narrative, with both positive and negative experiences frankly
discussed. Such protocols often had a distinct attitude of “telling it like it is,” that is, of frank
identification of negative life experiences and of not pulling any punches in describing the
foibles of caregivers, for example, “Did you ever feel rejected?” “Yeah, all the time.” In
addition, they conveyed an attitude of being “tough” or resilient in the face of those experiences,
as conveyed by their matter of fact or even darkly humorous presentations of such experiences.
Idealization was often low and/or inconsistent, and there was little appeal to lack of memory.
Involved anger was typically notably absent. However, the degree of vulnerability and pain
clinically known to be associated with such experiences went largely unacknowledged, and
was distanced by laughter and discourse style, “He was a drunk, but he was a good drunk
(laugh).”

Dev Psychopathol. Author manuscript; available in PMC 2007 April 26.

 LYONS–RUTH et al. Page 8

This newly developed category for the AAI differs from the coding of the U category in several
ways. First, whereas the existing coding system classifies participants as U when they show
lapses of monitoring of reason or discourse in regard to experiences of loss or trauma, the
NIH-PA Author Manuscript

coding system for pervasively unintegrated H/H states of mind examines discourse patterns
throughout the whole protocol regardless of relevance to particular experiences. Second, the
H/H coding system is compatible with the entire range of relational experiences in childhood
and is not contingent on the interviewee being able to identify instances of loss or abuse, as is
the case in coding U states of mind. Third, the H/H coding system is informed by clinical
descriptions of defensive functions among clinical populations with chronic trauma and makes
more explicit the connections between features of AAI discourse and clinical presentations
secondary to relational trauma. The system thus extends the potential of the codes for capturing
variations in attachment-related states of mind within clinical populations.

Three hypotheses guided the study. First, it was expected that the H/H coding system would
overlap with the current CC and Fearfully Preoccupied by Traumatic Events (E3) categories
of the Main and Goldwyn (1998) coding system and provide additional specifications for those
states of mind. Second, in high-risk or clinical samples, maternal H/H states of mind were
predicted to account for variance in disorganized infant behavior not associated with the U
classification. Third, H/H states of mind were predicted to relate to disruptions in maternal
affective communication with the infant as coded by the Atypical Maternal Behavior
Instrument for Assessment and Classification (AMBIANCE) coding instrument (Lyons–Ruth
NIH-PA Author Manuscript

et al., 1999), and the extent of these disruptions was expected to mediate any relation between
maternal state of mind and infant attachment disorganization. Parental disrupted affective
communication as coded by the AMBIANCE coding instrument has been shown in several
studies to relate both to parental U states of mind and to infant disorganization and to mediate
the statistical link between them, as well as accounting for additional variance in infant
disorganization not associated with U status. These relations have been demonstrated in both
low- and high-risk samples and in relation to maternal behaviors assessed in both the strange
situation (Grienenberger & Kelly, 2001; Lyons–Ruth et al., 1999) and in separate laboratory
assessments (Evans, Forbes, Bento, Moran, Pederson, & DeOliveira, 2003; Goldberg et al.,
2003; Kelly et al., 2003; Madigan et al., 2003; Madigan & Hawkins, 2003).

Methods
Participants
The sample for this study consisted of 45 mothers and their 7-year-old children who had been
participating in a longitudinal study since infancy (Lyons–Ruth, Connell, Grunebaum, &
Botein, 1990). Of the 45 children, 28 were male and 17 were female. In infancy, 66% of families
had incomes under $50 per person per week, and 62% received Aid to Families with Dependent
NIH-PA Author Manuscript

Children. The sample was 80% Caucasian and 20% Latino, African American, or biracial
children. Sixty percent of the mothers were high school graduates and 49% were single parents.

The infant sample consisted of 70 infants who were assessed for attachment security at 18
months of age and their mothers. Of those, 38 were low-income families referred to the study
by health or social service agency staff because of concerns about the quality of the parent–
infant relationship and 32 were demographically matched families from the community who
were screened for histories of maltreatment or psychiatric hospitalization.

At the 7-year assessment, five families refused participation, and the remainder could not be
relocated. The 45 families who participated in the 7-year sample did not differ significantly
from those who did not participate on demographic measures or measures of infant attachment,
maternal depression, or mother–infant interaction. The infant attachment distribution of the
infants seen at age 7 was 42% (n = 19) secure, 16% (n = 7) avoidant, 10% (n = 5) disorganized-

Dev Psychopathol. Author manuscript; available in PMC 2007 April 26.

 LYONS–RUTH et al. Page 9

forced secure, and 32% (n = 14) disorganized-forced avoidant or ambivalent. The

corresponding distribution for the full sample in infancy was 32% (n = 23), 21% (n = 15), 14%
(n = 10), and 32% (n = 23).
NIH-PA Author Manuscript

Measures
Demographic risk—A cumulative demographic risk variable was computed by summing
the presence of the following five factors: mother not a high school graduate; mother a single
parent; mother under the age of 20 at birth of first child; family supported by government
assistance; and family included three or more children under the age of 6.

Infant attachment security—At 18 months of age, mothers and infants were videotaped
in the Ainsworth Strange Situation (Ainsworth, Blehar, Waters, & Wall, 1978). In this
procedure the infant is observed in a playroom during a series of eight 3-min episodes in which
the mother leaves and rejoins the infant twice. Videotapes were coded for infant attachment
behaviors and for the three attachment classifications as described by Ainsworth et al.
(1978) and for disorganized/disoriented behaviors as described by Main and Solomon
(1990). The three original attachment classifications (secure, avoidant, ambivalent) were
assigned by both a computerized multivariate classification procedure developed on the
original Ainsworth data (Connell, 1976; see Lyons–Ruth et al., 1987; for additional details,
see also reference in Richters, Waters, & Vaughn, 1988) and a coder trained by M. Main.
Agreement between the two sets of classifications was 86%. Agreement on the disorganized
NIH-PA Author Manuscript

classification between M. Main and a second coder for 32 randomly selected tapes was 83%
(κ = .73). Coder reliability for the 9-point Level of Disorganized Behavior Scale was r = .84.

AAIs—The AAIs were administered to mothers when the children were age 7–8 (Davidson,
1993). The AAI (George, Kaplan, & Main, 1984/1985/1986) is a semistructured interview
designed to elicit a participant's current state of mind regarding attachment experiences with
parents and other significant caregivers during childhood. The interviewer asks about the
quality of childhood experiences with parents, the participant's responses to experiences of
rejection, separation, loss, and trauma during childhood, and the participant's evaluation of the
effects of those childhood experiences on his or her current functioning.

Using the Main and Goldwyn coding system (1998), the interview is scored from a transcript
using scale points that characterize the degree to which each parent was loving, neglecting,
rejecting, involving, and pressuring to achieve. A second set of scales is used to assess the
participant's state of mind and discourse style, including scales for overall coherence of
transcript and of thought, idealization, insistence on lack of recall, derogation, fear of loss of
child, metacognitive monitoring, passivity of speech, involved anger, and lack of resolution of
NIH-PA Author Manuscript

loss or trauma. The scale scores are used to assign the adult to one of four major attachment
classifications: secure, insecure/dismissing, insecure/preoccupied, and unresolved with respect
to loss or trauma (Main & Goldwyn, 1998). These parallel the secure, avoidant, ambivalent,
and disorganized classifications of the Ainsworth Strange Situation scoring system for infant
attachment. Emerging criteria for a fifth category, currently designated CC, include shifting
from one strategy to another over the course of the interview (e.g., dismissing to preoccupied)
or displaying low coherence on the interview as a whole without an elevated score on any of
the indicators of an insecure state of mind (Hesse, 1999). Stability of AAI classifications has
been demonstrated in several studies (e.g., Bakermans–Kranenburg & van IJzendoorn,
1993;Benoit & Kevin, 1994). Discriminant validity of the AAI has been demonstrated with
respect to intelligence, memory, cognitive complexity, social desirability, and overall social
adjustment (Bakermans–Kranenburg, & van IJzendoorn, 1993;Sagi, van IJzendoorn, Scharf,
Koren–Karie, Joels, & Mayseless, 1994).

