Journal of Social and Clinical Psychology, Vol. 20, No. 2, 2001, pp.

208-232
berant et al.
ATTACHMENT AND MENTAL HEALTH

THE ASSOCIATION OF MOTHERS’

ATTACHMENT STYLE AND THEIR
PSYCHOLOGICAL REACTIONS TO THE
DIAGNOSIS OF INFANT’S CONGENITAL
HEART DISEASE
ETY BERANT, MARIO MIKULINCER, AND VICTOR FLORIAN
Bar-Ilan University, Ramat Gan, Israel

The present study examines the relationship between mothers’ attachment style
and their immediate psychological reactions to the diagnosis of congenital heart
disease (CHD) in their infants. The sample consisted of 151 mothers of newborns,
who were divided into three groups according to their infant’s health conditions: (a)
healthy infants, (b) mild CHD infants, and (c) severe CHD infants. All the mothers
answered self-report scales on attachment style, cognitive appraisal of mother-
hood, perceived support, ways of coping with motherhood tasks, and a measure of
psychological distress. Results showed that securely attached mothers appraised
motherhood in more positive terms, perceived more available support, were more
likely to seek support, and reported less psychological distress than insecurely at-
tached mothers. These associations were more prominent in the severe CHD
group, compared with the other two groups. Moreover, appraisal and coping mea-
sures were associated with psychological distress and mediated the attach-
ment-distress link. The discussion emphasized the stress-resistance value of secure
attachment style immediately after the CHD diagnosis.

In the last decade, theoretical and empirical efforts have been spent in at-
tempting to understand the role adult attachment style plays in the pro-
cess of coping with stress. Two perspectives (Hazan & Shaver, 1987;
Main, Kaplan, & Cassidy, 1985) have guided this line of research. Within
a developmental psychology context, Main et al. (1985) assessed a per-
son’s state of mind and his or her freedom to explore attachment themes

This article is based in part on the doctoral dissertation of the first author under the super-
vision of the two other authors at the Department of Psychology, Bar-Ilan University.
Address correspondence to Mario Mikulincer, Department of Psychology, Bar-Ilan
University, Ramat Gan 52900, Israel; E-mail: mikulm@mail.biu.ac.il

208
ATTACHMENT AND MENTAL HEALTH 209

through an intensive interview, which demands a complex interpreta-

tion of narrative accounts. Within a personality and social psychology
context, Hazan and Shaver (1987) assessed a person’s current feelings
and cognitions in close relationships through self-report measures that,
although suffering from the typical shortcomings of self-report tech-
niques, have been found to be parsimonious and psychometrically
sound. In the current study, we adopt Hazan and Shaver’s approach and
examine the association between self-reports of mothers’ attachment
style and their reactions to the diagnosis of congenital heart disease
(CHD) in their infants. This disease is one of the most prevalent congeni-
tal malformations affecting 8 of every 1,000 newborns (Martin, Perry, &
Ferencz, 1989) and seems to be a major source of maternal distress (Aus-
tin, 1991; Cohn, 1996).

ATTACHMENT THEORY AND RESEARCH

Following Bowlby’s theory (1969, 1973, 1980) and Ainsworth, Blehar,
Waters, and Wall’s (1978) work on attachment style in infancy, Hazan
and Shaver (1987) defined three attachment styles in adulthood: se-
cure, avoidant, and anxious-ambivalent. The secure style was defined
by comfort with closeness and confidence in others’ love: the avoidant
style was defined by insecurity in others’ responses and preference for
distance, and the anxious-ambivalent style by insecurity in others’ re-
sponses and a strong desire for intimacy. Although some studies have
examined the strength of attachment to specific figures, attachment
style is conceptualized as a stable and global orientation toward close
relationships that is characteristic of a person beyond specific relation-
ships (Shaver & Hazan, 1993). Studies have shown that this construct is
stable across relationships (Banai, Weller, & Mikulincer, 1997) and is
involved in several interpersonal and intrapersonal phenomena
(Shaver, Collins, & Clark, 1996). There is also evidence that, although
attachment style shares some variance with other personality traits, it
has been found to still represent a separate psychological entity
(Brennan & Shaver, 1995).
One line of adult attachment research has focused on Bowlby’s (1988)
premise that security in attachment is an “inner resource,” which may
help the individual to cope and adjust to stressful events. In this context,
secure persons have been found to appraise stressful events in more be-
nign terms and view themselves as more capable of coping with these
events than less secure persons (Birnbaum, Orr, Mikulincer, & Florian,
1997; Mikulincer & Florian, 1995; Mikulincer, Florian, & Weller, 1993).
Moreover, avoidant and anxious-ambivalent persons have been found
to react with more psychological distress to stressful events than secure
210 BERANT ET AL.

persons (for a review see Mikulincer & Florian, 1998). With regard to
ways of coping with stress, secure persons tend to rely on active strate-
gies and support seeking, avoidant persons tend to rely on cognitive and
behavioral distancing strategies, and anxious-ambivalent persons tend
to ruminate mentally on their emotional state and to rely on emotion-fo-
cused strategies (Fraley & Shaver, 1997; Kobak, Cole, Ferenz, & Fleming,
1993; Mikulincer, Florian, & Tolmacz, 1990).
The current study examines the contribution of attachment style to the
emotional reactions of mothers who have to deal with the diagnosis of
CHD in their newborns. To date, there is no published systematic study
on the association between attachment style and reactions to chronic ill-
ness. The original contributions of our study are: (a) the focus on the
acute phase of a very stressful situation that could develop in a chronic
health condition; (b) the examination of a real-life stress involving the
potential loss of an infant; and (c) the possible moderating effect of the
severity of CHD on mother’s reactions. One should view our study as a
prototype for assessing the implications of attachment style to maternal
distress derived from congenital conditions that are potentially life
threatening.

