Research in Developmental Disabilities 76 (2018) 56–64

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Research in Developmental Disabilities

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Attachment quality of children with ID and its link to maternal

T
sensitivity and structuring
⁎
Rinat Feniger-Schaala, , Tirtsa Joelsb
a
University of Haifa, The Center for the Study of Child Development, Graduate School of Creative Arts Therapies, University of Haifa, 199 Aba
Khoushy Av., Haifa, 3498838, Israel
b
University of Haifa, The Center for the Study of Child Development, University of Haifa, 199 Aba Khoushy Av., Haifa, 3498838, Israel

A R T IC LE I N F O ABS TRA CT

Number of completed reviews is 2 Background: Attachment theory produced a fertile field of research and clinical application.
Keywords: Although the topic of attachment of children with intellectual disability (ID) has received in-
Intellectual disability creasing research attention over the past 15 years, the empirical evidence is still limited.
Attachment Aims: We applied theoretical and empirical knowledge of parenting typically developing chil-
Maternal sensitivity dren to examine the mother-child relationship in the ID population. The aim was to examine
Maternal structuring maternal sensitivity and structuring and its association with children’s attachment classification
and their disability.
Methods: Forty preschool children (mean age 47.25, range 26–75 months) with non-specific ID
and their mothers participated in the study. The mean developmental age was 25.92 months
(SD = 10.89), The DQ mean score was 55.45 (SD = 17.28). We assessed children’s quality of
attachment using the SSP and maternal interactive behavior using the Emotional Availability
Scales.
Outcomes: Forty percent of children showed secure attachment, and 32.5% showed disorganized
attachment. Attachment classifications correlated significantly with maternal sensitivity and
maternal structuring but not with the child’s cognitive disability.
Conclusions: The results point to the importance of maternal interactive behavior for children
with ID. Clinical implication may consider interventions aiming to enhance maternal sensitivity
and structuring to improve children’s quality of attachment.

What this paper adds

There are few studies on children with ID from an attachment perspective, emphasizing their socio-emotional development. The
association between maternal sensitivity and security of attachment in children with ID has been examined in only three studies: two
examined children with Down syndrome (one of which did not use the Strange Situation Procedure), and one study that used a very
small sample. None of these studies examined maternal structuring. This is the first study that examined the attachment quality of
children with non-specific ID, and its association with maternal sensitivity and structuring.

1. Introduction

Attachment theory is a fertile field of research and clinical application, with a broad spectrum of populations. But although the

⁎
Corresponding author.
E-mail address: Rinatfen@gmail.com (R. Feniger-Schaal).

https://doi.org/10.1016/j.ridd.2018.03.004
Received 4 September 2017; Received in revised form 5 March 2018; Accepted 7 March 2018
Available online 19 March 2018
0891-4222/ © 2018 Elsevier Ltd. All rights reserved.
R. Feniger-Schaal, T. Joels Research in Developmental Disabilities 76 (2018) 56–64

