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. Author manuscript; available in PMC: 2022 Jun 1.
Published in final edited form as: Attach Hum Dev. 2020 Mar 4;23(3):328–349. doi: 10.1080/14616734.2020.1734642

Developmental pathways from maternal history of childhood maltreatment and maternal depression to toddler attachment and early childhood behavioral outcomes

Michelle E Alto a, Jennifer M Warmingham a, Elizabeth D Handley a, Fred Rogosch a, Dante Cicchetti a,b, Sheree L Toth a
PMCID: PMC7483191  NIHMSID: NIHMS1571532  PMID: 32126891

Abstract

The current study examined the development of toddler attachment and early childhood behavior among children of mothers with a history of childhood maltreatment and current major depressive disorder. Maternal depression, maternal sensitivity, and toddler attachment were assessed as mediators of the association between maternal history of childhood maltreatment and child internalizing and externalizing behavior. Participants were from a low-income, largely racial minority urban sample and included 123 mothers with (n = 69) and without (n = 54) major depressive disorder at baseline and their children assessed at 12, 26, and 36 months old. Findings suggest maternal depression and maternal sensitivity mediated the association between maternal history of childhood maltreatment and disorganized attachment. Maternal depression, but not disorganized attachment, mediated the association between maternal history of childhood maltreatment and child symptomatology. Results suggest that supporting mothers through depression and processing their adverse childhood experiences are critical in fostering positive child development.

Keywords: Maternal history of childhood maltreatment, maternal depression, maternal sensitivity, toddler attachment, child behavior, developmental psychopathology

To best support children on a positive developmental trajectory, it is important to identify pathways of risk and resilience across domains and throughout a child’s life. This approach is the hallmark of the developmental psychopathology perspective (Cicchetti & Toth, 1997). According to this perspective, developmental outcomes at any given point are a function of earlier transactions between risk and protective factors, a process referred to as developmental cascades. Developmental cascades explain the cumulative developmental consequences of these processes across ecological levels, among domains at the same level, and across different systems (Masten & Cicchetti, 2010). In this way, the risk and protective factors that impact child development can reach across generations, creating implications for a mother’s history and current functioning on the course of her child’s development.

Because child maltreatment is a significant public health problem (Norman et al., 2012; Sedlak et al., 2010), many women enter into motherhood carrying with them a history of maltreatment from their childhoods. The National Incidence Study-4 (Sedlak et al., 2010) estimates that in the United States, approximately one child in every 58 is subjected to maltreatment. Of those who are maltreated, 58% of children experience physical abuse, 24% experience sexual abuse, 27% experience emotional abuse, 47% experience educational neglect, 38% experience physical neglect, and 25% experience emotional neglect. Many adults have experienced more than one subtype of maltreatment as a child, with approximately half of maltreated children experiencing chronic, multi-subtype maltreatment (Warmingham, Handley, Rogosch, Manly, & Cicchetti, 2019). Environmental factors can further increase risk for a history of childhood maltreatment. Sedlak etal. (2010) suggest that children of low socioeconomic status (SES) experience maltreatment at more than 5 times the rate of other children. They also found racial differences in maltreatment experiences, with Black children experiencing physical abuse, overall abuse, and overall maltreatment at the highest rates. However, this difference depended on socioeconomic status. For example, no differences in physical or emotional abuse were found between Black and White children in low SES households, but differences emerged in middle and high SES households. Therefore, women who were raised in low-income environments may be at the highest risk of having experienced maltreatment when they were children, regardless of race.

Childhood maltreatment is a significant risk factor for adult psychopathology, including depression (Kessler et al., 2010). Individuals with histories of physical abuse, emotional abuse, and neglect have been shown to be at higher risk for developing depressive disorders than those without histories of abuse (Norman et al., 2012). Among those with a history of childhood sexual abuse, rates of depression are approximately 2 to 3 times higher than among those without a history of childhood sexual abuse (Molnar, Buka, & Kessler, 2001). The postpartum period may be particularly challenging for mothers who experienced childhood maltreatment, as there is a significant association between current and past abuse and postpartum depression (Ross & Dennis, 2009). Childhood maltreatment also confers risk for the development of recurrent and persistent depression and lack of response or remission during treatment (Nanni, Uher, & Danese, 2012). As a result, mothers who experienced maltreatment as children are not only more likely to experience postpartum depression, but are also more likely for that depression to persist or recur throughout their child’s life. Low-income contexts also confer greater risk for depression (Inaba et al., 2005), suggesting that mothers with a history of childhood maltreatment who live in poverty may face compounded risk for psychopathology. Therefore, the risk from mothers’ histories of childhood maltreatment and from their depression both have the potential to set forth a negative developmental cascade in their children’s development, creating important potential points of intervention.

Development of attachment

A mother’s history of childhood maltreatment and her struggles with depression have significant implications for the quality of her interactions with her infant and the subsequent development of the attachment relationship. Early mother–child interactions influence the infant’s perception of the caregiver as a secure base from which to explore the world and as a source of protection (Bowlby, 1969). If a caregiver is responsive to the infant’s distress, then the infant learns to seek comfort from that caregiver in order to self-regulate and is more likely to develop secure attachment (Ainsworth, Blehar, Waters, & Wall, 1978; van IJzendoorn, Juffer, & Duyvesteyn, 1995). Conversely, if a caregiver is insensitive and inconsistent, then the infant is more likely to associate attempts to seek comfort from that caregiver with aversive consequences, increasing the likelihood of insecure attachment. This insecurity can be insecure-avoidant, characterized by clear avoidance of the caregiver as a source of comfort, or insecure-ambivalent, characterized by significant distress that interferes with the child’s ability to receive comfort (Ainsworth et al., 1978). Infants can also develop disorganized attachment, which is characterized by disoriented or fearful behavior in the presence of the caregiver (Main & Solomon, 1990). Disorganized attachment involves a breakdown of organized (secure or insecure) attachment strategies, and is therefore an important indication of dysfunction within the parent–child relationship.