MOTHERS’ COPING WITH THE DIAGNOSIS OF CHD IN

THEIR INFANTS
Although much of the work on maternal reactions to the diagnosis of
CHD, in particular, and chronic childhood illness, in general, is based on
clinical observations and intuitions, it is quite clear that mothers’ reac-
tions to such a diagnosis are very strong (Cohn, 1996). Usually mothers
do not grasp what they are told and they tend to react with denial and
disbelief at the diagnosis. They may also experience high levels of dis-
tress and guilt feelings about their responsibility for the disease (Cohn,
1996). These reactions may be aggravated in severe forms of CHD, in
which mothers face the gloomy possibility that the infant may die or will
not survive medical procedures (Rae-Grant, 1985).
Beyond the clinical observations that emphasize the intense emotional
reactions of mothers to the diagnosis of chronic childhood illness, more
systematic studies have documented wide individual variations in these
reactions (Kronenberger & Thompson, 1992; Mullins et al., 1991). The
stress and coping literature suggests that a person’s inner resources may
be an important determinant of emotional reactions to stressful events
(Dean, 1986; Wheaton, 1983). In this context, Silver, Bauman, and Ireys
(1995) emphasized that studies should take into consideration mothers’
inner resources to provide a better understanding of their reactions to
chronic illness in their children.
ATTACHMENT AND MENTAL HEALTH 211

In the current study, we adopted the theoretical framework offered by

Lazarus and Folkman’s (1984) in order to examine the possible link be-
tween one basic inner resource, attachment style, and maternal distress
following a CHD diagnosis. Specifically, Lazarus and Folkman (1984)
suggested that inner resources have an impact on the way a person ap-
praises the stressful event and the coping strategies he or she uses, which
may have a direct impact on psychological distress. The authors hypoth-
esize that appraisal and coping processes may mediate the link between
inner resources and distress.
In their model, Lazarus and Folkman (1984) emphasized the impor-
tance of cognitive appraisal and coping strategies in explaining emo-
tional reactions to stress. In support of this view, studies have shown
that parents of infants with chronic diseases who appraised their predic-
ament in less threatening terms and themselves as having more coping
abilities reported lower levels of distress (Florian & Elad, 1998; Sum-
mers, Behr, & Turnbull, 1989; Webster-Stratton, 1990). There is also evi-
dence that the reliance on problem-focused coping and the tendency to
look for social support has positive effects on mental health (Maes,
Leventhal, deRidder, & Denis, 1996; Mikulincer & Florian, 1996). In con-
trast, the tendency to mentally ruminate on one’s emotional state (emo-
tion- focused coping) has been found to have a detrimental impact on
mental health (Folkman & Lazarus; 1985). Attempts to escape or avoid
the confrontation with the source of stress (distancing coping) have been
found to have beneficial outcomes immediately after the experience of
stressful uncontrollable events but impair the long-term process of ad-
justment (Collins, Baum, & Singer, 1983; Roth & Cohen, 1986). Impor-
tantly, the associations between coping strategies and mental health
have been also found among mothers of children with chronic illness
(Davis, Brown, Bakeman, & Campbell, 1998; McCubbin et al., 1983;
Miller, Gordon, Daniele, & Diller, 1992).

THE CURRENT STUDY

A review of the literature indicates that attachment style acts as an inner
resource and may have important implications for mental health and ap-
praisal and coping processes (Fuendeling, 1998; Mikulincer & Florian,
1998). It also suggests that appraisal and coping factors are associated
with emotional reactions to stressful events and may mediate the impact
inner resources have on these reactions (Lazarus & Folkman, 1984). On
this basis, we suggest that mothers’ attachment style would be related to
the distress they experience after a CHD diagnosis in their infants and
that this link would be mediated by the way they appraise and cope with
motherhood tasks.
212 BERANT ET AL.

In the current study, we made four specific hypotheses. First, secure

mothers would show less psychological distress after CHD diagnosis
in their infants than insecure mothers. Second, secure mothers, com-
pared with insecure mothers, would appraise motherhood tasks in less
threatening terms and themselves as more capable of dealing with
these tasks and would be more likely to rely on support-seeking after
the CHD diagnosis. Moreover, whereas anxious-ambivalent mothers
would tend to rely on emotion-focused strategies, avoidant mothers
would rely on more distancing coping strategies. Third, the appraisal
of motherhood tasks and the ways of coping with these tasks would be
related to the distress mothers experience after the CHD diagnosis.
Specifically, (a) the lower the mothers’ appraisal of threat in mother-
hood tasks; (b) the higher their appraisal of their abilities to deal with
these tasks; and (c) the higher their reliance on support seeking, the
lower their distress after the CHD diagnosis. Fourth, the appraisal of
motherhood tasks and the ways of coping with these tasks would me-
diate the link between attachment style and distress. The statistical
control for appraisal and coping factors would dramatically reduce the
strength of the attachment-distress link.
In examining our four hypotheses, we took into account the medical
literature pointing to the importance of the objective severity of the in-
fant’s CHD (Rae-Grant, 1985). In mild CHD conditions, the infant may
feel well and may not need any special medical intervention. In contrast,
severe CHD may cause cyanosis and signs of heart failure (shortness of
breath, failure to thrive) and may demand regular medication or surgi-
cal intervention. In light of these differences, we examine our hypothe-
ses separately for two groups: (a) mothers of infants with a diagnosis of
mild CHD and (b) mothers of infants with a diagnosis of severe CHD.
Unfortunately, the lack of systematic study on mothers of infants with
CHD does not allow us to make any hypothesized prediction about the
effects of the CHD severity. We tentatively explore the potential moder-
ating role that the objective severity of the infant’s CHD may play in the
association between mothers’ attachment style and mental health.
To control for normative maternal distress reactions to the birth of an
infant, we also examined our hypotheses in a group of mothers who de-
livered healthy infants. These mothers served as control group, which
was compared with the two above CHD groups in all the research mea-
sures. This comparison would allow us to discern whether our findings
are specific to the coping with chronic childhood illness or can be ex-
tended to motherhood in general. On this basis, we designed a
well-controlled field research, which includes two study groups of
mothers of infants with CHD (mild and severe) and a control group of
mothers of healthy infants. All the mothers completed self-report mea-
ATTACHMENT AND MENTAL HEALTH 213

sures of attachment style, distress, and appraisal and coping with

motherhood.