Dev Psychopathol. Author manuscript; available in PMC 2007 April 26.

 LYONS–RUTH et al. Page 10

Coding how the participant discusses material related to abuse experiences is critical to coding
lack of resolution of abuse on the AAI. Because the AAI was developed for low-risk samples,
abusive experiences are not probed in the same depth as experiences of loss. In interviewing
NIH-PA Author Manuscript

mothers in this study on the AAI, additional questions were included in the interview
specifically asking about experiences of physical abuse, sexual abuse, or witnessed violence,
based on the Antecedent Experiences Questionnaire of Herman et al. (1989; see Appendix A).

Interviews were coded using the standard Main and Goldwyn (1998) coding system by a coder
from the lab of one of the trainers for AAI coding who was certified as reliable through the
standard training procedures of Main and Hesse. The coder had coded over 500 AAI protocols
and had received additional training in applying criteria for the CC category. The coder was
blind to all other data from the study. Using the standard Main and Goldwyn system, 58% of
AAIs were classified in organized categories (40% Autonomous, n = 18; 7% Dismissing, n =
3; 11% Preoccupied, n = 5), 29% were classified U (n = 13), and 13% were classified CC (n
= 6). Among those classified U, 10 were classified U for loss and 3 were classified U for abuse.

Disrupted maternal affective communication—Disrupted maternal communication

with the infant was coded using the AMBIANCE coding system (Lyons–Ruth et al., 1999)
over all episodes of the Strange Situation Procedure conducted at 18 months. Coders were
naïve to the criteria for coding infant disorganized attachment behaviors. The AMBIANCE
coding protocol yields a scaled score (1–7) for extent of disrupted communication and a
NIH-PA Author Manuscript

classification as Disrupted or Not Disrupted, as well as a count for total atypical communicative
behaviors, with five subtotals for affective communication errors, role confusion, negative-
intrusive behavior, disorientation and withdrawal (see Lyons–Ruth et al., 1999, for more
extended description).

Fifteen randomly selected tapes were coded by two coders to assess reliability. The reliabilities
were as follows: Level of Disrupted Communication Scale, κ = .93; Disrupted Classification,
87% agreement, κ = .73; Total Atypical Behavior Score, ri = .75; Affective Communication
Errors Subscore, ri = .75; Role Confusion Subscore, ri = .76; Negative-Intrusive Behavior
Subscore, ri = .84; Disorientation Subscore, ri = .73; Withdrawal Subscore, ri = .73. Only the
overall classification is used in the current analyses.

In studies to date, the AMBIANCE system has been coded both from the Strange Situation
and from separate laboratory procedures and, using both assessment situations, has been
validated in relation both to infant attachment disorganization and maternal U classification
on the AAI (Goldberg et al., 2003; Grienenberger & Kelly, 2001; Kelly et al., 2003; Lyons–
Ruth et al., 1999; Madigan et al., 2003; Madigan & Hawkins, 2003).
NIH-PA Author Manuscript

Additional work with the AMBIANCE codes at the person level rather than the variable level
identified three patterns of maternal behavior that were associated with infant disorganization:
frightening, fearful–inhibited, and withdrawn (Lyons–Ruth, Bronfman, & Atwood, 1999).
High levels of frightening, dissociated or role reversed behavior were associated with
disorganized–avoidant and/or resistant forms of infant behavior; fearful–inhibited and
withdrawing maternal behavior patterns were associated with disorganized–secure forms of
infant behavior (disorganized behaviors combined with approach and cessation of crying). All
three patterns of maternal behavior are classified in the Disrupted category.

H/H Coding system for the AAI—Following the coding conventions in the attachment
literature, the H/H coding system is made up of a number of indicators that contribute to an
overall scaled score for level of H/H state of mind (1–9). A score of 6 or above on the scale
results in a H/H classification, and a score of 5 leaves the classification decision open to the
coder's judgment. Consistent with the Main and Goldwyn practice, this continuous score is

Dev Psychopathol. Author manuscript; available in PMC 2007 April 26.

 LYONS–RUTH et al. Page 11

based on the coder's judgment as to how well the protocol fits the classification description in
the coding manual. The coding system is described in detail in Lyons–Ruth, Melnick, Atwood,
& Yellin, 2003.
NIH-PA Author Manuscript

A categorization as having an H/H state of mind regarding attachment indicates that the
interviewee displayed discourse that contained elements of one or both of two very different
hostile or helpless strategies for managing attachment-related affects. Although pure subtypes
of Hostile or Helpless states of mind are possible, they are not necessarily expected to appear
in pure form because they are viewed as related aspects of a single H/H internal model of self-
other relations (see Lyons–Ruth, Bronfman, & Atwood, 1999).

In the Hostile subtype, at least one attachment figure from childhood is represented in globally
negative terms and, in many cases, the participant seems to have identified with this hostile or
devalued attachment figure. Such global devaluation is viewed as an indicator of “split” all
good/all bad representations in the clinical literature and identification with the aggressor is a
commonly observed sequel to victimization, as noted earlier. Difficult or traumatic childhood
experiences are often directly described. There is also evidence of a tendency to block out or
constrict feelings of vulnerability by turning painful experiences into “dark humor.” Laughter
at painful anecdotes was considered an indicator of such a stance. The discourse structure of
those classified in this subcategory could remain in the concise or constricted range during the
entire interview. Although the importance of devaluation (and identification with the devalued
NIH-PA Author Manuscript

figure) might suggest that these were Ds2 or E2 protocols, only two protocols in the study were
classified E2 and none were classified Ds2. The poor fit to those categories occurs because the
devaluations have a “hot” or involved feel (e.g., “my enemy”) rather than a coolly dismissive
tone, but they often occur in concise narratives with no involved anger. Such a combination of
frank relating of negative experiences, “hot” devaluations, minimization of vulnerability, and
a concise narrative would provide a poor fit to any of the existing AAI categories.

In the Helpless subgroup, pervasive feelings of fearfulness and helplessness are evident, and
in some cases individuals classified in this subgroup are clearly identified with a victimized
attachment figure. Thus, while continuing to maintain some denial of vulnerability, individuals
in this subgroup are more likely to acknowledge vulnerable feelings, such as fear and globally
negative evaluations of the self, and to be more psychologically involved with unsuccessful
efforts to make sense of their painful attachment relationships. Fearful affect, as operationalized
here, need not occur in the context of identified (or inferred) traumatic experiences, but can be
described in relation to a variety of unrelated and nontraumatic events across the interview.
Discourse in this subgroup often provides a poor fit to existing categories because it can have
a predominantly passive and/or tangential structure, punctuated by dismissing features, such
as global devaluation and attempts to minimize vulnerability by laughing at painful anecdotes,
NIH-PA Author Manuscript

and by apparently autonomous features, such as frank discussion of negative aspects of early
experiences.

Readers familiar with the AAI will note that the description of the “Helpless” subgroup has
many points in common with Main and Goldwyn's (1998) description of the Preoccupied
subgroup E3, “Fearfully Preoccupied with Traumatic Events” and overlap with this subgroup
was predicted. However, the helpless classification differs from the E3 classification in several
respects. First, it does not require the reporting or inferring of traumatic experience per se but
only of repeated references to fearful affects across the context of the interview. Second, in
many cases fearful affect is expected to coexist with indicators of a hostile, as well as helpless,
state of mind. Third, empirically infants of these mothers are hypothesized to show
disorganized attachment behavior rather than organized ambivalent behavior, as would be
predicted if the mother's state of mind were best described as preoccupied.