A variety of contextual factors can increase the risk for disorganized attachment. For example, rates of disorganized attachment are significantly higher in low-income compared to middle class samples (van IJzendoorn, Schuengel, & Bakermans-Kranenburg, 1999). In order to foster the development of secure attachment and prevent disorganized attachment, researchers have worked to understand specific behavioral precursors to different attachment classifications. Findings suggest the ideal caregiver response is sensitive and responsive in a way that acknowledges the infant’s individual attributes, accepts the infant’s behaviors, soothes the infant’s distress, and creates harmonious interactions (Ainsworth, 1973). Sensitivity has been traditionally highlighted as the key precursor of secure attachment both theoretically and empirically, although effects have been shown to be weaker in low socioeconomic samples (de Wolff & Van IJzendoorn, 1997). Conversely, insensitivity has been found to predict disorganized attachment (van IJzendoorn et al., 1999), with stronger effects observed in samples of high sociodemographic risk (Gedaly & Leerkes, 2016). Race, however, has not been shown to moderate the relationship between parenting and child or adolescent attachment (Dexter, Wong, Stacks, & Beeghly, 2013; Haltigan et al., 2019), suggesting that socioeconomic status may have a stronger impact than race on the development of attachment.

Beyond maternal insensitivity, anomalous maternal behavior, including frightened, frightening, and dissociative behavior as described by Main and Hesse (1990), and disrupted behavior as described by Lyons-Ruth, Bronfman, and Parsons (1999), are also strongly predictive of disorganized attachment, with no difference in effect depending on the risk status of the sample (Madigan, Moran, & Pederson, 2006). Disconnected, extremely insensitive parenting has been implicated in the development of disorganized attachment in low risk samples as well (Out, Bakermans-Kranenburg, & van IJzendoorn, 2009). Although any of these positive or negative behaviors may occur within the attachment relationship at any given time, it is the frequency and overarching pattern of caregiving that most strongly influences the quality of attachment that develops.

Maternal history of childhood maltreatment and attachment

A mother’s past maltreatment history can impact the parenting behavior that underlies the development of attachment. Research has shown that mothers with a history of childhood abuse tend to demonstrate less positive parenting skills (Sidebotham & Golding, 2001), less sensitivity (Pereira et al., 2012), less responsivity (Bert, Guner, & Lanzi, 2009), and greater hostility and intrusiveness (Driscoll & Easterbrooks, 2007; Lyons-Ruth & Block, 1996) with their children. Furthermore, in both low-income samples and samples controlling for demographic risk, lower rates of secure attachment have been found among infants whose mothers experienced abuse in childhood as compared to those whose mothers did not (Lyons-Ruth & Block, 1996; Stacks et al., 2014). Specifically, infants of mothers who experienced childhood violence are more likely to have disorganized attachment, and infants of mothers who experienced childhood neglect are more likely to have insecure-avoidant attachment (Lyons-Ruth & Block, 1996). More generally, parental unresolved loss and trauma have also been found to predict disorganized infant attachment (van IJzendoorn et al., 1999).

Maternal depression and attachment

In a review of the early literature on parenting in caregivers affected by a range of depression from clinical levels to depressed mood, Gelfand and Teti (1990) found that maternal depression was associated with a number of negative parenting behaviors, including unresponsiveness, inattentiveness, intrusiveness, inept discipline, and negative perceptions of children. These results were later replicated in a meta-analysis that found maternal depression was associated with negative (e.g. threatening gestures, negative maternal affect and facial expression, greater expressed anger and intrusiveness) and disengaged (e.g. neutral affect, ignoring, withdrawal, silence during gaze aversion) maternal behavior (Lovejoy, Graczyk, O’Hare, & Neuman, 2000). Strongest effects were observed among disadvantaged women, suggesting that poverty may exacerbate the effect of depression on parenting behavior.

Although there are strong theoretical reasons to suspect that depression would be robustly associated with insecure attachment on the basis of parenting behavior, the findings in the literature are inconsistent. One meta-analysis found depression was significantly associated with attachment security, and this effect was stronger in clinical samples, which had consistently severe depressive symptoms, than community samples, which had greater heterogeneity in symptom severity (Atkinson et al., 2000). However, additional meta-analytic work by van IJzendoorn et al. (1999) suggests a nonsignificant association between maternal depression and disorganized infant attachment in more heterogeneous community samples, but a significant association in clinical samples. Variability in findings suggests that severity of depressive symptoms and method of assessment are important to consider in understanding the effect of depression on attachment.

Sensitivity has been shown to mediate the effect of maternal depressive symptoms on preschoolers’ attachment in a racially and socioeconomically diverse sample (Hopkins, Gouze, & Lavigne, 2013). However, other studies have not found empirical support for the depression-sensitivity-attachment relationship. Although a sample of low-risk mothers with depression were observed to be less sensitively attuned, less affirming, and more negating in a study by Murray, Fiori-cowley, and Hooper (1996), the nature of mothers’ interactions with their 2-month-old infants did not predict later attachment when their children were 18 months old. It is important to better understand how maternal depression impacts the development of attachment in order to prevent disorganized attachment and support positive child outcomes, particularly among families impacted by multiple risk factors.

Patterns of maternal risk

Because mothers who struggle with a history of childhood maltreatment are at greater risk for depression (Kessler et al., 2010), it may be particularly challenging for them to engage in sensitive and responsive parenting. Maternal depression has served as a mediator of the association between maternal history of childhood maltreatment and parenting behavior in predominantly racial minority, low-income samples (Banyard, Williams, & Siegel, 2003; Michl-Petzing, Handley, Sturge-Apple, Cicchetti, & Toth, 2019). However, attachment was not examined as an outcome in either of these studies. Understanding whether this pattern of maternal risk extends to the development of attachment will help researchers and clinicians more effectively prevent disorganized attachment.