METHOD
PARTICIPANTS

A total of 151 women volunteered to participate in the study, without

monetary reward. The study group consisted of 101 mothers of infants
with CHD (mean age = 30.1 years), who were diagnosed during the first
year of life and referred to treatment and follow up in the cardiological
institutes of various hospitals in the central area of Israel. Only mothers
of infants who survived at the time of the study despite the CHD were
included in the sample. In addition, mothers of CHD infants who suf-
fered from other medical conditions at the time of the diagnosis (mental
retardation, brain dysfunction, fetal alcohol syndrome) or mothers who
were known as substance abusers were excluded from the sample. In
this sample, the most frequent congenital heart defects were ventricular
septal defect (N = 37), atrial septal defect (N = 12), transposition of great
arteries (N = 8), tetralogy of fallot (N = 7), and pulmonic stenosis (N = 7).
The control group consisted of 50 mothers who delivered healthy infants
(mean age = 32 years).
To sort the study group according to the CHD severity, we made two
steps. In the first step, two senior pediatric cardiologists independently
read the medical files of each infant and rated the CHD severity on a
7-point scale, with scores ranging from 1 (not severe at all) to 7 (very severe, life
threatening defect). The physicians were requested not to discuss their ratings
with each other. These two ratings were highly correlated (r = .91, p < .01), im-
plying high interjudge reliability that allowed us to average the two ratings for
each participant. In the second step, we divided the CHD group into two sub-
groups according to the median of the severity rating (4). The mild CHD group
(N = 53, mean age = 30.5) included mothers of infants whose cardiac defect did
not affect their functioning and did not require any surgical intervention. The
severe CHD group (N = 48, mean age = 30.2) included mothers of infants
whose cardiac defect was severe and life threatening.
All 151 mothers were Jewish and resided in the central urban area of
the country. All were married, lived in intact families, and had an aver-
age of 1.64 children. A total of 64% were prima paris. A total of 23% of the
mothers completed high school; the remaining mothers had
higher-level education. At the time of CHD diagnosis, infants were 3
months old, on average. A total of 52% of the infants were boys. The
mothers in the study group were approached immediately after the in-
fants’ diagnosis, whereas mothers in the control group were approached
214 BERANT ET AL.

after being matched by criteria of infant’s age and gender and family so-
cioeconomic status to the study group. Chi-square tests and t-tests re-
vealed no significant differences in infant’s gender and age and mother’s
level of education, employment, religiosity, and income between the
study and control groups. No significant associations were found be-
tween sociodemographic characteristics of the mothers (age, number of
children, education level, religiosity, and income level) and the infant
(gender, age) or research variables. In addition, the findings remained
the same after statistically controlling for sociodemographic variables.

MATERIALS AND PROCEDURE

The data from mothers in the study group were collected during 12 con-
secutive months and represented all the infants who were diagnosed
with CHD in five major medical centers in the central area of Israel dur-
ing this period. The cardiologist who diagnosed their infants’ CHD first
contacted mothers in this group. After explaining the meaning of the
heart impairment and expected prognosis (including cases of poor prog-
nosis), the cardiologist asked mothers to participate in the research to
understand better how mothers of CHD infants feel and what would be
the best way to help women with a similar problem in the future. They
were also told that in the next 2 weeks a psychologist will contact them in
their house at their convenience and anonymity was assured. The moth-
ers signed an informed consent and the first author contacted them at
their home. The mothers of the control group were initially approached
by a pediatrician and were asked to participate in a study dealing with
the psychological adaptation of women during the first year of their in-
fants’ lives. They also signed an informed consent and were approached
in the same way as mothers in the research group. Refusal rate from
mothers who were initially approached (N = 170) was low (13%) and no
significant difference was found between study and control groups.
Mothers were requested to complete questionnaires revealing their at-
tachment style, cognitive appraisal and coping with motherhood, and
psychological distress. The scales were presented at random and were
filled individually in the presence of the interviewer. All the scales were
Hebrew versions of English scales that were translated in previous stud-
ies using usual and valid translation techniques.
Mothers’ attachment style was assessed via two instruments based on
Hazan and Shaver’s (1987) descriptions of how people typically feel in
close relationships. These descriptions dealt with a person’s habitual
feelings and cognitions in close relationships without circumscribing
the answers to a specific relationship. Participants were instructed to fo-
ATTACHMENT AND MENTAL HEALTH 215

cus on close relationships in general rather than on a specific relation-

ship. First, participants received the three Hazan and Shaver’s (1987)
prototypical descriptions of attachment styles and were asked to en-
dorse the description that best described their feelings. The frequencies
of attachment styles in our sample were similar to those found in previ-
ous samples (Mikulincer & Nachshon, 1991). In the mild CHD group,
58% of the mothers classified themselves as secure (N = 31), 29% as
avoidant (N = 15) and 13% as anxious-ambivalent (N = 7). In the severe
CHD group, 58% of the mothers classified themselves as secure (N = 28),
25% as avoidant (N = 12) and 17% as anxious-ambivalent (N = 8). In the
control group, 64% of the mothers (N = 33) classified themselves as se-
cure, 20% as avoidant (N = 10) and 16% as anxious-ambivalent (N = 8).
No significant difference was found between study groups in the distri-
bution of attachment styles.
Second, mothers received 10 statements, which were designed to tap
two basic dimensions that seem to underlie a person’s self-classifica-
tion of attachment style: anxiety and avoidance (Brennan, Clark, &
Shaver, 1998; Shaver et al., 1996). Although there is no standard self-re-
port measure of these dimensions, a factor analysis of the items in 60
subscales of the most widely used self-report instruments generated
two main factors that corresponded to the two theoretically derived di-
mensions (Brennan et al., 1998). On this basis, we decomposed Hazan
and Shaver’s (1987) descriptions of avoidant and anxious-ambivalent
styles and constructed five items for each dimensions (for details see
Mikulincer et al., 1990). A detailed examination of these items revealed
that our anxiety items corresponded to Brennan and colleagues’ (1998)
relevant items and that our avoidance items corresponded to Brennan
and colleagues’ (1998) avoidance items. Participants were asked to
read each item and to rate the extent to which the item described them-
selves on a 7-point scale, with scores ranging from 1 (not at all) to 7 (very
much).
In the current sample, a factor analysis with Varimax rotation ex-
plained 57% of the 10-item scale variance. Whereas the first factor (36%
of explained variance) included the 5 avoidance items (loading > .40), the
second factor included the 5 anxiety items. This factor-analytic solution
was indeed similar to Brennan and colleagues’ (1998) two-factor solu-
tion. Cronbach’s α for items corresponding to each factor implied ac-
ceptable internal consistence (.72 and .78, respectively). Moreover
Cronbach’s α in each study group were acceptable (from .71 to .84, re-
spectively). On this basis, two total scores were computed by averaging
items that corresponded to each factor. Higher scores reflect higher anxi-
ety and high avoidance. Importantly, Pearson correlations revealed that
216 BERANT ET AL.