Dev Psychopathol. Author manuscript; available in PMC 2007 April 26.

 LYONS–RUTH et al. Page 12

The coding system also includes a set of the following six individual frequency codes that serve
to tie the qualitative rating and classification to clearly specifiable features of the transcript:

“Global devaluation of a caregiver” was scored whenever the participant's language suggested
NIH-PA Author Manuscript

that globally negative representations of caregivers were held in the past, and that these
representations continued to be active in the present (i.e., have not been mitigated or distanced)
in adulthood. Examples included references such as “she was a witch,” “horrible,” or “I hated
him,” or their negatives, “I don't hate him.” This “all-bad” language could also be described
as “hot” devaluation in comparison to the “cool” derogation described by Main and Goldwyn
as a hallmark of the DS2 Dismissing subcategory. However, it should be noted that cool
derogation that was globally devaluing of a care-giver was also counted in these frequencies
and was considered a potential predictor of infant disorganization rather than avoidance.

“Identification with a hostile caregiver” was scored whenever a globally negative evaluation
of a caregiver was stated, yet the reader noted that the participant also identified with and
appeared to value or accept similarities between the negatively evaluated attachment figure
and the self. In some cases the parent's negative qualities were emphasized throughout the
interview and the identification with the parent was repeated in unrecognized form in the
present (e.g., participant's parent was criticized as extremely anxious and overprotective, and
participant justified her overly restrictive actions towards her own child). In other cases the
parent's negative qualities were emphasized, but the participant's similarity or closeness to the
NIH-PA Author Manuscript

parent was also emphasized, for example, “She was my enemy/we're very close.”

This form of contradiction was distinguished from the immediate evaluative oscillation
described by Main as characterizing Preoccupied participants in that these contradictions were
inferred over the entire interview, rather than necessarily existing as immediately juxtaposed
contradictory statements. In addition, these statements were not accompanied by involved
anger, suggesting that the expected negative affect had been segregated from the conscious
content.

“Recurrent references to fearful affect” was a frequency measure coded whenever the
participant made a reference to her own experiences of fearful affect states in the interview.
Fearful references could pertain to a variety of unrelated and/or not particularly threatening
circumstances.

“Sense of self as bad” referred to an internalized sense of “badness” or “blameworthiness” in

which the participant felt guilty, responsible, deserving of disrespectful treatment, or
undeserving of positive attention. By noting the continuation of this attitude into adulthood,
this code was thought to index an ongoing need to preserve a positive view of care-givers by
NIH-PA Author Manuscript

continuing to blame the self, as well as a lack of autonomy in making sense of childhood events.

“Laughter at pain” was coded whenever laughter followed anecdotes about psychological or
physical distress. Laughter at pain was understood as a defensive use of laughter to dismiss the
impact of childhood experiences of vulnerability.

“Ruptured attachments” was coded when a participant referred to no longer having contact
with one or more members of his or her nuclear family through a deliberate decision to
terminate contact. Because this code was relatively infrequent, the frequency of reference data
were converted to a dichotomous score with 0 = no references and 1 = one or more references.
Ruptured attachment relationships have been theoretically tied to all good/all bad unintegrated
representations in the clinical literature, as noted.

The initial version of the coding system for H/H states of mind was developed by Atwood and
Lyons–Ruth (Atwood, 1995). Blind to infant classification, Atwood examined a development

Dev Psychopathol. Author manuscript; available in PMC 2007 April 26.

 LYONS–RUTH et al. Page 13

set of 10 randomly selected AAIs stratified to include a sizeable number of interviews of

mothers of disorganized infants. Drawing on the theoretical literature reviewed earlier, an
initial version of the coding system was developed and the 10 interviews were coded blind to
NIH-PA Author Manuscript

all other data on the sample.

Two additional coders (C.Y. and S.M.) were then trained on this system using the 10 interviews
from the development set. Reliability coefficients on 15 additional randomly chosen interviews
were as follows: scaled score for H/H state of mind, ri = .83, H/H classification, κ = .86; global
devaluation of a care-giver, ri = .77; identification with a hostile caregiver, ri = .80; sense of
self as bad, ri = .85; recurrent references to fearful affect, ri = .70; recurrent laughter at pain,
ri = .90; and ruptured attachments in adulthood, ri = .71. All coders were blind to all other data
on the sample.

Results
Maternal states of mind on the AAI and demographic risk factors
Pearson correlations revealed no reliable relations between the H/H state of mind scale and
cumulative demographic risk within this uniformly low-income cohort (r = .06, ns). There were
also no reliable relations between individual demographic factors and H/H level (rs = −.11 to .
15, all ns). AAI classifications (1 = autonomous, 2 = dismissing or preoccupied, 3 = unresolved
or cannot classify) were also unrelated to cumulative demographic risk (r = −.04, ns), or any
NIH-PA Author Manuscript

individual measure of demographic risk. Given the lack of relation between demographic
factors and maternal states of mind, these variables were not included in further analyses.

H/H state of mind and unresolved loss on the AAI

The first hypothesis was that the H/H codes might overlap with the CC or E3 classifications
and provide additional specifiers of those states of mind. Table 1 displays the associations
between the H/H coding system and the existing Main and Goldwyn codes for U and CC states
of mind. As can be seen, the H/H state of mind scale was unrelated to maternal classification
as U using the Main and Goldwyn system, with the CC group omitted. The H/H scale was also
unrelated to the combined U and CC categories. Contrary to prediction, no AAI interview in
the current study was classified E3 or U/E3, so the relation between the H/H codes and the E3
subcategory could not be assessed in this study.

The individual frequency codes that are part of the H/H coding system were also unrelated to
both U and U or CC classifications, as shown in Table 1. Relations between the two systems
were no stronger using the 9-level U scale scores for loss and trauma (r = −.10 and −.04,
respectively) or scaling the AAI classifications to increase power (as Autonomous = 1/
Dismissing or Preoccupied = 2/U or CC = 3; r = .20, ns). Among mothers classified as having
NIH-PA Author Manuscript

organized states of mind, 54% were classified H/H: 56% of Autonomous (n = 18) mothers, 0%
of Dismissing (n = 3) mothers, and 80% of Preoccupied (n = 5) mothers. Among mothers
classified U or CC, 77 and 50%, respectively, were classified H/H.

Based on these results, the hypothesis that the H/H codes might represent additional specifiers
of states of mind now termed CC or Fearfully Preoccupied was not supported. Instead, H/H
codes captured aspects of parental state of mind that were unrelated to the U, CC, or E3
categories in the standard coding system.

Maternal H/H state of mind and infant disorganization

Hypothesis 2 was that in high-risk or clinical samples H/H states of mind would account for
additional variance in infant disorganization not associated with U states of mind. As shown
in Table 2, the extent of the mother's H/H state of mind on the AAI was significantly related

Dev Psychopathol. Author manuscript; available in PMC 2007 April 26.

 LYONS–RUTH et al. Page 14

to the extent of disorganized attachment behaviors displayed by the infant. Classification as

H/H was also related to infant disorganization. Given these significant correlations on the most
inclusive variables, the relations between infant disorganization and the frequency codes for
NIH-PA Author Manuscript

specific H/H features were assessed, as also shown in Table 2. The extent of mother's Laughter
at Pain and Devaluation of Caregivers were most strongly associated with the infant's
disorganization. Identification with a Hostile Caregiver and Recurrent References to Fearful
Affect both had reasonable effect sizes, but these were only marginally reliable with the present
sample size. Finally, one additional code, reflecting the presence of Ruptured Attachments in
Adulthood, was also a significant correlate of infant disorganization.