topic of attachment of children with intellectual disability (ID) has received increasing research attention over the past 15 years, the
empirical evidence is still limited. Thus, the present study aimed to contribute to the knowledge on attachment and children with ID.
The high prevalence of challenging behavior and mental health problems among children with ID (Dykens, 2000; Schuengel &
Janssen, 2006) attests to the importance of adopting a socio-emotional perspective in examining children with ID. The large number
of studies that were spawned by attachment theory, provided the understanding that mental health and social functioning are shaped
in many ways by early experiences of parent-child relationships (Schuengel, Schipper, Sterkenburg, & Kef, 2013).
By adopting a socio-emotional perspective, we join Zigler’s call for greater attention of this type to people with ID (Došen, 2005;
Zigler, 2001). Issues like affect regulation, social competences, and sense of autonomy may all be of significant importance to the
adjustment of people with ID to the everyday world (Sigman et al., 1999; Schuengel & Janssen, 2006), and may matter even more for
children with ID than for typically developing children (Baker, Fenning, Crnic, Baker, & Blacher, 2007; Bebko et al., 1998). Empirical
studies support the understanding that the parent-child relationship is the primary context in which these constructs develop
(Schuengel et al., 2013). Groh et al. (2017) showed in their meta-analysis that early secure attachment is associated with children's
socio-emotional adjustment, social competence and externalizing problems. Moreover, the findings underscored the across-the-board
significance of all insecure attachment patterns for social competence. Therefore, it seems especially important to further examine
early parent-child relationships and attachment quality among children with ID.
One of the tenets of attachment theory is that the formation of the parent-child relationship involves the processes of building
cognitive representation of past experience with this parent (Bowlby, 1982). Children with ID, by definition, have cognitive deficits,
and therefore it is not taken for granted that these children are able to form an attachment representation (Bretherton, 1990; Carlson
& Egeland, 2004). This is another reason to study attachment specifically among children with significant cognitive impairment and
to examine the role of the (ID) in attachment quality.
Intellectual disability as defined by the American Association on Intellectual and Developmental Disabilities (AAIDD), refers to
disability that arises before the age of 18, with significant limitation in both intellectual functioning and adaptive behavior (Schalock
et al., 2000). Under the term “intellectual disability” there is a broad spectrum of etiologies, but still for the majority of people with
mild to moderate ID the etiology is unknown (APA, 2000; Murphy, Boyle, Schendel, Decoufle, & Yeargin-Allsopp, 1998; Ropers,
2008; Walters & Kaufman Blane, 2000), and this is the target population of the present study. Although this group of non-specific ID is
not clearly defined because of its heterogenic characteristics, we join a large number of other studies that show interest in this group
(e.g., Beck, Daley, Hastings, & Stevenson, 2004; Jervis & Baker, 2004; Kaufman, Ayub, & Vincent, 2010), probably owing to its high
prevalence. Many clinicians thus meet children and their parents that are under this definition, and this is another main incentive to
study this group and to make contribution to the clinical field. Therefore, this study will focus on attachment quality and parent-child
relationship among children with non-specific ID.
Attachment theory produced extensive research that provided well established assessment tools to study parent-child relationship.
The Strange Situation Procedure (SSP;) is considered to be one of the main instruments to assess individual differences in attachment
quality (Lamb, Thompson, Gardner, Charnov, & Estes, 1984). It has been used to assess attachment patterns in a large number of
studies in a range of cultures (Van Ijzendoorn and Kroonenberg, 1988; Van IJzendoorn and Sagi, 2008), and within a variety of
clinical populations (e.g., Ganiban, Barnett, & Cicchetti, 2000). The SSP involves a structured observation of infants and their mothers
as well as an unfamiliar female in a laboratory playroom. Based on the children’s behavior during the SSP, they are classified into one
of four attachment patterns that reflect individual differences in the security of the child’s attachment to the caregiver (): secure (B),
insecure-avoidant (A), insecure-ambivalent (C), and insecure-disorganized (D). Children in the secure group use their mothers as a
secure base from which to explore; in her absence, they reduce their exploration and might be distressed, but greet her positively
upon her return and soon resume exploring. This pattern is shown by 65%–70% of infants in non-clinical, typically developing (TD)
children. The insecure-avoidant infants, explore with minimal reference to the mother, and minimally distressed by her departure,
ignoring or avoiding her on return. In TD non-clinical sample, this pattern characterizes between 20%–25% of infants. The insecure-
ambivalent/resistant infants explore minimally, showing high distress during separations and difficulty settling upon reunion and
express high level of resistance to the mother. In normative samples, approximately 10% of infants show this pattern (Van-
IJzendoorn, Goldberg, Kroonenberg, & Frenkel, 1992).
The insecure-disorganized attachment classification was conceptualized in a later stage than the previous ones, and therefore it is
not found in all attachment studies (Granqvist et al., 2017). Infants whose attachment pattern is insecure-disorganized (D) on reunion
with their caregiver display various conflicted, disoriented, or fearful behavior. In contrast to the previous three patterns, which are
characterized by a coherent strategy for managing arousal in the strange situation, the salient feature of this group is the breakdown
of the child’s strategy for dealing with the separations from the mother during the SSP. In a non-clinical sample of TD, 10–15% fit the
group D criteria (van IJzendoorn, Schuengel, & Bakermans- Kranenburg, 1999).When using the disorganized classification with
children with ID there might be some confusion between attachment behavior and neurological impairments. Therefore Pipp-Siegel
and colleagues (Pipp-Siegel, Siegel, & Dean, 1999) defined consideration need to be taken when using the disorganized classification
with children with neurological condition, and in the present study we followed their guidelines.
Extensive research has shown that the SSP is highly informative and that the classifications based on this procedure are associated
with the history of the interactions between the infant and the caregiver (Lamb et al., 1984). These classifications were found to
predict children’s socio-emotional development during childhood and along the lifespan (Main, Kaplan, & Cassidy, 1985; Sroufe,
Egeland, Carlson, & Collins, 2005; Thompson, 1999), and to show significant associations with development in various domains
(Bakermans-Kranenburg, van Ijzendoorn, & Juffer, 2003; Belsky & Fearon, 2002; Groh et al., 2017; Stams, Juffer, & van IJzendoorn,
2002).
Attachment theory and the SSP were first consolidated for TD children, followed by a small number of studies sought to examine