Attachment and child development

Attachment has been shown to predict both internalizing and externalizing symptoms in children. Insecure-avoidant attachment, but not insecure-ambivalent or disorganized attachment, has been associated with internalizing symptoms, with no differences depending on socioeconomic status (Groh, Roisman, van IJzendoorn, Bakermans-Kranenburg, & Fearon, 2012). With respect to externalizing symptoms, disorganized attachment has been shown to have the strongest predictive effects, with weaker effects for insecure-avoidant and insecure-ambivalent attachment, larger effects for boys, and no effect of socioeconomic status (Fearon, Bakermans-Kranenburg, van IJzendoorn, Lapsley, & Roisman, 2010). These results suggest that internalizing and externalizing behaviors may be important to examine as distinct outcomes when evaluating the developmental effects of disorganized attachment on children’s early behavior problems.

The pattern of development that takes place from a mother’s history of childhood maltreatment to the development of her attachment relationship with her child and her child’s subsequent behavioral outcomes represents a developmental cascade that spans time, domains (relationships, mental health), and systems (parent, child). Understanding this developmental pathway provides important information about how to intervene (e.g. parenting behavior, attachment) and with whom to intervene (e.g. mothers with histories of childhood maltreatment, mothers with depression) to support positive child development, particularly in a context where risk may be compounded by the effects of race and poverty.

Aims and hypotheses

The aim of the current study is to investigate the links between mothers’ histories of childhood maltreatment, mothers’ current major depressive disorder (MDD) status, and the development of the mother-child attachment relationship, and to further investigate how this attachment relationship is associated with behavioral outcomes in early childhood in a predominantly racial minority, low-income sample using a longitudinal design. Maternal depression and maternal sensitivity are predicted to mediate the association between maternal history of childhood maltreatment and disorganized attachment. Further, disorganized attachment is hypothesized to mediate the paths from maternal risk to child internalizing and externalizing behavior.

Methods

Participants

Participants in this study were recruited as part of a larger randomized clinical trial testing the efficacy of two interventions on MDD and the mother-child relationship in low-income mothers (see Toth et al., 2013). Non-treatment-seeking biological mothers between the ages of 18–44 who had a 12-month-old infant and were living at or below the federal poverty level were recruited from primary care and Women, Infant, and Children clinics in Western New York.

Women were initially screened with the Center for Epidemiologic Studies Depression Scale (CES-D; Radloff, 1977) by a project recruitment coordinator. Those who scored above a 16 were further assessed to determine eligibility for inclusion in the depressed group, and those who scored under a 16 were assessed for inclusion in the non-depressed group. Because the CES-D was used as a screening tool, data from this measure were not retained. Mothers were included in the depressed group if they met MDD diagnostic criteria based on the Diagnostic Interview Schedule for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DIS-IV; Robins, Cottler, Bucholz, & Compton, 1995), which was administered during their first visit and after they had provided consent. Mothers in the non-depressed group did not meet criteria for current or past MDD.

Only mothers without MDD (n = 54) and mothers with MDD randomized to the enhanced control condition (n = 69) were included in the current analyses to control for any confounding intervention effect. Mothers were also excluded if they met criteria for bipolar disorder (n = 4). Mothers with MDD in the enhanced control condition were offered referrals to services in the community, but were not required to attend treatment. Of the referrals provided, 66.5% of women in the enhanced control condition elected to receive individual counseling, 52.6% began medication, 42.1% attended support groups, 10.5% received family/marital counseling, and 21.1% attended day treatment. In addition, all participants with MDD were connected to a project staff member throughout the study who provided education, support, and referrals as requested. As a result, treatment received in the enhanced control group ranged from no intervention to psychotherapy and additional services.

The final sample ranged in age from 18 to 38 years (Mage = 25.1) and their children (49% female) were approximately 12 months old at baseline. The sample identified as largely Black (60% Black, 22% White, 18% Other) and non-Hispanic (84% non-Hispanic, 16% Hispanic). Three families were lost at both waves following baseline, and all were in the depressed group.

Procedure

Families were assessed at baseline when infants were approximately 12 months old (T1), again when infants were approximately 26 months old (T2), and again when children were 36 months old (T3). Mothers provided informed consent for their and their children’s participation prior to data collection. Research was conducted with Institutional Review Board’s approval. All assessments were conducted by trained interviewers who were unaware of group condition or study hypotheses. At each time period, assessments took place over four visits at home and at the research center. At T1, mothers were administered the DIS-IV and the BDI-II (Beck, Steer, & Brown, 1996) to assess their depression, and the Childhood Trauma Questionnaire (Bernstein & Fink, 1998) to assess their history of childhood maltreatment. At T2, mothers participated in the Strange Situation (Ainsworth et al., 1978) to assess attachment. Research assistants completed their observations of maternal sensitivity using the Maternal Behavior Q Sort (Pederson & Moran, 1995) after the series of T2 visits was complete. At T3, mothers reported on children’s behaviors using the Child Behavior Checklist (Achenbach & Rescorla, 2000). Due to variations in literacy and reading ability among study participants, all self-report measures were read aloud while participants followed along and marked their answers.

Measures

Center for epidemiologic studies depression scale

(CES-D; Radloff, 1977). The CES-D is a 20-item self-report scale designed to assess depressive symptoms within the last week. Scores range from 0 to 60 with a cut-off of ≥16 indicating clinically meaningful depressive symptoms. This measure was used as an initial screen in the recruitment process to determine mothers’ eligibility for study participation.

Beck depression inventory-II

(BDI-II; Beck et al., 1996). The BDI-II uses 21 self-report, multiple-choice items to assess the severity of depression. Scores at or above 19 indicate clinically significant depressive symptoms. This measure was used to assess severity of current depressive symptoms. In the current sample, internal consistency was good (α =.956).

Diagnostic interview schedule

(DIS-IV; Robins et al., 1995). The DIS-IV is a structured interview that assesses for Axis I disorders according to diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (American Psychiatric Association, 1994). The DIS-IV assesses symptoms present in the past year, the past 6 months, and those that are current or remitted. Current symptoms were assessed as a measure of MDD in the present study. All interviewers were trained to criterion reliability in administration of the DIS-IV and computer-generated diagnoses were used for the purpose of this study. In the current sample, 56% (n = 69) of mothers met criteria for a current major depressive episode, and 44% (n = 54) were classified as non-depressed (no current or past history of MDD). Depression was therefore classified as a binary variable. The DIS-IV demonstrated good internal reliability at T1 (α =.956) and at T2 in the current sample (α =.947).