Table 2 also shows that in this high-risk sample neither U nor U/CC classifications on the AAI
were related to level of infant disorganized attachment behavior. A multiple regression analysis
on level of infant disorganized behavior confirmed that an H/H state of mind explained a
significant portion of the variance in infant disorganization not accounted for by U and CC
status on the AAI, as shown in Table 3.

Maternal U and H/H states of mind and subtypes of infant disorganization

Closer examination of the relation between U status and infant disorganization revealed that
concordance rates between mothers and infants differed significantly by the subtype of infant
disorganization displayed. Consistent with Main and Hesse's (1990) hypothesis, 80% of
mothers of disorganized–secure infants were classified U or CC on the AAI. However, only
NIH-PA Author Manuscript

23% of mothers of disorganized–insecure infants were classified U or CC, whereas 53% were
classified autonomous.

The HH coding system yielded similar results to the standard Main and Goldwyn system in
classifying mothers of D-secure infants, as shown in Figure 1. However, the H/H codes were
significantly more concordant with infant classification than U or CC classifications among
mothers of D-insecure infants, as also shown in Figure 1, χ2 (1, N = 24) = 6.00, p < .02. Among
mothers of D-insecure infants, 23% were classified U or CC compared to 75% classified HH.
Comparable figures for mothers of organized infants were 45% classified U or CC by the
standard system versus 54% classified HH by the current system.

Previous reports from this study have also documented that, compared to the disorganized–
secure group, mothers of disorganized–insecure infants were more hostile and role reversing
in interaction with their infants, had experienced higher rates of parental psychopathology as
children, and had higher rates of psychosocial problems in adulthood (Lyons–Ruth et al.,
1999; Lyons–Ruth, Repacholi, McLeod, & Silva, 1991). These multiple converging sources
of data indicate that failing to identify atypical states of mind among mothers in this subgroup
could result in misleading assessments of clinical samples.
NIH-PA Author Manuscript

Maternal H/H states of mind and disrupted mother–infant affective

communication—Hypothesis 3 was that any relations between maternal states of mind and
infant disorganization would be mediated by deviations in parent–infant interactions. Maternal
H/H states of mind were also related to maternal disrupted affective communication with the
infant (H/H classification, biserial r = .39, p < .03), and maternal U states of mind were also
marginally related to disrupted affective communication (biserial r = .33, p < .06). Adding the
CC classification to the U classification decreased the relation to maternal behavior (r = .15).
Frequencies of specific H/H codes were not significantly related to maternal disrupted
communication (rs = .08–.24). Consistent with previous reports from the larger infancy sample
(Lyons–Ruth et al., 1999), maternal disrupted communication was also related to infant
disorganization (r = .38, p < .03).

Dev Psychopathol. Author manuscript; available in PMC 2007 April 26.

 LYONS–RUTH et al. Page 15

Because there were three profiles of disrupted maternal behavior included in the overall
disrupted classification, it was of interest to examine whether some profiles of maternal
disrupted behavior were being better accounted for by maternal U or H/H states of mind than
NIH-PA Author Manuscript

others. The proportion of H/H and U states of mind associated with each maternal profile is
displayed in Figure 2. Although the cell sizes preclude meaningful statistical analysis, it is
apparent that all disrupted profiles, including the more subtle maternal behaviors represented
in the fearful–inhibited and withdrawing profiles, were contributing to the obtained significant
relation between disrupted communication and H/H states of mind, and with the CC groups
omitted, all disrupted profiles also contributed to the marginally significant relation between
disrupted communication and U states of mind.

When mothers with unresolved loss and mothers with unresolved abuse were differentiated in
the analysis, the incidence of disrupted maternal behavior increased linearly with the
progression from organized states of mind to unresolved loss to unresolved abuse, 44 to 78 to
100%, r (37) = .39, p < .02. However, only three mothers were classified U in relation to abuse,
indicating the need for replication of this finding. The finding does point to the potential
importance of differentiating the sequellae of loss from the sequelae of abuse, as well as of
developing broader criteria to capture states of mind associated with the aftermath of hostile,
emotionally unprotective, or frankly abusive relationships.

Given that the relations among maternal H/H state of mind, maternal behavior, and infant
NIH-PA Author Manuscript

disorganization were all significant, the criteria were met for a possible mediational role of
maternal behavior in transmitting the influence of maternal H/H states of mind to the infant
(Baron & Kenny, 1986). Therefore, a final regression analysis testing the mediational model
was conducted. With H/H states of mind entered first into the equation, the regression equation
for the relation between H/H state of mind and infant disorganization was significant, β = .37,
F (1, 35) = 5.43, p < .03. In the second equation, after variance associated with maternal
disrupted communication was accounted for by entering it first into the equation, the relation
between maternal H/H state of mind and infant disorganization decreased to nonsignificance,
β = .26, ΔF (1, 34) = 2.40, p < .13, while the coefficient for disrupted communication was
significant, β = .38, F (1, 35) = 5.85, p < .02.

This finding supports the conclusion that the effect of maternal H/H state of mind on infant
attachment behavior is at least partly mediated by the mother's disrupted affective
communication with her infant. However, the effect size associated with H/H state of mind (.
26) was still sizeable enough to reach significance in a larger sample, indicating the need for
replication before complete mediation is assumed. It is also notable that maternal disrupted
communication did not relate to the individual H/H frequency codes and so could not be
mediating the obtained relations between those codes and infant disorganization.
NIH-PA Author Manuscript

Discussion
The results of this study indicate that the coding system for H/H states of mind captures features
of discourse on the AAI that are associated with infant disorganization. Contrary to our
hypotheses, the aspects of discourse that indexed an H/H state of mind did not overlap
substantially with the standard criteria for assigning the classifications for U, CC, or E3 in the
standard Main and Goldwyn (1998) system. The CC category is currently applied to transcripts
in which the discourse characteristics change over the course of the interview (dismissing to
preoccupied) or change from parent to parent or in which coherence is low but no particular
state of mind scale is elevated. Although we had expected otherwise, the results indicate that
these CC indicators were independent of the HH indicators. There appear to be many ways to
manifest contradictory strategies on the AAI, not all of which are included in the U or CC
coding criteria.

Dev Psychopathol. Author manuscript; available in PMC 2007 April 26.

 LYONS–RUTH et al. Page 16

Rather than elaborating on the current criteria for those existing classifications, the H/H codes
appear to delineate additional trauma-related ways in which a contradictory or pervasively
unintegrated state of mind can be manifested on the AAI. The HH system both codes new
NIH-PA Author Manuscript

elements that do not overlap with the traditional system, and combines those new elements
with elements of the existing rare classifications (Ds2, E3) into more elaborated profiles
associated with the intergenerational transmission of disorganization. Thus, the H/H system is
an important augmentation to the current system for capturing indicators of a pervasively
unintegrated state of mind.As is evident, however, this work exists within the Main and
Goldwyn theoretical framework regarding integrated and unintegrated states of mind and
expands the existing Main and Goldwyn system to include additional ways that incoherence
manifests itself in more disturbed samples.

Consistent with standard AAI coding, it is not the content of the participant's experiences that
is used to classify the participant's state of mind. Instead, it is the way the participant organizes
his or her discourse about these experiences, that is, how the participant tells the story. The
discourse of H/H mothers when describing relational experiences with their own caregivers
was characterized by global devaluation of attachment figures, continued identification with
those devalued figures, a sense of self as bad, fearful affect, and laughter at pain, as well as
contradictory and unintegrated evaluations of central caregivers over the course of the
interview (see also Steele, 2003, for similar features in the AAIs of severely dissociative abused
patients).
NIH-PA Author Manuscript

It is important to note that a number of the simple frequency codes were also significantly
related to infant disorganization. Although capturing only specific and limited aspects of the
H/H conceptualization, the frequency codes were retained for analysis because they are more
closely tied to objectively specifiable features of the transcript than are the overall rating scale
and classification, which allow the coder to weight more global features of the transcript that
cannot easily be coded as frequency data. Given the limited and specific nature of the frequency
codes, their generally robust associations with infant disorganization were somewhat
surprising.