the anxiety and avoidance scores were not significantly associated in

each of the three study groups.
The cognitive appraisal of motherhood was assessed by a Hebrew
version of Folkman and Lazarus’ (1985) scale, which was tailored to
motherhood tasks. This scale consisted of 21 items revealing the ap-
praisal of threats and challenges in motherhood and the perceived abil-
ity to deal with them. Participants rated the extent to which they ap-
praised their current motherhood tasks in the way described in each
item. Ratings were made on a 5-point scale, with scores ranging from 1
(not at all) to 5 (very much). In our sample, a factor analysis with Varimax
rotation yielded four main factors (eigen value >1) that explained
54.1% of the variance. Factor 1 (30.4% of explained variance) included
seven items (loading >. 40) tapping a threat appraisal of motherhood
(“taking care of this infant seems difficult to me”). Factor 2 (9%) in-
cluded five items that tap a benefit appraisal of motherhood (“this in-
fant makes my life meaningful”). Factor 3 (8.3%) included five items
that tap the appraisal of personal ability to cope with motherhood tasks
(“I feel I can effectively care for this baby”). Factor 4 (6.4%) included
four items that tap the appraisal of conflicts between motherhood and
other life tasks (“I feel my professional career is impaired by being the
mother of this baby”). Cronbach’s α coefficients were reasonably high
for the four factors (from .77 to .85). Moreover, Cronbach’s α were ac-
ceptable in each of the three study groups (from .75 to .88). Four scores
were then computed by averaging items that loaded high on a factor.
Higher scores reflected higher appraisals of threat, benefit, coping abil-
ities, and role conflict.
Ways of coping with motherhood tasks were assessed with Parkes’
(1984) shortened version of Folkman and Lazarus’ (1985) Ways of
Coping checklist. This questionnaire was translated into Hebrew by Sol-
omon, Mikulincer, and Avitzur (1988) and adapted to motherhood tasks
in the current study. The current version of the scale consisted of 41
items, retaining the broad range of cognitive and behavioral strategies
women may use to deal with motherhood tasks. In the present study,
participants were asked to think about motherhood problems that oc-
curred in the last month and to rate them on a 5-point scale, with scores
ranging from 1 (not at all) to 5 (very much), the extent to which they tend to
act in the way described in each item when confronted with these prob-
lems.
Previous factor analyses of the Hebrew version of this scale have
yielded four main factors (Mikulincer et al., 1993; Solomon et al., 1988):
(a) problem-focused coping (“I simply concentrate on my tasks”); (b)
emotion-focused coping (“ Somehow I ventilate and express my feel-
ings”); (c) support seeking (“I look for emotional support and under-
ATTACHMENT AND MENTAL HEALTH 217

standing from others”); and (d) distancing coping (“I try to forget the
whole matter”). In the current sample, Cronbach’s α for items corre-
sponding to each factor ranged from .72 to .87, implying acceptable in-
ternal consistence. Moreover, Cronbach’s α were acceptable in each of
the three study groups (from .71 to .89). On this basis, four scores (prob-
lem-focused, emotion-focused, support seeking, and distancing) were
calculated by averaging items that corresponded to a factor. Higher
scores reflected higher reliance on a particular type of coping strategy.
Mothers’ distress was assessed via the Mental Health Inventory (MHI;
Veit & Ware, 1983). This self-report scale consists of 38 items, that were
translated into Hebrew by Florian and Drory (1990). Answers were
given on a 6-point scale, with scores ranging from complete confirma-
tion to complete rejection of the applicability of the item to a participant
over the preceding 2 weeks. Items were collected from the General
Well-being part of the Rand Health Insurance study and were found to
predict psychological functioning over time (Veit & Ware, 1983). The
Hebrew version of this scale has been found to be highly reliable and
valid (Florian & Drory, 1990). Previous factor analyses led Veit & Ware
(1983) to conclude that the MHI consists of 14 items tapping psychologi-
cal well-being and 24 items tapping psychological distress. In the cur-
rent study, Cronbach’s α indicated adequate internal consistency for
these two factors in the total sample (.93; .91) and in each of the three
study groups (from .90 to .93). On this basis, we computed two scores by
averaging items that corresponded to a factor. However, because these
two scores were highly correlated, r(149) = -.62, p < .01, we conducted
statistical analyses only on the distress score to avoid any statistical re-
dundancy or artifact. Similar findings were found when analyses were
conducted on the well-being MHI score. It is important to note that a de-
tailed item inspection of the MHI and attachment measures revealed no
overlap in their contents.

RESULTS
In examining our hypotheses on the association between attachment style
and psychological distress and on the mediational role of appraisal and
coping factors, we adopted the analytical steps suggested by Baron and
Kenny (1986). These steps deal with wheather (a) attachment style was as-
sociated with distress; (b) attachment style was significantly associated
with the hypothesized mediating factors (appraisal and coping); (c) the
mediating factors (appraisal and coping) were significantly associated
with distress; and (d) the statistical control of the contribution of appraisal
and coping scores to distress could weaken the attachment-distress link.
218 BERANT ET AL.