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their use for children with ID. The subgroup that attracted the most research attention among children with ID were children with
Down syndrome (DS), possibly because it is the most common genetically-based ID syndrome (Presson et al., 2013).
Vaughn and colleagues conducted one of the first large-scale studies that used the SSP with children with DS (Vaughn et al.,
1994). The researchers compared the SSP classifications of 138 children with DS aged 14–54 months, from three different samples,
with those of a sample of TD children aged 12–14 months. The result showed that 46% of children with DS were classified as secure,
compared to 60% in the TD group. Vaughn et al. (1994) also reported a fourth group in the DS group: U (unclassifiable), and
commented that some of the children in this group may belong to the disorganized classification, which they did not use in their
study.
Atkinson and colleagues also used the SSP to study attachment among children with DS (Atkinson et al., 1999). In a sample of 53
children with DS, they found that 40% were classified as secure at 26 months and 48% at 42 months; 2% were classified as having
disorganized attachment at 26 months, and 12.5% at 42 months. Similar rates of secure attachment were found by Ganiban, Barnett,
and Cicchetti (2000), who observed 30 infants with DS using the SSP at 19 and 27 months, and found that many of the children were
securely attached to their mothers (43% at 19 months and 53% at 27 months), and a relatively high percentage showed disorganized
attachment among infants in their sample (23% at 19 months and 30% at 27 months).
Cicchetti and colleagues (e.g. Cicchetti & Ganiban, 1990; Cicchetti and Serafica, 1981; Cicchetti & Sroufe, 1978; Cicchetti,
Ganiban, & Barnett, 1991; Ganiban et al., 2000) performed the most systematic effort to extend the use of the SSP and its classifi-
cation to children with DS, by conducting a series of studies using a broad organizational perspective of development in their
interpretation of the behavior of children with DS during the SSP. Based on these studies, Cicchetti and colleagues concluded that
between the ages of 12 and 24 months of developmental age (DA), attachment becomes consolidated among children with DS
(Cicchetti & Beeghly, 1990), with an organization of SSP responses similar to that of TD children, and with secure attachment as the
normative pattern (Cicchetti & Ganiban, 1990; Cicchetti et al., 1991). The works of Cicchetti and colleagues, therefore, support the
applicability of the SSP to children with ID.
Thirty years ago, Goldberg (1988) conducted one of the few attachment studies that included also children with developmental
delay with unknown etiology. Goldberg used the SSP to study three groups of preschoolers with developmental delays: 40 children
with DS, 29 children with neurological disorder, and 40 children with delay of unknown etiology. The distribution of attachment
classifications of all children in the study who could be classified using the conventional classification system did not differ from
normative data, but one third of the SSPs could not be classified using the conventional classification system, and were classified as
avoidant (A) and resistant (C) because of a mixture of proximity seeking, anger, and avoidance toward the mother. There were no
significant differences in the distribution of attachment classifications between the diagnostic subgroups. The disorganized classi-
fication was not used in this study. In their meta-analysis study about attachment quality among different clinical groups, van
IJzendoorn and colleagues (Van IJzendoorn et al., 1992) commented that the A/C classification can be considered as part of the
disorganized category, and therefore the children in Goldberg’s study may be considered to have disorganized attachment.
The studies on attachment and ID reviewed above indicate that many of the children exhibit secure attachment relationships to
their mothers. Relatively to findings from studies of TD children, however, the ID population showed an elevated rate of attachment
insecurity and disorganization. These results call attention to the factors that may explain these distributions in children with ID. For
TD children, matFernal behavior is one of the strong predictors of the child’s attachment and the question remains as to the role of
maternal behavior in the consolidation of attachment of children with ID.
Maternal sensitivity is thought to be the main mechanism accounting for individual differences in children's attachment
(Ainsworth et al., 1978). Sensitive mothers, according to Ainsworth, read the infant’s signals accurately and respond to them ap-
propriately, promptly, and effectively. This mechanism received support from numerous studies with TD children (e.g., Biringen,
Derscheid, Vliegen, Closson, & Easterbrooks, 2014; Wolff & IJzendoorn, 1997; Weinfield et al., 1999), reinforcing the significant link
of maternal sensitivity to various domains of child development including brain development (Kok et al., 2015).
Data about maternal sensitivity and children with ID is scarce, but the few studies on the subject present findings that are similar
to what we know from the study of TD children. Atkinson et al. (1999) showed that among children with DS attachment classifi-
cations were related to measures of maternal sensitivity obtained over a two-year period under varying conditions, with mothers of
secure children rated as more sensitive than those of insecure children. Similarly, Moran and colleagues (Moran, Pederson, Petit, &
Krupka, 1992) found positive associations between maternal sensitivity and attachment security within a group of toddlers with
developmental delay, although in their study security was assessed by Waters and Deane’s (1985) Attachment Behavior Q-Sort (AQS),
not by the SSP.
In a more recent study, van IJzendoorn and colleagues (Van IJzendoorn et al., 2007) examined maternal sensitivity and at-
tachment among children with autism. Using a group of children with ID as one of the comparison groups, the authors found positive
association between children’s security of attachment and maternal sensitivity. The generalizability of the results is limited, however,
because of the small number of participants in the ID group (N = 10). The correlation between maternal sensitivity and security of
attachment emerged also in other studies of children with autism, many of whom are also intellectually disabled (Capps, Sigman, &
Mundy, 1994; Koren-Karie, Oppenheim, Dolev, & Yirmiya, 2009).
Maternal structuring is another construct that was found to be related to children’s quality of attachment (Bretherton, 2000).
Although maternal structuring is not as studied as maternal sensitivity, several studies showed the connection between appropriate
parental structuring, and children’s secure attachment (Bretherton, 2000). Maternal structuring is the extent to which the parent
adequately guides, scaffolds, and serves as a mentor in the child’s activities. It refers to the parent’s ability to follow the child’s lead
while setting appropriate boundaries (Biringen et al., 2014). The literature on the interaction between mothers and their children
with ID describes a tendency of the parents to be direct and didactic (Al-Yagon & Margalit, 2012; Hauser-Cram, Howell-Moneta, &