Childhood trauma questionnaire

(CTQ; Bernstein & Fink, 1998). The CTQ is a 25-item self-report scale that assesses retrospective accounts of childhood maltreatment within the domains of physical abuse, sexual abuse, physical neglect, emotional neglect, and emotional abuse. Bernstein et al. (2003)’s moderate maltreatment scores were used for the purposes of the current study. Using these cut-offs, dichotomous variables reflecting either the presence or absence of each subtype of maltreatment were created. These dichotomous variables were then summed to create a variable representing the number of subtypes of maltreatment experienced, ranging from 0 (no maltreatment experienced) to 5 (all subtypes of maltreatment experienced). This continuous number of maltreatment subtypes variable was used in subsequent analyses. Conceptualizing maltreatment as number of subtypes experienced rather than a binary maltreated/not maltreated variable or by the severity of any one subtype has been supported in the literature. A study by Cecil, Viding, Fearon, Glaser, and Mccrory (2017) showed that subtypes of maltreatment are interrelated and frequently co-occur, and that symptom severity increases linearly with the number of subtypes experienced, particularly for self-report ratings of maltreatment. The CTQ demonstrated good internal consistency at baseline in the current sample (α =.793).

Maternal behavior Q-set

(MBQS; Pederson & Moran, 1995). The MBQS is a 90-item Q sort measure that assesses observed maternal sensitivity. Data used in the current study were collected from a home visit conducted when the infants were 26 months old. Sorts were completed by two research assistants who were both present at the visit: one who worked consistently with the family over the set of visits for that time point, and an additional observer who was less familiar with the family. The intra-class correlation coefficient was established at r =.383, p <.001. Because scores were only moderately correlated, scores from only one rater were used in subsequent analyses rather than taking a mean score from both reports. Scores from the research assistant who worked consistently with the family (rather than the research assistant whose observations were used for the purposes of reliability) were used because their greater level of interaction with the family allowed them to report more informed observations of sensitivity.

Strange situation

(SS; Ainsworth et al., 1978). The standard Strange Situation was conducted with mothers and their children when the children were approximately 26 months old (range = 24–31 months, Mage = 26 months) to assess the toddler’s attachment organization. Ainsworth et al.’s (1978) criteria for A (insecure-avoidant), B (secure), and C (insecure-ambivalent) classifications were used, and D (disorganized) classifications were based on the Main and Solomon (1990) criteria. This classification system was supplemented by a developmental systems approach for children ages 18 to 26 months (Gersten et al., 1986; Schneider-Rosen, 1990; Schneider-Rosen, Braunwald, Carlson, & Cicchetti, 1985). Two independent raters (MEA and JMW) were trained to reliability by Alan Sroufe and Elizabeth Carlson. Raters were unaware of the diagnostic group of each mother-child dyad. Interrater reliability was assessed by comparing the primary rater’s scores with those of a secondary rater on 64 of 169 selected tapes (tapes were coded for the entire sample, including cases randomized to intervention, to maintain a lack of awareness of condition). Cases that were discrepant were discussed until a consensus was reached. Interrater agreement on the 4-category ABCD classifications in the current sample was 75% (weighted κ =.661), which is consistent with previous levels of agreement (cf., Raby et al., 2015). Classifications were also conceptualized as a binary organized/disorganized variable and interrater agreement on this variable was 85.9% (κ =.551).

Child behavior checklist

(CBCL: ages 1 ½ to 5 years version; Achenbach & Rescorla, 2000). The CBCL is a 100-item questionnaire designed to assess child behavioral and emotional symptoms within the past 2 months. Mothers in the current study completed the CBCL when their children were 36 months old. Total raw values for the internalizing and externalizing subscales were used. Internal consistency on the CBCL in the current sample was good (α =.956).

Results

Data preparation

Prior to hypothesis testing, the following endogenous continuous study variables were tested for skewness and kurtosis to assess for violations of normality using SPSS Software, Version 25.0: maternal sensitivity, child externalizing, and child internalizing. No variables showed evidence of non-normality.

Preliminary analyses

Mothers were classified in the depressed group if they met criteria for current MDD on the DIS-IV (Robins et al., 1995) at baseline. To assess for comparability of sample characteristics between mothers with and without MDD, comparisons were made on a number of baseline demographic variables, including maternal age, race, ethnicity, education, and marital status using χ2 and t-tests (see Table 1). Mothers with MDD were significantly more likely to be unmarried. No other significant differences were observed on demographic characteristics.

Table 1.

Group differences on sample demographics and study variables between mothers with and without depression.

Depressed (n = 69) Non-Depressed (n = 54) Statistical Test p value
Age M = 25.22 M = 24.90 t(121) = −0.36 0.72
Race χ2(2, N = 123) = 1.65 0.44
 Black 56.52% 64.81%
 White 21.74% 22.22%
 Other 21.74% 12.96%
Ethnicity χ2(1, N = 123) = 3.47 0.06
 Hispanic 21.73% 9.26%
 Non-Hispanic 78.26% 90.74%
Education χ2(2, N = 123) = 2.71 0.26
 Did Not Complete HS 43.47% 40.74%
 GED/HS Diploma 49.27% 42.59%
 Some College 7.24% 16.67%
Marital Status χ2(1, N = 123) = 5.49 0.02
 Married 8.70% 24.07%
 Not Married 91.30% 75.93%
Subtype of Maternal Childhood
 Maltreatment
 No Maltreatment 27.69% 62.26% χ2(1, N = 118) = 14.22 <0.001
 Sexual Abuse 49.23% 24.53% χ2(1, N = 118) = 7.55 0.01
 Emotional Abuse 49.23% 15.09% χ2(1, N = 118) = 15.18 <0.001
 Physical Abuse 49.23% 11.32% χ2(1, N = 118) = 19.22 <0.001
 Emotional Neglect 47.69% 9.43% χ2(1, N = 118) = 20.16 <0.001
 Physical Neglect 35.38% 15.09% χ2(1, N = 118) = 6.21 0.01
Number of Subtypes of Maternal Childhood Maltreatment M = 2.31 M = 0.75 t(110.93) = -5.34 <0.001
Maternal Depressive Symptoms (12 months) M = 30.8 M = 5.07 t(90.94) = −22.04 <0.001
Maternal Sensitivity (26 months) M = 0.40 M = 0.61 t(111.30) = 3.09 <0.01
Child Internalizing (36 months) M = 9.51 M = 5.48 t(112.77) = −3.40 0.001
Child Externalizing (36 months) M = 15.98 M = 9.40 t(111.75) = −4.04 <0.001
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HS = high school.