THE ASSOCIATION BETWEEN MOTHER’S ATTACHMENT STYLE

AND PSYCHOLOGICAL DISTRESS

The association between mother’s attachment style and reports of psy-

chological distress was examined by a two-way analysis of variance
(ANOVA). The factors were the self-classification of attachment style
(secure, avoidant, and anxious-ambivalent) and study group (severe
CHD, mild CHD, and control). We also computed Pearson correlations
between the continuous attachment scores (anxiety and avoidance) and
mothers’ reports of psychological distress. The correlations were sepa-
rately performed in each study group.
The ANOVA performed on the MHI psychological distress score
yielded significant main effects for attachment style F(2,141) = 12.46, p <
.01 and study group F(2,141) = 5.90, p < .01. Scheffe post-hoc tests (α = .05)
revealed that anxious-ambivalent mothers reported more psychological
distress (M = 3.09) than avoidant mothers (M = 2.60), who reported more
psychological distress than secure mothers (M = 2.21). In addition,
mothers of infants with severe CHD reported higher levels of distress (M
= 2.96) than mothers of infants with mild CHD (M = 2.63), who reported
more distress than mothers in the control group (M = 2.32).
Importantly, the main effects were qualified by a significant interac-
tion F(4,141) = 2.40, p < .01. Tests for Simple Main Effects revealed the fol-
lowing pattern of differences: in the mild CHD and control groups, anx-
ious-ambivalent mothers reported more psychological distress (M =
3.23, M = 2.84) than secure (M = 2.16, M = 2.14) and avoidant mothers (M
= 2.49, M = 1.98). However, in the severe CHD group, both anxious- am-
bivalent and avoidant mothers reported more distress (M = 3.20, M =
3.33) than secure mothers (M = 2.34). In addition, avoidant mothers of in-
fants with severe CHD reported more psychological distress than their
counterparts in the mild CHD group, who reported more psychological
distress than those in the control group. This effect of study group was
not significant among secure and anxious-ambivalent mothers. As can
be seen, whereas secure mothers showed relatively stable low levels of
distress in the three study groups, anxious-ambivalent mothers showed
higher stable levels of distress. Avoidant mothers’ levels of distress de-
pended on the severity of the infant’s cardiac condition.
Pearson correlations revealed that the attachment anxiety score was sig-
nificantly correlated with distress in all the study groups (Table 1). How-
ever, the attachment avoidance score showed a significant and positive
correlation with distress only in the severe CHD group (Table 1). Whereas
higher attachment anxiety seemed to be related to higher distress even in
the control group, higher attachment avoidance was related to higher
psychological distress only when the infant’s illness was severe.
ATTACHMENT AND MENTAL HEALTH 219

TABLE 1. Pearson Correlations between Continuous Attachment Scores and Measures

of Psychological Distress, Cognitive Appraisal, Perceived Support, and Coping
Strategies in Each Study Group
Control (N = 50) Mild CHD (N = 53) Severe CHD (N = 48)
Measures Anxiety Avoidance Anxiety Avoidance Anxiety Avoidance
Distress .33* -.23 .32* .11 .39** .43**
Cognitive Appraisal
Threat .14 .11 .06 .06 .34* .15
Benefit -.03 -.04 -.01 .08 -.06 -.10
Coping Ability -.25 -.26 -.34* -.09 -.43** -.32*
Role Conflict .05 -.01 .14 .05 .32* .36*
Coping Strategies
Emotion
Focused .04 .23 .34* .15 .37* .31*
Problem
Focused -.21 -.14 .09 -.01 .12 .01
Support
Seeking .07 -.16 -.09 -.17 -.32* -.27
Distancing .01 .36* -.07 -.14 -.39* -.13
Note. Significance levels were corrected according to Bonferroni technique (Tabachnick & Fidell, 1996).
*p < .05; **p < .01.

THE ASSOCIATION BETWEEN MOTHER’S ATTACHMENT STYLE

AND COGNITIVE APPRAISAL

The multivariate ANOVA (MANOVA) performed on the four cognitive

appraisal factors (threat, benefit, coping abilities, and role conflict)
yielded significant main effects for attachment style F(8,276) = 2.71, p <
.01 and study group F(8,276) = 2.07, p < .05 as well as a significant interac-
tion F(16,422) = 2.45, p < .05.
The ANOVAs performed on threat appraisal and perceived coping
abilities only yielded a significant main effect for attachment style,
F(2,141) = 3.29, p < .05, F(2,141) = 9.53, p < .01, respectively. Scheffe post
hoc tests indicated that (a) anxious-ambivalent mothers appraised
motherhood tasks in more threatening terms (M = 2.77) than secure ones
(M = 2.28) and (b) secure mothers perceived having more abilities to
cope with these tasks (M = 4.44) than avoidant (M = 4.13) and anx-
ious-ambivalent ones (M = 3.91). The ANOVA performed on benefit ap-
praisal yielded no significant main effect or interaction.
The ANOVA performed on role conflict yielded significant main ef-
fects for attachment style F(2,141) = 4.54, p < .01 and study group F(2,141)
= 3.13, p < .05 and a significant interaction F(4,141) = 5.13, p < .01. Scheffe
220 BERANT ET AL.

tests yielded that avoidant and anxious-ambivalent mothers reported a

higher level of role conflict (M = 2.43, M = 2.66) than secure mothers (M =
2.11). These tests also revealed that mothers of healthy infants and moth-
ers of infants with severe CHD reported higher role conflict (M = 2.44, M
= 2.58) than mothers of infants with mild CHD (M = 2.12). Tests for Sim-
ple Main Effects yielded the several differences. In the control group,
anxious-ambivalent mothers reported more role conflict than avoidant
mothers. Secure mothers were in between the two other groups. In the
mild CHD group, anxious-ambivalent mothers reported more role con-
flict than secure and avoidant mothers. In the severe CHD group,
avoidant mothers reported more role conflict than the two other groups
(see means in Table 2). Interestingly, whereas avoidant mothers re-
ported the highest role conflict in the severe CHD condition, secure
mothers reported less role conflict in CHD than control conditions.
Pearson correlation revealed the several associations. In the control
group, the two attachment scores showed no significant association
with appraisal factors. In the mild CHD group, there was only one sig-
nificant correlation: the higher the mother’s attachment anxiety, the
lower her appraisal of abilities to cope with motherhood tasks. How-
ever, in the severe CHD group, attachment scores were significantly as-
sociated with most of the appraisal factors. The higher the mother’s at-
tachment anxiety, the higher the appraisal of threat and role conflict in
motherhood and the lower the appraisal of coping abilities. The higher
the mother’s attachment avoidance, the lower the appraisal of coping
abilities and the higher the appraisal of role conflict in motherhood (see
Table 1).
Fitting previous findings, secure mothers perceived motherhood
tasks in less threatening terms and thought of themselves as more capa-
ble of dealing with these tasks than insecure mothers. These associations
were most prominent in the severe CHD group.