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Young, 2012; Mahoney, Fors, & Woods, 1990; Marfo, Dedrick, & Barbour, 1998). Therefore the construct of maternal structuring may
be of special relevance in the study of parental interactive behavior with children with ID and its possible correlation to attachment
quality.
In sum, a small number of studies have examined children with ID from an attachment perspective. The association between
maternal interactive behavior and security of attachment in children with ID has been examined in only three studies: two involving
children with DS (one of which did not use the SSP), and one that used a very small sample. None of these studies examined maternal
structuring. The goal of the present study was to examine maternal sensitivity and structuring, and its association with attachment
classification among children with non-specific ID, hypothesizing that higher levels of maternal sensitivity and structuring are as-
sociated with security of attachment. In addition, we examined the severity of the child’s diagnosis as a possible correlator to the
study’s variable: maternal interactive behavior and attachment quality.

2. Method

2.1. Participants

Forty preschool age children and their mothers were recruited from child development clinics, special needs educational in-
stitutions, and medical services for children with ID to participate in the study. The main inclusion criteria were a diagnosis of non-
specific ID. All the children included in the study had a prior diagnosis of non-specific ID by a pediatrician or a developmental
psychologist, and had no other known medical problems. The children were diagnosed again as having ID as part of the study. One
child was found to have a score above the cut-off on the screening test for autism spectrum disorders (ASD) and was therefore
excluded from the study. An additional inclusion criterion was that the diagnosis was known to the mothers for at least six months
before being recruited for the study, to allow for a period of adjustment.
Nine percent of the families that were approached refused to participate in the study. The main reason for the refusals was the
parents' feeling that their child was already burdened with clinical assessments. Other reasons were unspecified. Two families
dropped out during the study: one family did not want to proceed with the diagnostic assessment, and in one family the father
opposed his wife’s participation.
The sample included 25 boys and 15 girls, with a mean chronological age of 47.25 months (SD = 12.4, range = 26–75 months)
and a mean developmental age of 25.92 months (SD = 10.89), based on the Mullen Scales of Early Learning (MSEL; Mullen, 1995).
Fifteen of the children were firstborns. The mothers’ mean age was 33.59 years (SD = 5.9), and their mean number of years of
education was 13.18 (SD = 2.42). Thirty two of the mothers were married, and the others were single or divorced. The time since
receiving the diagnosis ranged from 6 to 57 months.

2.2. Procedure

The study received ethical permission number 920060525 from the Israeli ministry of health.
In the first stage, families were approached by child-development clinics followed by the researcher of the study. The study
included two meetings: the first meeting took place in the family’s home, and included the diagnostic assessment and the completion
of questionnaires. The second meeting took place at the Center for the Study of Child Development, University of Haifa where
observations of mother-child interactions and the SSP were conducted.