It is also important to note that because of the importance of assessing lack of resolution of
abuse in this sample, the standard AAI protocol was augmented with a set of questions
developed by trauma researchers to ask about the occurrence of physical abuse, sexual abuse,
and witnessed violence (Herman et al., 1989; see also Appendix A). These questions were
added to the protocols to enhance the ability to detect and code U states of mind and are not
necessary for the coding of the H/H system. In contrast to coding U states of mind, coding for
H/H states of mind does not rely on portions of the interview that relate to experiences of loss
or abuse. Similar to traditional coding procedures for organized states of mind, HH states of
NIH-PA Author Manuscript

mind are coded from discourse over the entire interview and the sections of the AAI that elicit
the most relevant material for H/H coding are the early adjectives and examples describing the
quality of the parent–child relationship and the later questions asking the parent to reflect on
childhood experiences. In support of the applicability of the HH coding system to standard
AAI protocols (without additional probes for abuse experiences), the coding system has also
been applied to the standard AAI interviews of borderline and dysthymic patients reported on
by Patrick et al. (1994; Melnick & Patrick, 2003). Those protocols did not include additional
questions about abuse and the HH system significantly differentiated between dysthymic and
borderline patients, with no problem applying the system.

Recent evidence indicates that the primary gain from the additional questions is likely to lie in
increased reporting of sexual abuse experiences. Bailey, Moran, and Forbes (2003) reported
that physical abuse experiences were reported at about the same rate on the standard format of
the AAI as on a structured traumatic experiences questionnaire; however, sexual abuse

Dev Psychopathol. Author manuscript; available in PMC 2007 April 26.

 LYONS–RUTH et al. Page 17

experiences were underreported on the AAI compared to the traumatic experiences

questionnaire. Therefore, the additional questions are likely to result in increased identification
of sexual abuse experiences compared to the standard AAI format. The validity of the AAI in
NIH-PA Author Manuscript

relation to the prediction of infant disorganization depends on accurate identification of abuse

experiences so that lack of resolution of such experiences can be assessed. Therefore, the
additional probes should have maximized the potential for experiences of abuse to be identified
during the interview and coded for U status.

Despite these attempts to identify abuse and provide opportunity for abuse-related discourse,
however, and despite the high rates of childhood abuse and infant disorganization in the sample
(47% of mothers, n = 21, had experienced physical or sexual abuse during childhood using
state criteria; Lyons–Ruth & Block, 1996), only three protocols met criteria for unresolved
abuse using the standard coding criteria. Thirteen percent of women considered abused by the
AAI coder (n = 23) were coded U for abuse, while 22% of women who had suffered a loss
(n = 45) were coded U for loss. Greater difficulty resolving loss than abuse experiences is
unexpected and difficult to justify given existing theory and research on sequellae of abuse. In
addition, most losses had not occurred prior to age 16, and did not involve nuclear family
members, while abuse experiences were all prior to adulthood.

There is almost no published data for comparison from other studies on the relative rates of
subjects with abuse histories who are classified U for abuse compared to rates of subjects with
NIH-PA Author Manuscript

loss histories who are classified U for loss. Such a breakdown would be valuable in future
reports. To date, however, there is no reason to consider these data atypical. Because the criteria
for U states of mind were originally developed for loss experiences and only subsequently
extended to abuse experiences, current criteria for lack of resolution may be more sensitive to
processes involved in integrating loss and less sensitive to processes involved in integrating
abuse. Abused mothers of D infants who were not captured by the U abuse scale included those
who either consistently denied occurrence of abusive events, for example, “She abused all the
other kids but she didn't hit me because I was too fast” (not a believable statement to those who
work with abusive families), or those who fit the profile described above where negative
experiences are frankly and vividly and concisely described, for example, “Did you consider
it abusive?” “Sure, it was abusive.” The essential problem is likely to be that “unresolved”
abuse presents in discourse in very different ways than does unresolved loss. In contrast, a high
proportion of abused women were classified as H/H, and the severity of both sexual and
physical abuse experiences were related to HH states of mind (Lyons–Ruth et al., 2003).

It seems unlikely that including the few additional questions about the occurrence of abuse
experiences altered the process of the AAI for the participant. First, for the large group who
have not experienced abuse, the questions do not apply. Second, recent data indicate that the
NIH-PA Author Manuscript

group who has experienced physical abuse is already reporting those experiences on the
standard AAI interview at the same rates as any structured questionnaires, as noted above.
Therefore, the AAI process for this group is also unlikely to be different. Only for the small
group who have experienced sexual abuse would we expect the AAI process to be different,
in that those experiences are often not elicited in the usual AAI format (Bailey et al., 2003)
and would be more likely to be elicited and discussed with the additional questions. However,
the opportunity to hear how such experiences are discussed in the interview should result in a
gain rather than a loss of coding validity for the AAI and, particularly, for the coding of lack
of resolution of abuse.

Given that the AAI data were gathered 5.5 years after the infant attachment and mother–infant
interaction data, the significant associations between state of mind and maternal and infant
behavior are especially notable. These predictive associations over time from infant attachment

Dev Psychopathol. Author manuscript; available in PMC 2007 April 26.

 LYONS–RUTH et al. Page 18

to maternal state of mind were also evident in the original Berkeley study data where AAIs
were gathered when the children were age 6 (Main et al., 1985).
NIH-PA Author Manuscript

In addition to being associated with infant disorganization and maternal disrupted

communication, an H/H state of mind has been associated with the severity of childhood trauma
in other analyses (Lyons–Ruth et al., 2003). Both exposure to physical violence and sexual
abuse alone, but not severity of loss experiences, were significantly associated with increased
indicators of a H/H state of mind. Severity of trauma was not directly associated with infant
disorganization, however. Therefore, the parent's H/H state of mind provided one indirect path
through which the parent's traumatic experiences were associated with disorganized attachment
in the next generation.

An H/H state of mind was not theoretically conceived as related only to trauma, however. An
important impetus for developing the current coding system was the view that parental
emotional unavailability, whether due to chronic hostility, role reversal, or withdrawal from
the child, responses that do not meet current criteria for abuse, constitutes a primary relational
trauma. The serious relational deviations inherent in parental hostility, role reversal, and
withdrawal can now be coded reliably from early infancy onward, and are robust predictors of
infant disorganization, as noted earlier (e.g., Goldberg et al., 2003; Kelly et al., 2003; Lyons–
Ruth et al., 1999; Madigan et al., 2003). According to this conceptualization, such primary
early relational trauma would be expected to impact overall symptom severity by adulthood
NIH-PA Author Manuscript

through at least three mechanisms. First, serious early relational deviations create early
impairments in the sense of safety and protection of the infant and young child, with
concomitant impact on neurobiological stress responses and psychological symptom
formation. Second, these parental stances are also likely to be correlated with the child's
exposure to physically threatening events over time. Third, unresponsive parental stances are
likely to contribute to more pronounced symptom formation around particular traumatic events,
due to the lack of parental comfort and help in integrating the traumatic experience. In this
light, it should be noted that despite the increased prevalence of H/H states of mind among
parents with a history of childhood abuse (Lyons–Ruth et al., 2003), such trauma histories were
neither necessary nor sufficient for the occurrence of H/H states of mind in this sample.

Given the relation between U states of mind and infant disorganization repeatedly found in
low-risk samples (van IJzendoorn et al., 1999), we view the lack of prediction from U to D in
this sample as resulting from the high prevalence of parenting dysfunction and adverse events
experienced during childhood by mothers in the current clinical sample. The standard coding
system for the AAI may be most sensitive to identifying lapses of monitoring of reason and
discourse related to family disruption and loss, while the H/H coding system was specifically
designed to detect the more pervasively unintegrated states of mind that accompany
NIH-PA Author Manuscript

experiences of relational trauma, including the cumulative traumas of consistently hostile or

withdrawn parenting, as well as the episodic traumas of abuse events.