THE ASSOCIATION BETWEEN MOTHER’S ATTACHMENT

STYLE AND COPING STRATEGIES
The MANOVA performed on the four coping factors (emotion-fo-
cused, problem-focused, distancing, and support seeking) yielded sig-
nificant main effects for attachment style F(8,276) = 3.54, p < .01 and
study group F(8,276) = 3.30, p < .01 and a significant interaction
F(16,422) = 1.93, p < .05.
The ANOVA for emotion-focused coping yielded significant main ef-
fects for attachment style F(2,141) = 5.47, p < .01 and study group F(2,141)
= 7.50, p < .01. Scheffe post hoc tests indicated that anxious-ambivalent
221 BERANT ET AL.

TABLE 2. Means and SD of Cognitive Appraisal Scores According to Attachment Style

and Study Group
Control Group Mild CHD Severe CHD
Secure Avoid Ambiv Secure Avoid Ambiv Secure Avoid Ambiv
(33) (10) (8) (31) (15) (7) (28) (12) (8)
Threat
M 2.30 2.21 2.64 2.19 2.20 2.73 2.27 2.84 2.72
SD 0.83 0.67 1.06 0.79 0.69 0.91 0.77 1.00 0.62
Benefit
M 4.68 4.66 4.54 4.67 4.72 4.52 4.65 4.25 4.40
SD 0.43 0.45 0.37 0.47 0.39 0.78 0.42 1.17 1.05
Secondary
M 4.28 4.20 4.00 4.51 4.31 3.92 4.51 3.87 3.81
SD 0.50 0.21 0.45 0.51 0.51 0.78 0.44 0.91 0.88
Conflict
M 2.60 2.15 3.00 1.89 2.00 2.46 1.83 3.13 2.37
SD 0.31 0.84 0.70 0.90 0.64 0.80 0.67 1.19 0.64
Note. Numbers within parentheses are Ns within each cell. Avoid = avoidant; Ambiv = anxious-am-
bivalent.

mothers reported more frequent use of emotion-focused strategies

when dealing with motherhood tasks (M = 2.94) than both secure (M =
2.37) and avoidant mothers (M = 2.57). In addition, these tests revealed
that mothers of infants with severe CHD reported more frequent use of
emotion-focused strategies (M = 3.01) than mothers of infants with mild
CHD (M = 2.59), who reported more frequent use of these strategies than
mothers in the control group (M = 2.30).
The ANOVA performed on problem-focused coping only yielded a
significant main effect for study group F(2,141) = 2,91, p < .05. Scheffe
post hoc tests showed that mothers in the control group reported more
frequent use of problem solving strategies when dealing with mother-
hood tasks (M = 3.15) than mothers in the mild CHD group (M = 2.86).
Mothers of infants with severe CHD were in between the two other
groups (M = 3.07).
The ANOVA performed on support seeking only yielded a significant
main effect for attachment style F(2,141) = 4.75, p < .01. As expected,
Scheffe tests indicated that secure mothers reported more seeking of
support when dealing with motherhood tasks (M = 3.31) than avoidant
(M = 2.27) and anxious-ambivalent mothers (M = 2.84).
The ANOVA for distancing coping only yielded a significant interac-
tion effect F(4,141) = 2.90, p < .05. Tests for Simple Main Effects revealed
222 BERANT ET AL.

TABLE 3. Means and SD of Coping Strategies According to Attachment Style and

Study Group
Control Group Mild CHD Severe CHD
Secure Avoid Ambiv Secure Avoid Ambiv Secure Avoid Ambiv
(33) (10) (8) (31) (15) (7) (28) (12) (8)
Emotion Focused
M 2.26 2.00 2.62 2.31 2.57 2.89 2.56 3.14 3.31
SD 0.59 0.46 0.74 0.73 0.90 0.84 0.82 0.71 0.71
Problem Solving
M 3.23 3.07 3.17 2.97 2.80 2.83 2.99 2.86 3.36
SD 0.53 0.59 0.61 0.74 0.66 0.75 0.59 0.32 0.62
Distancing
M 2.83 3.55 2.85 3.34 2.95 3.10 3.25 2.77 3.09
SD 0.56 0.63 0.56 0.92 0.97 0.54 0.75 1.44 0.53
Support Seeking
M 3.45 2.90 3.00 3.26 2.84 2.38 3.21 2.57 3.12
SD 0.89 0.62 1.51 0.88 1.33 1.03 0.72 1.22 1.26
Note. Numbers within parentheses are Ns within each cell. Avoid = avoidant; Ambiv = anxious-am-
bivalent.

that in the control group, avoidant mothers reported more frequent use of
distancing strategies than secure and anxious-ambivalent mothers. How-
ever, in both mild and severe CHD groups, secure mothers reported more
frequent use of these strategies than avoidant ones (Table 3).
Pearson correlations yielded several associations. In the control
group, there was only one significant association in that the higher the
mother’s attachment avoidance, the higher the reported reliance on dis-
tancing coping. In the mild CHD group, the attachment anxiety score
was significantly related to emotion-focused coping, whereas the avoid-
ance score was not significantly related to any of the coping factors. In
the severe CHD group, the higher the mother’s attachment anxiety and
avoidance scores, the higher the reported reliance on emotion-focused
coping. In addition, the higher the mother’s anxiety, the lower the re-
ported reliance on support seeking and distancing coping.
Overall, the findings for emotion-focused coping and support seeking
fit previous results (Mikulincer & Florian, 1998). Secure mothers were
more likely to rely on support seeking and less likely to rely on emo-
tion-focused coping when dealing with motherhood tasks than anx-
ious-ambivalent mothers were. This association was most prominent in
the CHD groups. Quite interestingly, whereas avoidant mothers tended
to use distancing coping in dealing with the regular demands of mother-
ATTACHMENT AND MENTAL HEALTH 223

hood, secure mothers tended to use it mainly when there was a real
threat for their infants’ life.