Group differences on the additional study variables of maternal history of childhood maltreatment, maternal sensitivity, and child internalizing and externalizing behavior are also shown in Table 1. Mothers with MDD were significantly more likely to have experienced any and all forms of childhood maltreatment. They were also significantly more likely to have experienced a greater number of subtypes of maltreatment, be less sensitive, and have children with more internalizing and externalizing behavior.

Of the 111 non-intervention families who completed the Strange Situation at 26 months, 24.3% of the children were classified as insecure-avoidant (A), 27.9% secure (B), 10.8% insecure-ambivalent (C), and 36.9% disorganized (D). Tables 2 and 3 illustrate group differences on study variables by the 4-category attachment classification (Table 2) and the binary organized/disorganized attachment classification (Table 3). There were no significant group differences in attachment based on maternal depression or mean levels of maternal history of childhood maltreatment. However, there were significant differences in maternal sensitivity depending on attachment classification. Specifically, results from Tukey’s LSD post hoc tests indicated that disorganized attachment was associated with significantly less maternal sensitivity than insecure-avoidant or secure attachment (see Table 4). This difference was also present with the binary organized/disorganized attachment variable, with disorganized attachment associated with significantly less maternal sensitivity than organized attachment. Child sex did not significantly predict the 4-category attachment classification, but did significantly predict the binary organized/disorganized variable, with more males classified as disorganized than females.

Table 2.

Descriptive statistics for 4-category attachment variable.

4-Category Attachment Classification
A B C D Statistical Test
Total
Depressive Status 24.32% 27.83% 10.81% 36.94% χ2(3, N = 111) = 2.08, p = 0.56
 Depressed 21.31% 31.15% 8.20% 39.34%
 Non-Depressed 28.00% 24.00% 14.00% 34.00%
Maternal History of Childhood Maltreatment M = 1.74 M = 1.67 M = 1.25 M = 1.33 F(3) = 0.45, p = 0.72
Maternal Sensitivity (26 months) M = 0.61 M = 0.57 M = 0.48 M = 0.35 F(3) = 2.90, p = 0.04
Child Internalizing (36 months) M = 7.85 M = 7.10 M = 8.73 M = 7.88 F(3) = 0.17, p = 0.91
Child Externalizing (36 months) M = 11.42 M = 12.86 M = 12.27 M = 14.75 F(3) = 0.71, p = 0.55
Child Sex χ2(3, N = 111) = 4.60, p = 0.20
 Male 20.75% 22.64% 9.43% 47.17%
 Female 27.59% 32.76% 12.07% 27.59%
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A = Insecure-Avoidant, B = Secure, C = Insecure-Ambivalent, D = Disorganized.

Table 3.

Descriptive statistics for binary organized/disorganized attachment variable.

Binary Attachment Classification
Organized (A, B, C) Disorganized (D) Statistical Test
Total 63.06% 36.94%
Depressive Status (12 months) χ2(1, N = 111) = 0.34, p = 0.56
 Depressed 60.66% 39.34%
 Non-Depressed 66.00% 34.00%
Maternal History of Childhood Maltreatment M = 1.62 M = 1.33 t(106) = 0.82, p = 0.41
Maternal Sensitivity (26 months) M = 0.57 M = 0.35 t(64.09) = 2.63, p = 0.01
Child Internalizing (36 months) M = 7.67 M = 7.88 t(104) = −0.16, p = 0.88
Child Externalizing (36 months) M = 12.20 M = 14.75 t(104) = −1.36, p = 0.18
Child Sex χ2(1, N =111) = 4.56, p = 0.03
 Male 52.83% 47.17%
 Female 72.41% 27.59%
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A = Insecure-Avoidant, B = Secure, C = Insecure-Ambivalent, D = Disorganized.

Table 4.

Post hoc tests for differences in maternal sensitivity by 4-category attachment classification.

Attachment Comparison Mean Difference SE p value
A vs. B 0.03 0.10 0.79
A vs. C 0.12 0.13 0.37
A vs. D 0.25 0.10 0.01
B vs. C 0.09 0.13 0.48
B vs. D 0.22 0.09 0.02
D vs. D 0.13 0.13 0.32
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A = Insecure-Avoidant, B = Secure, C = Insecure-Ambivalent, D = Disorganized. Means for maternal sensitivity by 4-category attachment classification can be found in Table 2.

Zero-order correlations among the main study variables (except the 4-category attachment variable) can be found in Table 5. Mothers with histories of greater childhood maltreatment were significantly more likely to have children with greater internalizing and externalizing behavior. Mothers were also significantly less sensitive with boys than girls, and children of less sensitive mothers showed greater internalizing and externalizing behavior.

Table 5.

Zero-order correlations among main study variables.

1 2 3 4 5 6 7
1. Depressive Status –
2. Child Sex .01 –
3. MHCM .43** −.08 –
4. Maternal Sensitivity −.27** −.25** −.16 –
5. Organized/Disorganized .06 .20* −.08 −.26** –
6. Child Internalizing .29** −.04 .30** −.28** .02 –
7. Child Externalizing .34** .15 .35** −.41** .13 .70** –
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MHCM = Maternal History of Childhood Maltreatment; Depression coded non-depressed = 0, depressed = 1. Child sex coded female = 0, male = 1. Organized/disorganized attachment coded organized = 0, disorganized = 1.