Theoretically, we view a hostile adult stance, either as captured by the HH coding system or
as revealed in parent–infant interaction, as a likely outgrowth of a controlling/punitive stance
in childhood (Cassidy, Marvin, & the MacArthur Working Group, 1991). Additional codes for
controlling/punitive or controlling/caregiving stances in childhood and adulthood have been
added to the coding system since this study was completed. In the only work to date to use
those additional codes, Melnick and Patrick (2003) found that references to caregiving or
punitive stances in childhood, as well as other H/H codes, differentiated adult borderline
patients from adult dysthymic patients.

Although the description of a hostile stance has features in common with a dismissing stance,
it is notable that none of the protocols classified H/H were classified dismissing by Main and

Dev Psychopathol. Author manuscript; available in PMC 2007 April 26.

 LYONS–RUTH et al. Page 19

Goldwyn criteria, despite such indicators of denial of vulnerability as “laughter at pain.” These
protocols were not coded as dismissing because of the low or inconsistent levels of idealization
displayed in the devaluations of caregivers and the frankness with which negative experiences
NIH-PA Author Manuscript

were discussed. They were also not often coded as preoccupied because the negative
evaluations were usually not presented in the context of angry, entangled speech patterns but
as closed judgments in the context of a concise or even constricted discourse structure. In
addition, a number of these clinical protocols have features that are rare in normative samples,
including normative low-income samples, such as “hot” but concise devaluation, and those
features provide a poor fit to any of the existing category descriptions. Protocols like these in
which negative experiences were vividly related but the vulnerability and pain normally
associated with such experiences were distanced by laughter and discourse style tended to be
coded F1 or F4 in the Main and Goldwyn system, but to the clinician's eye these represent
tough, “street-kid” stances. It appears that the difficulties in early relationships were too
encompassing to be dealt with by lack of memory or by consistent idealization and caregivers
were often too frightening or vulnerable to risk any anger, so the difficulties are presented as
matter of fact or even as having a certain entertainment or shock value.

The H/H protocols closer to a helpless prototype were characterized most often by repeated
references to fearful affects, as well as global devaluation of caregivers, a sense of self as bad,
laughter at pain, and often frank reporting of negative experiences. Protocols of the helpless
subtype were not coded E3, however, because in many cases traumatic events were not the
NIH-PA Author Manuscript

topic of the fearful statements and/or were not identified or could not be inferred. Instead,
fearful statements were made about a variety of different topics throughout the interview. The
discourse of Helpless protocols was also likely to convey an attitude of lack of autonomy of
thought, although not necessarily through childlike or passive speech forms, in combination
with active role reversal in regard to a caregiver. Some participants classified in the Helpless
category described caregivers who were frightened or victimized and at the same time showed
identification with the victimized caregiver.

Theoretically, we view a helpless adult state of mind as a potential outgrowth of a caregiving

stance in childhood, organized around the (largely impossible) goal of helping an impaired
parent to function more effectively. At the most basic level, we would view the child's sense
of helplessness as grounded in a primary failure to receive effective care around attachment
needs in infancy. This sense of helplessness would be further elaborated in childhood as a
function of the inability to ease the parent's vulnerability, as well as by the identification with
and modeling of the parent's anxiety and dysfunction. Converging with this formulation,
Solomon and George (1999) described mothers of disorganized/controlling children as “…
helpless, in the sense of feeling themselves to be without strategies” (p. 19).
NIH-PA Author Manuscript

Although these hostile or helpless profiles anchor the two extremes of the distribution captured
by this coding system, it should be reiterated that these hostile or helpless states of mind often
occur in mixed rather than pure form. Consistent with the view that hostile and helpless working
models represent complementary roles in an unbalanced dyadic relational structure (Lyons–
Ruth et al., 1999), it is not surprising that women in the sample often displayed aspects of both
hostile and helpless discourse features, as well as mixed references to both caregiving and
punitive stances in childhood.

The H/H codes add to the Main and Goldwyn system in three ways. First, the coding system
for H/H states of mind examines discourse patterns throughout the whole interview. Second,
H/H codes can be assigned regardless of the occurrence of particular experiences in childhood,
so that coding does not depend on the identification of an experience of loss or abuse. Third,
the H/H coding system is informed by descriptions of defensive functions among clinical

Dev Psychopathol. Author manuscript; available in PMC 2007 April 26.

 LYONS–RUTH et al. Page 20

populations, thus extending the potential of the codes for capturing variations in attachment-
related states of mind within clinical groups.
NIH-PA Author Manuscript

Given the initial promise of these results, additional work is needed exploring the concurrent
correlates and predictive validity of these codes in a wider range of clinical samples with
concurrent infant attachment data. Data from one recent study of clinically referred outpatients
indicates that H/H states of mind (as well as U states of mind) are more prevalent among women
with borderline personality disorder than those with dysthymic disorders (Melnick & Patrick,
2003). However, no infant data from clinical samples are yet available to assess the
intergenerational transmission of H/H states of mind among specific diagnostic groups.
Assessing the factors associated with infant disorganization among clinical populations now
constitutes a critical agenda if adequate early prevention programs are to be designed for the
parents and infants at greatest risk.

Appendix A
Additional trauma questions inserted into the AAI
The following series of questions were inserted after the standard AAI question “Were your
parents ever threatening with you in any way?”.
a. When you were angry, what would happen?
NIH-PA Author Manuscript

b. How would your parents discipline you or others in your family?

c. Was it ever harsh enough for you to feel it was abusive?
d. How did it make you feel?
e. How do you feel the experience affects you now?
f. How do you feel this experience influences your approach to your own child?
g. Was there ever any (other) violence in your home?
h. How did you get your early sexual information?
i. How old were you when you had your first sexual experiences?
j. Have your sexual experiences been fully your choice, or was there some pressure or
coercion involved?
k. Were any of these experiences scary or upsetting?
l. Were any of these inappropriate enough to seem abusive?
NIH-PA Author Manuscript

m. How did it make you feel?

n. How do you feel this experience affects you now?
o. How do you feel this experience influences your approach to your own child?
(Herman et al., 1989). The standard questions continue with Question 10: “How do you think
these experiences with your own parents have affected your adult personality?”

References
Ainsworth, MDS.; Blehar, M.; Waters, E.; Wall, S. Patterns of attachment. Erlbaum; Hillsdale, NJ: 1978.
Allen JP, Hauser ST, Borman–Spurrell E. Attachment theory as a framework for understanding sequelae
of severe adolescent psychopathology: An 11-year follow-up study. Journal of Consulting and Clincial
Psychology 1996;64:254–263.

Dev Psychopathol. Author manuscript; available in PMC 2007 April 26.