THE MEDIATIONAL ROLE OF COGNITIVE APPRAISAL AND

COPING
In this section, we examine the possibility that the link between attach-
ment style and psychological distress was mediated by cognitive ap-
praisal and coping strategies. After showing that attachment style was
significantly associated with both the criterion (distress) and the two hy-
pothesized mediating factors (appraisal, coping), we examined (a) the
association between appraisal, coping, and distress; and (b) the attach-
ment- distress link after statistical controlling for the contribution of ap-
praisal and coping.
In examining the contribution of appraisal and coping to psychologi-
cal distress, we computed Pearson correlations and multiple regressions
separately for each study group. In the multiple regression analyses, we
entered eight predictors (four appraisal scores and four coping scores).
Overall, the appraisal and coping scores made significant contributions
to psychological distress in all the three study groups (Fs in Table 4) and
explained between 45% and 58% of the distress variance. In the control
group, appraisals of threat and role conflict and emotion-focused coping
made significant unique contributions to psychological distress: the
higher the appraisals of threat and role conflict and the higher the reli-
ance on emotion-focused coping, the higher the reported distress (re-
gression coefficients in Table 4). In the mild CHD group, three variables
made a significant unique contribution to distress (see Table 4). The
higher the appraisal of threat, the higher the reliance on emotion-fo-
cused coping; the lower the reliance on distancing coping, the higher the
psychological distress. Finally, in the severe CHD group, six variables
made a significant unique contribution to distress (see Table 4). The
higher the appraisal of threat and role conflict, the lower the appraisal of
coping abilities, the higher the reliance on emotion-focused coping and
the lower the reliance on distancing coping and support seeking, the
higher the reported distress (see Table 4).
In the next step, we examined whether appraisal and coping scores
mediated the attachment-distress link. This was explored through the
use of a variant of path analyses (Batson, 1975) that compared two re-
gression analyses that were performed separately for each study group.
In the baseline regression, the two continuous attachment scores were
entered as predictors of distress and their contribution to distress (per-
cent of explained variance) was calculated. In another regression, ap-
praisal and coping scores that significantly contributed to distress (see
ATTACHMENT AND MENTAL HEALTH 224

TABLE 4. Pearson Correlations, Unstandardized Regression Coefficients, and

Standard Error of Psychological Distress as Predicted by Appraisal and Coping Scores
in Each Study Group
Control (N = 50) Mild CHD (N = 53) Severe CHD (N=48)
Measures r URC SE r URC SE r URC SE
Cognitive Appraisal
Threat .63** .33** .12 .66** .90** .15 .64** .35** .12
Benefit -.26 .20 .21 -.09 -.01 .21 -.35* -.01 .19
Coping
Ability -.34* -.18 .17 -.27 -.01 .19 -.54** -.32* .11
Role Conflict .54** .24* .11 .26 .21 .14 .56** .27* .12
Coping Strategies
Emotion
Focus .36* .24* .12 .49** .26* .11 .37* .33* .11
Problem
Focus .09 -.20 .14 .20 .11 .13 .05 -.14 .15
Support
Seek -.28 -.02 .07 -.18 .02 .08 -.38* -.28* .12
Distancing .18 -.12 .10 -.33* -.34* .10 -.36* -.27* .11
F 6.07** 10.01** 8.96**
R2 (%) 45 58 52
Note. URC = unstandardized regression coefficients; SE = standard error. Significance levels of
Pearson correlations were corrected according to Bonferroni techniques (Tabachnick & Fidell, 1996).
*p < .05; **p < .01

regression coefficients in Table 4) were entered in the first step of the

analyses. In the control group, we entered threat appraisal, role conflict
appraisal, and emotion-focused coping. In the mild CHD group, we en-
tered threat appraisal, emotion-focused coping, and distancing coping.
In the severe CHD group, we entered the six variables that made a signif-
icant contribution to distress (see Table 4). After controlling for the con-
tribution of these variables, the two continuous attachment scores were
entered as predictors in the second step of the analyses. If appraisal and
coping scores mediated the attachment-distress link, then the contribu-
tion of attachment scores to distress (percent of explained variance) as
observed in the baseline regression should be drastically reduced when
these mediating factors were introduced first and controlled for in the
second regression.
In the three groups, the regressions revealed that the two attachment
scores made no significant contribution to psychological distress when
appraisal and coping scores were entered first. Moreover, the percent of
distress variance explained by attachment style was reduced by the in-
troduction of appraisal and coping scores in the regression. Specifically,
ATTACHMENT AND MENTAL HEALTH 225

this portion of variance was reduced from 8.2% to 3.8% in the control
group; from 11% to 3.4% in the mild CHD group; and from 25% to 4.8%
in the severe CHD group. In all the three groups, emotion-focused cop-
ing was found to make a significant contribution of distress even after at-
tachment scores were introduced in the equation (p < .05). Appraisal and
coping scores seemed to mediate the attachment-distress link. This is
particularly true in the severe CHD group in which the strong attach-
ment-distress link was quite entirely explained by appraisal and coping
scores.

DISCUSSION
The understanding of mothers’ abilities to deal with their infant’s
chronic illness has important scientific and practical implications. The
current findings revealed that 2 weeks after the diagnosis, mothers of in-
fants with severe CHD reported more distress than mothers of infants
with mild CHD, who reported more distress than mothers of healthy in-
fants. In addition, when the infant had severe CHD, mothers tended to
simultaneously use problem-focused and emotion-focused coping strat-
egies. These findings were in parallel with previous results showing the
detrimental effects of infant’s illness on maternal mental health (Daniels,
Moos, Billings, & Miller, 1987; Mullins et al., 1991) and with findings em-
phasizing the mother’s need to mobilize a wide array of coping strate-
gies (Moos & Tsu, 1977). However, the design of our study allows us to
go one step forward and show that mothers’ reactions to the diagnosis of
CHD were related to their attachment style. Specifically, the findings fit
our main hypothesis that mothers’ inner resource of secure attachment
was associated with relatively low levels of distress.
In the current study, secure attachment was found to moderate the
mother’s immediate emotional reactions to the diagnosis of CHD. More-
over, secure attachment was found to be associated with patterns of cog-
nitive appraisal and coping, which were inversely related to mother’s
psychological distress. These associations were particularly meaningful
in the case of the diagnosis of a severe life threatening CHD.
The findings of this study broaden our knowledge about secure moth-
ers’ pattern of coping. Generally, regardless of study group affiliation,
secure mothers reported lower levels of psychological distress.
Compared with insecure mothers, they perceived motherhood tasks in
more positive terms and appraised themselves as having more coping
abilities and lower levels of motherhood-related role conflicts. In addi-
tion, secure mothers tended to rely on support seeking as their main
strategy for coping with motherhood tasks. Quite interestingly, secure
mothers’ immediate coping reactions to the diagnosis of a severe CHD
226 BERANT ET AL.