2.3. Measures

2.3.1. Diagnostic assessment

As noted, all the children participating in the study were diagnosed with ID by clinicians before the study, and their diagnoses
were confirmed as part of the study procedure, using the following assessments.
Vineland Adaptive Behavior Scales (VABS: Sparrow, Balla, & Cicchetti, 1984). This maternal interview assesses adaptive abilities in
the domains of socialization, communication, motor skills, and daily living skills. It yields five standardized scores: four scores for
each of the four domains and a global adaptive behavior score, all with means of 100 and standard deviations of 15. In this study we
used the adaptive behavior score, which reflects the overall level of adaptive behavior.
Mullen Scales of Early Learning (MSEL; Mullen, 1995). An individually administered measure of cognitive functioning for infants
and preschool children, from birth to 68 months. The MSEL assesses the child’s abilities in the visual, linguistic, and motor domains,
and distinguishes between receptive and expressive processing. The five MSEL domains are: gross motor, visual reception, fine motor,
receptive language, and expressive language. Standard scores with a mean of 50 and a standard deviation of 10 are calculated for
each domain. Children’s overall level of cognitive functioning was measured using the Early Learning Composite, by converting the
raw scores into derived score on the basis of the child’s chronological age. The final DQ score derived from the sum of the standard
scores on all five domains, has a mean of 100 and a standard deviation of 15. The MSEL manual reports good internal, test–retest, and
interrater reliabilities (Mullen, 1995). In addition to the validity reported in the MSEL manual, validity of the MSEL was also tested in
a study of children with Autism, of which some had also ID (Bishop, Guthrie, Coffing, & Lord, 2011). The validity study compared
non-verbal IQ (NVIQ) and verbal IQ (VIQ) of the MSEL to the NVIQ and VIQ of the DAS (Differential Ability Scales; Elliott, 1990).The
results show a correlation of 0.74 between the MSEL NVIQ to the DAS NVIQ, and 0.82 between the MSEL VIQ to the DAS VIQ, hence
presenting good validity scores.

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The Social Communication Questionnaire (SCQ; Rutter et al., 2003). The SCQ, used to rule out ASD among the participant children,
is a screening questionnaire completed by parents. Total scores range 0–39. The validity of the SCQ in discriminating ASD from non-
ASD has been confirmed at a cut-off score of ≥15 (Chandler et al., 2007).
Diagnosis. Children were classified as having ID if they received a score of 75 or below on the MSEL and the VABS, and a score
lower than 15 on the SCQ. In case of a discrepancy between the MSEL and the VABS, the children were evaluated clinically, and a
final diagnosis was made by a senior researcher or clinician. The mean DQ score, based on the MSEL, was 55.45 (SD = 17.28,
range = 49–82). The mean adaptive behavior score, based on the VABS, was 60.72 (SD = 10.43, range = 31–83). One child had a
score of 22 on the SCQ, and was therefore excluded from the study.

2.3.2. Attachment assessment

The Strange Situation Procedure (Ainsworth et al., 1978). The SSP consists of eight episodes: a short introduction to the laboratory
room followed by seven 3-min episodes, including contact and interaction with an unfamiliar woman, and two separation and
reunion episodes with the mother. Children’s behavior was classified based on videotapes, using the coding systems developed by
Ainsworth et al. (1978). Children’s developmental age was between 11 and 47 months, therefore the Ainsworth coding system of the
SSP was applied. The SSP and the Ainsworth coding system have been used in previous studies of children with developmental delays,
for example, in a study by Atkinson et al. (1999), who applied the SSP to children with DS aged 29.89–57.43 months, and in a study
by Koren-Karie and colleagues (Koren-Karie et al., 2009), which used the Ainsworth coding with children with autism aged 33.6–70.8
months.
The Ainsworth’s coding system was designed for children age 12–20 month, and therefore we used both the Ainsworth and the
Cassidy and Marvin (1989) coding system for children with developmental age older than two years and the results were the same. In
addition, the reliability on 25% of the sample yields good result that reinforces the use of Ainsworth’s classifications system.
In the coding of the SSP we also used Pipp-Siegel et al. (1999) guidelines to distinguish between neurological and non-neuro-
logical D behavior. In their paper the authors list D behaviour that can reflect dual indices of disorganized attachment to the primary
caregiver and/or neurological impairment in the infant. We used their criteria and excluded D indices that could be explained by
neurological abnormalities, and were manifested during all the SSP procedure and not just with the mother.
The classification of the SSP was carried out by an experienced coder, trained by Mary Main and Erik Hesse, to code attachment
classification. The coder was blind to any other information about the participants. Another trained coder analyzed 25% of the SSP
videos for reliability purposes. Inter-rater reliability on the four-way attachment classification, was 0.82 (Kappa).