 LYONS–RUTH et al. Page 21

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth
Edition. Author; Washington, DC: 1994.
Atwood, G. Adult attachment disorganization: A new classification and scoring scheme for the adult
NIH-PA Author Manuscript

attachment interview. Harvard University; 1995. Unpublished doctoral dissertation

Bailey, HN.; Moran, G.; Forbes, LM. Adolescent mothers'trauma symptoms, unresolved attachment, and
maladaptive parent–child interactions; Paper presented at the biennial meeting of the Society for
Research in Child Development; Tampa, FL. Apr. 2003
Bakermans–Kranenburg MJ, van IJzendoorn MH. A psychometric study of the Adult Attachment
Interview: Reliability and discriminant validity. Developmental Psychology 1993;29:870–880.
Baron R, Kenny D. The modulation–mediator variable distinction in social psychological research:
Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology
1986;51:1173–1182. [PubMed: 3806354]
Benoit DP, Kevin CH. Stability and transmission of attachment across three generations. Child
Development 1994;65:1444–1456. [PubMed: 7982361]
Bowlby, J. Attachment and loss: Vol. 2. Separation anxiety and anger. Basic Books; New York: 1973.
Calverley R, Fischer KW, Ayoub C. Complex splitting of self-representations in sexually abused
adolescent girls. Development and Psychopathology 1994;81:195–213.
Cassidy, J.; Marvin, RS.; The MacArthur Working Group on Attachment. Attachment organization in
preschool children: Coding guidelines. 3rd ed.. 1991. Unpublished manuscript
Connell, DB. Individual differences in attachment: An investigation into stability, implications, and
relationships to structure of early language development. Syracuse University; 1976. Unpublished
NIH-PA Author Manuscript

doctoral dissertation
Coplan JD, Andrews MW, Rosenblum LA, Owens MJ, Friedman S, Gorman JM, Nemeroff CB. Persistent
elevations of cerebrospinal fluid concentrations of corticotropin-releasing factor in adult nonhuman
primates exposed to early-life stressors: Implications for the pathophysiology of mood and anxiety
disorders. Neuorobiology 1996;93:1619–1623.
Crittenden PM. Maltreated infants: Vulnerability and resilience. Journal of Child Psychology and
Psychiatry and Allied Disciplines 1985;26:85–96.
Davidson, C. The intergenerational transmission of resilience and risk: Maternal depression, maternal
attachment states, and the competence of school-aged children. Tufts University; 1993. Unpublished
doctoral dissertation
Ethier, LS.; Lacharite, C.; St-Laurent, D. Parental negligence; Paper presented at the Quebec Attachment
Conference; Quebec. Apr. 2002
Evans, EM.; Forbes, LM.; Bento, S.; Moran, G.; Pederson, DR.; DeOliveira, CA. Continuity and change
from infancy to toddlerhood in measures of attachment and maternal behavior; Poster presented at
the biennial meeting of the Society for Research in Child Development; Tampa, FL. 2003.
Francis D, Diorio J, Liu D, Meaney M. Nongenomic transmission across generations of maternal behavior
and stress responses in the rat. Science 1999;286:1155–1158. [PubMed: 10550053]
George, C.; Kaplan, N.; Main, M. Adult Attachment Interview. University of California Berkeley;
NIH-PA Author Manuscript

198419851996. Unpublished manuscript

Goldberg S, Benoit D, Blokland K, Madigan S. Atypical maternal behavior, maternal representations and
infant disorganized attachment. Development and Psychopathology 2003;15:239–257. [PubMed:
12931826]
Grienenberger, J.; Kelly, K. Maternal reflective functioning and caregiving: Links between mental states
and observed behavior in the intergenerational transmission; Paper presented at the biennial meeting
of the Society for Research in Child Development; Minneapolis, MN. Apr. 2001
Herman, JL. Trauma and recovery. Basic Books; New York: 1992.
Herman JL, Perry JC, van der Kolk BA. Childhood trauma in borderline personality disorder. American
Journal of Psychiatry 1989;146:490–495. [PubMed: 2929750]
Hesse, E. The adult attachment interview: Historical and current perspectives. In: Cassidy, J.; Shaver,
PR., editors. Handbook of attachment: Theory, research, and clinical applications. Guilford Press;
New York: 1999.

Dev Psychopathol. Author manuscript; available in PMC 2007 April 26.

 LYONS–RUTH et al. Page 22

Hesse E, Main M. Second generation effects of unresolved trauma in nonmaltreating parents: Dissociated,
frightening, and threatening parental behavior. Psychoanalytic Inquiry 1999;19:481–540.
Holtzworth–Munroe A, Stuart GL, Hutchinson G. Violent versus nonviolent husbands: Differences in
NIH-PA Author Manuscript

attachment patterns, dependency, and jealousy. Journal of Family Psychology 1997;11:314–331.

Horowitz, M. Stress response syndromes. 2nd ed.. Jacob Aronson; New York: 1986.
Kelly, KM.; Ueng–McHale, J.; Grienberger, J.; Slade, A. Atypical maternal behaviors at 4 months of age
and their relation to infant attachment disorganization; Paper presented at the biennial meeting of the
Society for Research in Child Development; Tampa, FL. Apr. 2003
Kernberg, O. Borderline conditions and pathological narcissism. Jacob Aronson; New York: 1975.
Kluft, R. Multiple personality. In: Tansman, A.; Goldfinger, S., editors. Review of psychiatry. 10.
American Psychiatric Press; Washington, DC: 1991. p. 161-188.
Lyons–Ruth K, Block D. The disturbed care-giving system: Relations among childhood trauma, maternal
caregiving, and infant affect and attachment. Infant Mental Health Journal 1996;17:257–275.
Lyons–Ruth, K.; Bronfman, E.; Atwood, G. A relational diathesis model of hostile–helpless states of
mind: Expressions in mother–infant interaction. In: Solomon, J.; George, C., editors. Attachment
disorganization. Guilford Press; New York: 1999. p. 33-70.
Lyons–Ruth K, Bronfman E, Parsons E. Maternal frightened, frightening, or atypical behavior and
disorganized infant attachment patterns. Monographs of the Society for Research in Child
Development 1999;64(3)Serial No. 258
Lyons–Ruth K, Connell D, Grunebaum H, Botein S. Infants at social risk: Maternal depression and family
support services as mediators of infant development and security of attachment. Child Development
NIH-PA Author Manuscript

1990;61:85–98. [PubMed: 2307048]

Lyons–Ruth K, Connell D, Zoll D, Stahl J. Infants at social risk: Relations among infant maltreatment,
maternal behavior, and infant attachment behavior. Developmental Psychology 1987;23:223–232.
Lyons–Ruth, K.; Melnick, S.; Atwood, G.; Yellin, C. Pervasively unintegrated hostile–helpless states of
mind on the Adult Attachment Interview: Classification and coding manual version 3.0. Harvard
Medical School; 2003. Unpublished manuscript
Lyons–Ruth K, Repacholi B, McLeod S, Silva E. Disorganized attachment behavior in infancy: Short-
term stability, maternal and infant correlates, and risk-related subtypes. Development and
Psychopathology 1991;3:377–396.
Lyons–Ruth K, Yellin C, Melnick S, Atwood G. Childhood experiences of trauma and loss have different
relations to maternal unresolved and hostile–helpless states of mind on the AAI. Attachment and
Human Development 2003;5:330–352. [PubMed: 15061308]
Madigan, S.; Hawkins, EJ. Pathways to disorganization: Links between histories of physical and sexual
abuse and atypical maternal behavior; Poster presented at the biennial meeting of the Society for
Research in Child Development; Tampa, FL. Apr. 2003
Madigan, S.; Pederson, DR.; Moran, G. Bridging the gap between unresolved states of mind and
disorganized attachment relationships: Links to atypical maternal behavior; Poster presented at the
biennial meeting of the Society for Research in Child Development; Tampa, FL. Apr. 2003
NIH-PA Author Manuscript

Main, M.; Goldwyn, R. Adult attachment scoring and classification system. Version 6.3. University of
California at Berkeley; 1998. Unpublished manuscript
Main, M.; Hesse, E. Parents' unresolved traumatic experiences are related to infant disorganized
attachment status: Is frightened and/or frightening parental behavior the linking mechanism?. In:
Greenberg, M.; Cicchetti, D.; Cummings, EM., editors. Attachment in the preschool years: Theory,
research and intervention. University of Chicago Press; Chicago: 1990. p. 161-184.
Main M, Kaplan N, Cassidy J. Security in infancy, childhood and adulthood: A move to the level of
representation. Monographs of the Society for Research in Child Development 1985;50(1–2):66–
104.Serial No. 209)
Main, M.; Solomon, J. Procedures for identifying infants as disorganized/disoriented during the
Ainsworth Strange Situation. In: Greenberg, M.; Cicchetti, D.; Cummings, EM., editors. Attachment
in the preschool years: Theory, research and intervention. University of Chicago Press; Chicago:
1990. p. 121-160.
Melnick, S.; Patrick, M. Discriminating borderline states of mind: Operationalizing the concept of
affective splitting and pervasively unintegrated states of mind on the adult attachment interview;

Dev Psychopathol. Author manuscript; available in PMC 2007 April 26.