*

p <.05,

**

p <.01,

***

p <.001.

Primary analyses

In the structural model, attachment was modeled as a binary variable (organized = 0, disorganized = 1) to facilitate statistical estimation. Disorganized attachment was chosen as the focus of analyses rather than secure attachment because of its relevance as a risk factor in the development of psychopathology and its association with maternal depression and maternal history of childhood maltreatment, as explained above. The structural model was specified as follows. Maternal history of childhood maltreatment was modeled to predict maternal depression at T1, maternal sensitivity at T2, disorganized attachment at T2, and child internalizing and externalizing behavior at T3. Maternal depression at T1 was modeled to predict maternal sensitivity at T2, disorganized attachment at T2, and child internalizing and externalizing behavior at T3. In addition, child sex (female = 0, male = 1) was added as a covariate because more boys were classified as disorganized and rated as having greater externalizing behavior than girls. Initially, child sex was modeled to predict maternal depression, maternal sensitivity, disorganized attachment, and child internalizing and externalizing behavior. Child sex only uniquely and significantly predict maternal sensitivity and child externalizing, and therefore the other paths were dropped from the model. Finally, residual covariance was modeled between child internalizing and child externalizing behavior at T3.

Because attachment and maternal depression were represented as binary variables in this model, coefficients were estimated using the weighted least squares estimator with mean and variance adjustments (WLSMV), which calculates probit parameter estimates for categorical variables. For categorical variables using WLSMV, missingness is allowed to be a function of the observed covariates, but not the observed outcomes (Asparouhov & Muthén, 2010). Data were determined to be missing completely at random according to Little’s MCAR test (χ2 (35) = 33.367, p = 0.547). Model fit was evaluated using WLSMV chi square (χ2), the comparative fit index (CFI), root mean square error of approximation (RMSEA), and the weighted root mean square residual (WRMR). A nonsignificant χ2 statistic, CFI values greater than 0.95, RMSEA values less than 0.06, and WRMR values less than 0.90 are considered evidence of good model fit (Hu & Bentler, 1999; Yu & Muthen, 2002). Indirect effects were tested using bias-corrected bootstrapped 95% confidence intervals. Confidence intervals without the value of 0 are considered statistically significant at α =.05. A total of five participants were missing data on maternal history of childhood maltreatment. Therefore, these final models were estimated with N = 118.

The model showed good fit to the data, χ2(3) = 3.408, p = 0.333, RMSEA = 0.034, CFI = 0.996, WRMR = 0.340. Mothers with histories of greater childhood maltreatment were significantly more likely to have MDD at T1 and marginally significantly more likely to have children with greater externalizing behavior at T3. Maternal history of childhood maltreatment did not significantly predict maternal sensitivity at T2 or child internalizing behavior at T3. Maternal depression at T1 predicted significantly less sensitive maternal behavior at T2, significantly greater child internalizing behavior at T3, and marginally significantly greater child externalizing behavior at T3. Maternal depression did not significantly predict attachment disorganization. Less sensitive maternal behavior at T2 significantly predicted attachment disorganization at T2, marginally significantly greater child internalizing behavior, and significantly greater child externalizing behavior at T3. Attachment disorganization did not significantly predict child internalizing or externalizing behavior. Mothers were significantly less sensitive with boys and boys exhibited marginally significantly greater externalizing behavior (see Figure 1 for path model and Table 6 for all path coefficients).

Figure 1.

Figure 1.

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Path model with standardized path coefficients presented for significant and marginally significant effects.

Nonsignificant paths indicated with a dashed line; marginally significant paths indicated with a bolded dashed line. Depression coded non-depressed = 0, depressed = 1. Child sex coded female = 0, male = 1. Attachment coded organized = 0, disorganized = 1.†p <.10, *p <.05, **p <.01, ***p <.001

Table 6.

Standardized path coefficients.

Independent Variable Dependent Variable B SE p value
MHCM → Maternal Depression T1 0.54 0.09 <0.001
MHCM → Maternal Sensitivity T2 0.01 0.11 0.96
Maternal Depression T1 → Maternal Sensitivity T2 −0.35 0.09 <0.001
Child Sex → Maternal Sensitivity T2 −0.30 0.10 <0.01
MHCM → Disorganized Attachment T2 −0.18 0.17 0.29
Maternal Depression T1 → Disorganized Attachment T2 0.05 0.21 0.80
Maternal Sensitivity T2 → Disorganized Attachment T2 −0.24 0.12 0.01
MHCM → Internalizing Behavior T3 0.12 0.11 0.27
Maternal Depression T1 → Internalizing Behavior T3 0.28 0.13 0.03
Maternal Sensitivity T2 → Internalizing Behavior T3 −0.18 0.10 0.08
Disorganized Attachment T3 → Internalizing Behavior T3 −0.02 0.12 0.90
MHCM → Externalizing Behavior T3 0.21 0.11 0.06
Maternal Depression T1 → Externalizing Behavior T3 0.26 0.15 0.07
Maternal Sensitivity T2 → Externalizing Behavior T3 −0.23 0.09 0.01
Disorganized Attachment T3 → Externalizing Behavior T3 0.09 0.12 0.47
Child Sex → Externalizing Behavior T3 0.15 0.08 0.07
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MHCM = Maternal History of Childhood Maltreatment.