2.3.3. Assessing maternal behavior

The Emotional Availability Scales (EAS; Biringen, Robinson, & Emde, 20001) were used to code maternal behavior during inter-
acting with her child over a –a 7-min session of free play without toys. The instructions were: for the next five minutes you can play
together in whatever game you want. The interaction was videotaped with three cameras and later coded.
The Maternal Sensitivity Scale ranges from 1 (highly insensitive) to 9 (highly sensitive). It describes the parent's attunement and
responsiveness to the child's signals, expressing warmth and emotional connectedness to the child. The scale is based on the following
elements: positive affect, clarity of perceptions, awareness of timing, flexibility, acceptance, and amount of interaction and nego-
tiation in conflict situations.
The Maternal Structuring Scale ranges from 1 (non-optimal structuring) to 5 (optimal structuring). It describes the parent’s ability
to create appropriate structuring to the child’s play by following the child’s lead, providing the needed scaffolding and setting
appropriate limits for the child’s behavior or misbehavior.
Three coders, blind to all other information about the dyads, coded maternal sensitivity. The coders were trained by a skilled EAS
coder, who analyzed 20% of the interactions to establish inter-rater reliability, which was assessed using intra-class correlations, and
ranged from ICC = 0.76 to ICC = 0.97, with a mean of 0.89.

3. Results

3.1. Descriptive statistics

Attachment classification: Children were assigned to one of four attachment classifications with the following distribution: 16
(40%) were secure; 5(12.5%) were insecure-avoidant; 6 (15%) were insecure-resistant; 13 (32.5%) were insecure-disorganized.
Because of the small size of the four attachment classification cells, in the results we addressed children’s attachment classification by
comparing secure (N = 16, 40%) vs. insecure (N = 24, 60%), and disorganized (N = 13, 32.5%) vs. organized (N = 27, 67.5%)
attachment. In the last post hoc analyses we looked at the different subgroups.
Emotional availability scores: Table 1 shows the descriptive statistics of the maternal sensitivity and maternal structuring scores.

1
In this study’ the 3rd edition was available to our lab and the team working with us. However, the main difference of the 4th edition, hence, the uniformity of all
the dimensions into a 7-points scale is of a less relevance to our study that focused on sensitivity and structuring as separate dimensions.

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Table 1
Descriptive statistics of the maternal sensitivity and structuring.

M SD Range

Maternal sensitivity 6.18 1. 04 4–8

Maternal structuring 4.03 0.77 2.5–5

3.2. Associations between maternal sensitivity and structuring, attachment classification and background variables

No associations were found between the study variable: maternal sensitivity, maternal structuring, and children’s attachment
classification with any of the background variables: maternal education, mothers’ age, number of children, marital status, child’s
gender, child’s age, birth order, and time since receiving the diagnosis.
No significant differences were found in the level of DQ derived from the MSEL between children with secure vs. insecure
attachment (t (38) = −2, p = 0.06). In addition, no significant differences in the level of DQ were found between children with
organized vs. disorganized attachment (t (38) - 1.96, p = 0.06). No associations were found between children’s adaptive behavior and
attachment classifications.
Level of DQ was also none significantly correlated with the dependent variable-maternal sensitivity (r (40) = 0.14, p = 0.40) and
maternal structuring (r (40) = 0.2, p = 0.22).

3.3. Association between maternal sensitivity and structuring and secure vs. insecure attachment classification of the child

A significant difference was found for maternal sensitivity comparing secure (M = 6.59, SD = 1.06) vs. insecure (M = 5.90,
SD = 0.95) children’s attachment: (t (38) = −2,15, p = 0.04, d = 0.69). A significant difference was also found for maternal
structuring comparing secure (M = 4.34, SD = 0.79) vs. insecure (M = 3.82, SD = 0.70) children’s attachment (t (38) = −2.2,
p = 0.03, d = 0.70).