 LYONS–RUTH et al. Page 23

Poster presented at the biennial meeting of the Society for Research in Child Development; Tampa,
FL. Apr. 2003
Ogawa JR, Sroufe LA, Weinfield NS, Carlson EA, Egeland B. Development and the fragmented self:
NIH-PA Author Manuscript

Longitudinal study of dissociative symptomatology in a nonclinical sample. Development and

Psychopathology 1997;9:855–879. [PubMed: 9449009]
Patrick M, Hobson RP, Castle P, Howard R, Maughan B. Personality disorder and mental representation
of early social experience. Development and Psychopathology 1994;6:375–388.
Putnam FW. Recent research on multiple personality disorder. Psychiatric Clinics of North America
1991;14:489–502. [PubMed: 1946019]
Radke–Yarrow M, Cummings EM, Kuczynski, Chapman M. Patterns of attachment in two-and three-
year olds in normal families and families with parental depression. Child Development 1985;36:884–
893.
Richters JE, Waters E, Vaughn BE. Empirical classification of infant–mother relationships from
interactive behavior and crying during reunion. Child Development 1988;59:512–522. [PubMed:
3359869]
Sagi A, van IJzendoorn M, Scharf M, Koren–Karie N, Joels T, Mayseless O. Stability and discriminant
validity of the Adult Attachment Interview: A psychometric study in young Israeli adults.
Developmental Psychology 1994;30:771–777.
Solomon, J.; George, C. The measurement of attachment security in infancy and childhood. In: Cassidy,
J.; Shaver, PR., editors. Handbook of attachment: Theory, research, and clinical applications.
Guilford Press; New York: 1999. p. 287-316.
NIH-PA Author Manuscript

Spangler, G.; Grossmann, K. Individual and physiological correlates of attachment disorganization in

infancy. In: Solomon, J.; George, C., editors. Attachment disorganization. Guilford Press; New York:
1999. p. 95-124.
Steele H. Unrelenting catastrophic trauma within the family: When every secure base is abusive.
Attachment and Human Development 2003;5:353–366. [PubMed: 15061309]
Teicher MH. Scars that won't heal: The neurobiology of child abuse. Scientific American 2002;286(3):
68–75. [PubMed: 11857902]
Terr LC. Childhood traumas: An outline and overview. American Journal of Psychiatry 1991;148:10–
20. [PubMed: 1824611]
Wartner UG, Grossmann K, Fremmer–Bombik E, Suess G. Attachment patterns at age six in south
Germany: Predictability from infancy and implications for preschool behavior. Child Development
1994;65:1014–1027.
van der Kolk B, Fisler R. Childhood abuse and neglect and loss of self-regulation. Bulletin of the
Menninger Clinic 1994;58:145–168. [PubMed: 7519094]
van IJzendoorn MH. Adult attachment representations, parental responsiveness, and infant attachment:
A meta-analysis on the predictive validity of the Adult Attachment Interview. Psychological Bulletin
1995;117:387–403. [PubMed: 7777645]
van IJzendoorn MH, Feldbrugge J, Derks F, de Ruiter C. Attachment representations of personality-
NIH-PA Author Manuscript

disordered criminal offenders. American Journal of Orthopsychiatry 1997;67:449–459. [PubMed:

9250345]
van IJzendoorn MH, Schuengel C, Bakermans–Kranenburg MJ. Disorganized attachment in early
childhood: Meta-analysis of precursors, concomitants, and sequelae. Development and
Psychopathology 1999;11:225–249. [PubMed: 16506532]
Yehuda R, Hallig S, Grossman R. Childhood trauma and risk for posttraumatic stress disorder:
Relationship to intergenerational effects of trauma, parental posttraumatic stress disorder, and cortisol
excretion. Development and Psychopathology 2001;13:733–753. [PubMed: 11523857]
Zanarini MC, Williams AA, Lewis RE, Reich DB, Vera SC, Marino MF. Reported pathological childhood
experiences associated with the development of borderline personality disorder. American Journal
of Psychiatry 1997;154:1101–1106. [PubMed: 9247396]

Dev Psychopathol. Author manuscript; available in PMC 2007 April 26.

 LYONS–RUTH et al. Page 24
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Figure 1.
Maternal states of mind on the AAI and subtypes of disorganized infant attachment strategies.
NIH-PA Author Manuscript

Dev Psychopathol. Author manuscript; available in PMC 2007 April 26.

 LYONS–RUTH et al. Page 25
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Figure 2.
Maternal states of mind on the AAI and profiles of maternal disrupted affective communication.
NIH-PA Author Manuscript

Dev Psychopathol. Author manuscript; available in PMC 2007 April 26.

 LYONS–RUTH et al. Page 26

Table 1
Relations between unresolved (U) or cannot classify (CC) AAI classifications and Hostile/Helpless (HH) state
of mind codes
NIH-PA Author Manuscript

AAI Classification

U or
U vs. Organized CC vs. Organized
H/H Codes (N = 39)a (N = 45)

Overall state of mind

Level of HH state of mind .14 .15
Classification as HH .22 .15
Individual codes
Identification with a hostile caregiver −.02 −.05
Global devaluation of caregiver −.03 −.10
Sense of self as bad −.02 −.09
Recurrent references to fearful affect .08 .01
Recurrent laughter at pain .02 −.01
Ruptured attachments in adulthood .09 .01

Note: Point biserial correlations are shown, except for the HH classification and ruptured attachments in adulthood where phi is shown. All p values are
nonsignificant.
a
Six AAIs classified as CC were omitted.
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Dev Psychopathol. Author manuscript; available in PMC 2007 April 26.

 LYONS–RUTH et al. Page 27

Table 2
Magnitude of association between maternal states of mind on the AAI and extent of infant disorganized
attachment behavior
NIH-PA Author Manuscript

Maternal AAI Codes r

H/H codes
Overall state of mind codes
Level of HH state of mind .35*
HH classification .35*
Individual codes
Identification with a hostile caregiver .29†
Global devaluation of caregiver .31*
Sense of self as bad .27†
Recurrent references to fearful affect .28†
Recurrent laughter at pain .36*
Ruptured attachments in adulthood .43**
Main and Goldwyn codes
Classification as U (CC omitted)a .05
Classification as U or CC −.10

Note: N = 41. Pearson correlations are shown, except for HH and U or CC classifications where point biserial correlations are shown.
a
N = 35.
†
p < .10.
*
p < .05.
NIH-PA Author Manuscript

**
p < .01.
NIH-PA Author Manuscript

Dev Psychopathol. Author manuscript; available in PMC 2007 April 26.

 LYONS–RUTH et al. Page 28

Table 3
Contribution of maternal state of mind on the AAI to infant disorganization

Results of Regression
Analysis on Infant
NIH-PA Author Manuscript

Disorganization

Maternal State of
Mind β R ΔR2 ΔF

Step 1
U or CC −.13 .10 .01 .37
Step 2
Level H/H .36 .37 .13 5.74*

Note: N = 41.
*
p < .02.
NIH-PA Author Manuscript
NIH-PA Author Manuscript

Dev Psychopathol. Author manuscript; available in PMC 2007 April 26.