Mediation hypotheses were then evaluated. There was evidence of mediation from maternal history of childhood maltreatment to maternal depression, maternal sensitivity, and disorganized attachment (95% CI [0.003, 0.219]). Contrary to hypotheses, disorganized attachment did not mediate the association between maternal history of childhood maltreatment and child internalizing (95% CI [−0.056, 0.081]) or externalizing behavior (95% CI [−0.087, 0.047]) or between maternal depression and child internalizing (95% CI [−0.091, 0.029]) or externalizing behavior (95% CI [−0.087, 0.047]). However, maternal depression was found to significantly mediate the association between maternal history of childhood maltreatment and child internalizing (95% CI [0.003, 0.403]) and externalizing behavior at T3 (95% CI [0.009, 0.332]). In addition, although it was not hypothesized, maternal sensitivity significantly mediated the association between child sex and disorganized attachment (95% CI [0.013, 0.286]), and between child sex and child externalizing behavior (95% CI [0.001, 0.157]). No other indirect paths were significant.

Discussion

The aim of the current study was to examine developmental pathways from maternal history of childhood maltreatment and maternal depression to toddler attachment and child internalizing and externalizing behavior in a largely racial minority, low-income sample. Maternal depression and maternal sensitivity were hypothesized to serve as mediators of the association between maternal history of childhood maltreatment and disorganized attachment. Disorganized attachment was hypothesized to mediate the association between each maternal risk factor and each child outcome. Hypotheses were partially supported, as described below.

Development of attachment

As anticipated, mothers with MDD showed significantly less sensitivity with their children. Although maternal history of childhood maltreatment did not directly predict maternal sensitivity, there was an indirect effect via maternal depression. These findings replicate previous research that has shown a direct effect of depression on maternal behavior (Campbell et al., 2004; Campbell, Matestic, Stauffenberg, Mohan, & Kirchner, 2007) and an indirect effect of maternal history of childhood maltreatment on maternal behavior via maternal depression in predominantly racial minority, low-income samples (Banyard et al., 2003; Michl-Petzing et al., 2019).

As predicted, less sensitive mothers were more likely to have toddlers with disorganized attachment. Further, group differences in maternal sensitivity according to the 4-category attachment variable indicated that lower maternal sensitivity was specifically associated with disorganized (vs. secure or avoidant) attachment. In previous meta-analytic research, lower sensitivity also has been shown to be a risk factor for disorganized attachment (van IJzendoorn et al., 1999). However in previous research, this association showed a smaller effect (r = −.05 to −.10; NICHD Early Child Care Rearch Network, 1997; van IJzendoorn et al., 1999) than in the current study (r = −.264). The stronger association between sensitivity and disorganized attachment in the current study may indicate that sensitivity has a greater impact in samples with multiple risk factors, including a low-income context, maternal history of childhood maltreatment, and MDD. As a result, sensitivity may be particularly important to target in the prevention of disorganized attachment in children of high-risk mothers.

Results provide preliminary evidence to suggest that maternal history of childhood maltreatment increases risk for maternal depression, which in turn is associated with less maternal sensitivity and a greater likelihood of disorganized attachment. Although maternal sensitivity has previously been identified as a mediating factor between maternal depression and attachment security (Hopkins et al., 2013), the findings from the current study extend these results to suggest that risk for disorganized attachment can begin far in a mother’s past and operate through the association between her childhood experiences and her mental health and subsequent parenting behavior. However, future research measuring maternal depression and maternal sensitivity at multiple time points is needed to assess for directionality and sequential mediation over and across time.

Development of child outcomes

Results suggest that disorganized attachment did not directly predict child internalizing or externalizing behavior, although previous studies have found evidence for this association (Fearon et al., 2010; Groh et al., 2012). The high-risk nature of the sample may have weakened the association observed in previous studies. Although previous meta-analytic work did not find differences in the association between attachment and internalizing and externalizing behavior based on socioeconomic status (Fearon et al., 2010; Groh et al., 2012), these studies did not examine the impact of multiple risk factors, such as the effect of maternal history of childhood maltreatment, MDD, and poverty that are captured in the current sample. The association between maternal risk and child outcomes appears to be stronger than the association between disorganized attachment and child outcomes given the nature of the sample. It could also be that maternal report introduced bias into the measurement of these child outcomes and a more independent rating of child functioning would be more strongly related to attachment.

Because of the nonsignificant association between attachment and child outcomes, there was no evidence of mediation from either maternal risk factor to either child outcome via attachment as predicted. Instead of attachment serving as a mediator, maternal depression significantly mediated the association between maternal history of childhood maltreatment and child internalizing and externalizing behavior. Previous research also has found that maternal depression mediates the link between maternal history of childhood maltreatment and child internalizing and externalizing behavior (Koverola et al., 2005; Miranda, de la Osa, Granero, & Ezpeleta, 2013). This pattern of findings suggests that attachment does not appear to significantly contribute to the developmental path from maternal history of childhood maltreatment to child outcomes beyond maternal depression in a high-risk sample.

Although results showed that mothers with a history of greater childhood maltreatment were more likely to be depressed, mothers with depression were less sensitive, and less sensitive mothers were more likely to have toddlers with greater externalizing behavior, this overall developmental sequence did not emerge as a statistically significant indirect effect in the current study. Due to the relatively small sample size, this study may be underpowered to detect the combined indirect effect. Previous research has also found that maternal depression predicts less sensitive maternal behavior (Campbell et al., 2004, 2007), and that lower maternal sensitivity predicts greater child externalizing behavior (Wang, Christ, Mills-Koonce, Garrett-Peters, & Cox, 2013). Additionally, among mothers with depressive symptoms, maternal sensitivity has been linked to child externalizing behavior (Garai et al., 2009). It would therefore be important for future research to evaluate this developmental pathway in a larger sample.

Effects of child sex

Although no effects of child sex were hypothesized at the outset of this study, findings suggest important differences exist in maternal behavior, attachment, and externalizing behavior depending on child sex. As in previous research, there were trend findings to suggest that boys exhibit greater externalizing behavior than girls (Miner & Clarke-Stewart, 2008) and are more likely to be classified with disorganized attachment compared to girls (Hayes, Goodman, & Carlson, 2013). Often, studies point to mothers’ tendency to be less sensitive with boys as the process by which boys develop greater externalizing behavior (e.g. Edwards & Hans, 2016; Miner & Clarke-Stewart, 2008; Rothbaum & Weisz, 1994). Similarly, the findings from the current study suggest that lower levels of maternal sensitivity put boys at greater risk for both disorganized attachment and externalizing behavior.