3.4. Association between maternal sensitivity and structuring and organized vs. disorganized attachment classification of the child

A significant difference was found for maternal sensitivity comparing organized (M = 6.47, SD = 0.99) vs. disorganized
(M = 5.58, SD = 0.91) children’s attachment (t (38) = 2.736, p = 0.009, d = 0.94). A significant difference was also found for
maternal structuring comparing organized (M = 4.24, SD = 0.72) vs. disorganized attachment (M = 3.59, SD = 0.68) children’s
attachment (t (38) = 2.66, p = 0.01, d = 0.91).
Post hoc comparisons using the Scheffe test indicated that the mean score for maternal sensitivity of the secure attachment group
(M = 6.59, SD = 1.06) was significantly higher than for the disorganized attachment group (M = 5.58, SD = 0.91) but not sig-
nificantly different from the insecure (a + c) attachment group (M = 6.28, SD = 0.89).
Similar results were found for maternal structuring, showing that the mean score for maternal structuring of the secure attach-
ment group (M = 4.34, SD = 0.64) was significantly higher than for the disorganized attachment group (M = 3.59, SD = 0.69), but
not significantly different than the insecure attachment group (M = 4.09, SD = 0.63).

4. Discussion

Confirming our hypothesis, the results revalidated the connection between maternal interactive behavior, with respect to sen-
sitivity and structuring, and security of attachment in children with ID. Our findings show that the sensitive behavior and appropriate
structuring of mothers of children with secure attachment were significantly different than maternal interactive behavior of children
with disorganized attachment. The difference between the insecure attachment and secure or disorganized attachment was not found
to be statistically significant, although, caution should be exercised in interpreting the results because of the small size of the insecure
group (11 children).
Hence, the main differences were between the secure and disorganized attachment classifications. This is not surprising, as these
two classifications may be regarded as the two extreme opposite attachment qualities. Similar results were found in a study of
mothers who suffer from depression, with maternal sensitivity and structuring differentiating between secure to disorganized chil-
dren’s attachment (Easterbrook, Biesecker & Lyons-Ruth, 2000). Thus, our results indicate that the behavior of the mothers of
insecure children did not exhibit significantly higher sensitivity or structuring interactive behaviour than did that of mothers of
children with disorganized attachment (Lyons-Ruth and Jacobvitz, 1999; Easterbrooks et al., 2000). The means scores of maternal
interactive behavior of children with insecure attachment were located between the scores of secure attachment and disorganized
attachment, pointing towards a coherent direction of the results.
Our findings of the association between maternal sensitivity and structuring and children’s secure attachment emphasize once
more the importance of maternal interactive behavior towards children with ID and validated this link in the context of children with
non-specific ID. These findings add to the many studies that showed this association in various populations (Atkinson et al., 2000). To
present, only few studies, however, examined this link and its relevance among children with ID. These findings also contribute to the
realization that paradigms based on TD children can be applied to children with ID, and as such, add to the understanding of the

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relationship between parents and children with ID (Baker, Blacher, Crnic, & Edelbrock, 2002).
Sensitivity is the ability of the mother to read a variety of signals of the child, interpret them correctly, and respond to them
accurately and promptly (Ainsworth et al., 1978). In the case of children with ID, reading the signals and responding accurately may
be challenging for the caregiver. Nevertheless, our findings show that the average sensitivity scores in our sample are similar to
average score in other studies of TD children. Although caution must be exercised in making a direct comparison, the similarity in the
mean rates of maternal sensitivity shows that despite the challenges presented by the child’s disability, mothers are able to present a
normative range of sensitivity scores. Taking into account the stress and sometime traumatic experience (Olsson & Hwang, 2001),
alongside the everyday constrains and challenges that are part of parenting a child with ID, it is even more appreciated that these
mothers are able to be emotionally available and to show a range of sensitive maternal behavior.
Our finding show that maternal sensitivity and structuring were not correlated with ID. The disability of the child, which includes
difficulties in signaling and communication, may pose challenges to interactive maternal behavior. Nevertheless, mothers were able
to compensate (Biringen, Robinson, & Emde, 2005) for these difficulties and display an interactive behavior that is not directly
influenced by the difficulties presented by the child or linked to it. This result confirms once again one of the basic tenets of
attachment theory, stressing that the parent plays a more important role than the child in shaping the quality of the child-parent
attachment relationship. This idea was strongly supported by the meta- analysis of van IJzendoorn and colleagues (Van IJzendoorn
et al., 1992), which compared the relative effect of the mother’s and the child’s problems on attachment quality in different clinical
groups. The authors showed that in clinical samples, maternal problems have a stronger effect on attachment quality than does the
child’s problem. It is, therefore, the mothers’ role to fine-tune their behavior to the needs of the child despite the difficulties presented
by the child.
Forty percent of the children in our sample were found to have secure attachment. This ratio is similar to the findings of other
studies of attachment in children with ID, mostly with DS (e.g., Atkinson et al., 1999). This ratio is, however, lower than that found in
many studies of TD children, which is between 60%–70% (Van Ijzendoorn et al., 1999). Nevertheless, it shows that children with ID
are able to form secure attachment, as measured using the SSP.
Children’s attachment classification was not linked to the level of the disability measured by the DQ. This important finding
suggests that in the level of DQ presented in this study, including mild-to moderate ID, attachment quality is not affected directly by
cognitive disability. Although cognition plays a part in the formation of attachment (Bowlby, 1982), the cognitive disability of
children with mild-to-moderate ID did not contribute significantly or directly to the quality of their attachment with the parent.
Thirty two point five percent of the children in our sample showed disorganized attachment. This is a high proportion compared
to studies of TD children, where 5%–10% show disorganized attachment (Van Ijzendoorn et al., 1999; Granqvist et al., 2017). In
clinical samples, including ASD, Cerebral Palsy, and DS, the findings show that 35% of the children display disorganized attachment
(van Ijzendoorm et al., 1999). The present study is the first to examine disorganized attachment in a sample of children with non-
specific ID. As several studies of TD children have shown, disorganization can be a risk factor to psychopathologies as borderline and
other personality disorders, in addition to antisocial disorders (Granqvist et al., 2017). Hence disorganization is a highly un-adaptive
strategy that involves a dissociative mechanism. Because individuals with ID are at greater risk for emotional and behavioral pro-
blems (Emerson, 2003; Koskentausta, Iivanainen, & Almqvist, 2007), the overrepresentation of disorganization is a reason for
concern.
Several reasons may contribute to the overrepresentation of disorganized attachment among children with ID. In a recent con-
sensus paper summarizing two decades of research of disorganized attachment, a group of leading researchers in the e field of
attachment described the different antecedents leading to disorganized attachment: “...Pathways to disorganized attachment may
feature a parent’s unresolved trauma or loss. Such experiences may lead a parent to display subtly frightening, frightened, or dis-
sociative behaviors toward their infant” (p. 2, Granqvist et al., 2017). Most parents who receive a diagnosis of a serious develop-
mental disability such as ID for their child experience strong emotional reactions, including shock, sadness, despair, and confusion
(Blacher, 1984). This is a painful process that shares many similarities with grief and mourning. Indeed, many studies have likened
this experience to a metaphorical loss, as it were, of the hoped-for, typically developing child (Oppenheim, Koren-Karie, Dolev, &
Yrmiya, 2009). Such a strong emotional experience may therefore cause mothers to become psychological unavailable to the child
and to display frightened or frightening behavior that leads to disorganized attachment (Granqvist et al., 2017).
The assumptions regarding the reasons for the overrepresentation of disorganized attachment among children with ID needs
further examination, including a detailed assessment of the behavior of mothers of children with disorganized attachment. The
Emotional Availability Scales used in the present study were not designed specifically to assess this type of maternal behavior. Future
studies may use the AMBIANCE coding system, which was specifically designed to assess maternal behavior related to disorganized
attachment (Bronfman, Parsons, Lyons-Ruth, 1999).
The small sample size of the present study limits the ability to generalize the findings. Other limitations have to do with the
correlates of maternal behavior. The present study focused on several maternal background factors (including education, age, marital
status, and number of children), and on some child factors (including gender, chronological age, developmental age, birth order,
adaptive behavior and DQ), and found no correlations with interactive maternal behavior. These factors, however, form only a small
part of the puzzle. It is necessary to further explore the contribution of other variables to the understanding of the socio-emotional
development of children with ID, including parental representation, family support, cultural context, socio-economic factors, genetic
predisposition, and more (Granqvist et al., 2017; Pelchat, Bisson, Bois, & Saucier, 2003).
Intervention studies with TD children demonstrated the causal link between maternal sensitivity and security of attachment
(Schuengel & Janssen, 2006). Enhancing maternal sensitivity has emerged as the most significant factor in parent-child interventions
with high–risk, TD children (Bakermans-Kranenburg et al., 2003). Our design is limited in its ability to draw conclusions regarding

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causality. Nevertheless, the strong correlations we found between maternal sensitivity and structuring on one hand, and attachment
security on the other, reinforces the idea that intervention aimed at enhancing these interactive maternal behaviors has promising
results, which are yet to be pursued (Guralnick, 2017).

Acknowledgments

We thank all the families who took part in the study, and all the students and colleagues that helped in collecting and analysing
the data. Special thanks to David Oppenheim for his help in this study. We thank the Shalem Fund for the support in this study.

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