It is possible that gender roles and expectations, together with the added contextual risk associated with growing up as a racial minority in low-income neighborhoods where community violence is more prevalent, contributed to mothers displaying less sensitivity with male children. In an attempt to protect their boys from potential threats, mothers raising boys in riskier environments may be motivated to be less sensitive in order to raise boys who are “tough.” Despite these protective efforts, however, this pattern of parenting behavior may put boys at increased risk for externalizing behavior, which could pose challenges in social settings. Prevention efforts should pay close attention to parenting among mothers of young boys in an effort to intervene early, partner with parents to understand their values and motivations for parenting behaviors, and provide both mothers and children with the support they need for positive development.

Strengths and limitations

This study is characterized by several notable strengths, as well as a number of limitations. With respect to strengths, it utilized a multi–informant, multi-method longitudinal design to examine intergenerational developmental pathways in a high-risk sample of mothers and their children. In addition, the study’s multi-method approach, which included observational measures of maternal sensitivity and attachment, eliminated several potential confounds related to shared method variance. Further, the observers who rated maternal sensitivity and the coders who scored attachment were independent. An additional strength of this study is its use of a largely racial minority, low-income sample of mothers and their children, which provided an acknowledgement of the impact of the environmental context on developmental processes, a key tenant of the developmental psychopathology framework (Cicchetti & Toth, 1997).

While this study has several notable strengths, it is important to acknowledge several limitations. Although this study uses a longitudinal design, the concurrent modeling of attachment and maternal sensitivity at T2 limits the conclusions that can be drawn regarding the directional association between these constructs. Despite this limitation, the directionality interpreted in the results is supported by substantial literature on the role that maternal sensitivity plays in the development of attachment (de Wolff & Van IJzendoorn, 1997; van IJzendoorn et al., 1999). In addition, mothers’ current behavior toward their children may have a strong effect on that child’s attachment behaviors, particularly if that maternal behavior has changed as the child has grown older and developed more autonomy.

Further, mothers’ retrospective reports of their childhood maltreatment may have led to an underestimation of maltreatment experiences (Thornberry, Knight, & Lovegrove, 2012). Maternal reports of child outcomes also may have resulted in a biased assessment of child behavior. There is conflicting evidence in the literature regarding whether or not mothers with depression have biased reports of their children’s behavior (Najman et al., 2001; Richters, 1992). Therefore, these outcomes may need to be interpreted with caution. Maternal sensitivity outcomes should also be interpreted with caution given the low interrater reliability on the Maternal Behavior Q Sort and consideration of scores from only one rater. In addition, although the use of a largely racial minority, low-income sample is a strength in that it provides much-needed information about these developmental phenomena in an under-studied population, the nature of this sample also limits the generalizability of findings. Finally, because the majority of the women in this sample resided in single-parent, female-headed households, results of this study may not generalize to families with other significant caregivers, such as fathers or grandparents.

Clinical implications

The findings of this study suggest that addressing maternal history of childhood maltreatment in tandem with the treatment of MDD may be an effective way to target maternal sensitivity and consequently prevent disorganized attachment and child internalizing and externalizing behavior. Many psychological treatments have been developed to treat depression in adults and have been shown to be relatively comparable in their effectiveness (Cuijpers, van Straten, Andersson, & van Oppen, 2008). However, interpersonal psychotherapy (IPT; Klerman, Weissman, Rounsaville, & Chevron, 1984), which focuses on building strong relationships, may be particularly relevant for predominantly racial minority, low-income mothers, and their attachment with their children (Handley, Michl-Petzing, Rogosch, Cicchetti, & Toth, 2017; Toth et al., 2013).

In addition, encouraging mothers to participate in programs that directly address parenting behavior may be another way to promote sensitivity. One intervention that has been developed to simultaneously address parents’ histories of childhood maltreatment alongside their sensitivity and attachment relationship with their young children is Child Parent Psychotherapy (CPP; Lieberman, Ghosh Ippen, & Van Horn, 2015). CPP also emphasizes engagement, acknowledges parenting values, incorporates cultural sensitivity, and examines intergenerational experiences, which may be particularly relevant to racially and ethnically diverse families. CPP has been shown to be effective in increasing sensitivity (Cicchetti, Rogosch, & Toth, 2006) and improving attachment in racially and ethnically diverse, low-income samples (Cicchetti et al., 2006; Lieberman, Weston, & Pawl, 1991). Importantly, CPP also has been found to be effective in promoting secure attachment in samples of mothers with MDD (Cicchetti, Toth, & Rogosch, 1999; Toth, Rogosch, Manly, & Cicchetti, 2006). Therefore, CPP may be particularly promising for a population of low-income, predominantly racial minority mothers such as this one that has a high prevalence of childhood maltreatment and MDD.

These findings also have important public health implications, particularly for prevention. Clinics offering prenatal care have a critical opportunity to prevent postpartum depression. If used in combination with trauma screenings, prenatal clinic settings could be an important place to identify women with histories of childhood maltreatment who might be at risk for postpartum depression. Therefore, the findings of the current study have important implications for trauma-informed care and depression prevention from a broader public health perspective.

Conclusion

Overall, this study identifies important developmental processes that take place in the context of maternal risk. Childhood maltreatment puts women at greater risk for depression in adulthood. Because mothers with depression are less likely to be sensitive with their children, their children are at greater risk for disorganized attachment. Maternal depression also increases risk for internalizing and externalizing behavior in early childhood. These findings suggest that supporting mothers is a critical part of supporting positive child development. Therefore, allocating resources to such programming is essential for not only helping to heal the current generation, but also for promoting the success of the next.

Acknowledgments

Funding

We acknowledge and greatly appreciate the funding support of this research by the National Institute of Mental Health [R01 MH067792].

Footnotes

Disclosure statement

No potential conflict of interest was reported by the author(s).

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