in their infants also included distancing strategies. This coping response,

which was found to be positively associated with mothers’ well-being,
might have provided a moratorium until mothers could grasp the mean-
ing of their predicament.
The current findings fit previous results showing that secure persons
react to stressful situations with manageable levels of psychological dis-
tress (Mikulincer & Florian, 1998), positive appraisals of the self and the
world (Collins & Read, 1990; Mikulincer 1995), and actively search for
available sources of support (Mikulincer & Florian, 1998; Shaver &
Hazan, 1993). On this basis, one can speculate that a mother’s secure at-
tachment style may serve as a stress resistance or a resilience factor even
in the difficult initial stages of the coping process with the diagnosis of
CHD in their infants. This may be further accentuated in the case of se-
vere CHD, where sometimes there is a real threat to the infant’s life. In
this case, the overwhelming demands of the infant’s illness did not dis-
courage secure mothers. Rather, they still felt capable to deal with moth-
erhood tasks.
The findings indicate that although support seeking is the main cop-
ing strategy of secure mothers, they seemed also to deal with the spe-
cial demands of the diagnosis of a severe CHD in their infants by using
distancing strategies. These strategies may allow them to suppress
painful thoughts about the uncontrollable threat and to maintain posi-
tive appraisals even in critical circumstances. This finding emphasizes
the richness of a secure mother’s coping repertoire and her flexible ac-
commodation to situational demands. Of course, this finding only re-
flects secure mothers’ immediate reactions to the diagnosis of CHD in
their infants. There is still a question about the frequency and effects of
distancing coping in the long run, after years of coping with a chronic
illness.
With regard to anxious-ambivalent mothers, the findings revealed a
mirror image of secure mothers’ appraisal, coping, and psychological
distress scores. First, anxious-ambivalent mothers showed relatively
high levels of psychological distress even in the case of a healthy infant.
Second, they appraised motherhood tasks in relatively threatening
terms and themselves as being unable to cope with these tasks. Third,
these mothers tended to rely on emotion-focused coping strategies,
which may exacerbate their basic negative emotions and thoughts. Im-
portantly, these psychological characteristics of anxious-ambivalent
mothers were found regardless of the infant’s medical condition. Over-
all, this pattern of findings fits previous results that emphasize the psy-
chological weakness of anxious-ambivalent persons, which puts them at
risk for emotional problems even in normal life circumstances (Shaver &
Hazan, 1993).
ATTACHMENT AND MENTAL HEALTH 227

The results also pointed to the vulnerability of avoidant mothers. This

vulnerability was particularly manifested when the infant was diag-
nosed as suffering from a severe CHD. Whereas avoidant mothers in the
control group reported similar patterns of appraisal and distress as se-
cure mothers, avoidant mothers in the severe CHD group were more
similar to anxious-ambivalent mothers. Specifically, avoidant mothers
of infants with severe CHD reported higher levels of distress than secure
mothers and more negative appraisals of the self and the world. More-
over, they tended to rely on emotion-focused coping strategies, similar
to anxious-ambivalent mothers. Interestingly, the habitual reliance of
avoidant persons on distancing coping (Mikulincer & Florian, 1998) was
observed only in the control group, and not in the CHD groups. It seems
that in the case of a healthy infant, avoidant mothers relied on distancing
strategies for coping with motherhood tasks. However, the demands
imposed by a sick infant might have drawn away the resources neces-
sary for activating distancing coping, probably exposing avoidant
mothers to negative emotions.
The above results are in parallel with Mikulincer and Florian’s (1998)
hypothesis about the fragile nature of the “pseudo-safe” world of
avoidant persons. Their reliance on distancing coping seems to be suffi-
cient when dealing with normative life events. However, when facing
uncontrollable and persisting stressful events, this defense may fade out
and the basic insecurity of avoidant persons may become overtly mani-
fested, leading to pessimistic appraisals and the adoption of more inef-
fective ways of coping. When facing such conditions, avoidant mothers’
high levels of perceived role conflict could impair further their ability to
deal with the demands related to the caregiving of an infant with severe
CHD. These mothers may be bothered by basic questions concerning
their identity as women and mothers, which may increase the accessibil-
ity of negative emotions and thoughts and complicate the process of
coping with the infant’s illness.
This line of thinking fits the theoretical view that the distress associ-
ated with avoidant attachment style is a maladaptive response to a
stressful situation, rather than a definitional component of this style
(Mikulincer et al., 1993). It is possible that avoidant attachment style acts
as a predispositional factor to psychological distress, which becomes ev-
ident mainly in highly stressful conditions
The current findings also provide empirical support to Lazarus and
Folkman’s (1984) theoretical model of stress and coping. Specifically, the
cognitive appraisal of motherhood and ways of coping with mother-
hood tasks were found (a) to be significantly related to psychological
distress and (b) to mediate the association between attachment style and
psychological distress. Importantly, more appraisal and coping factors
228 BERANT ET AL.

were found to be associated with psychological distress in the severe

CHD group than in two other study groups. In this group, as long as
mothers had more negative appraisal of motherhood and were more
likely to rely on emotion-focused coping strategies, the more psycholog-
ical distress they reported. In contrast, as long as mothers had more posi-
tive appraisals of their coping abilities and were more likely to rely on
support seeking and distancing coping strategies, the less the distress
they reported.
The present findings raise an important question concerning the clini-
cal significance of psychological distress: Is more distress inevitably a
sign of greater maladjustment? Although this issue was not addressed in
the current study, we think that it would depend on the severity and du-
ration of the distress and on the functional impact of the distress on the
mother-child relationship or family life. Future studies should explore
the possible association between mothers’ attachment style, maternal
stress level, and the quality of mother-child relationship. At this point,
one can speculate that secure mothers, who may to deal quite well with
the threatening news received about their infant’s health condition, may
have more available psychological resources for caring their infants at
this critical age. As a result, these mothers may be emotionally available
and responsive to the infant and his or her special needs, thereby facili-
tating his or her physical and psychological development. In contrast,
insecure mothers, who may appraise motherhood in negative terms and
report high levels of distress, may experience serious difficulties in deal-
ing with the stressful condition and may put infants at risk of developing
physical and psychological problems.
As with other field studies, a note of caution is required. Because of the
cross-sectional design of our study, no conclusive statement could be
made about causal relations between the assessed variables. In this con-
text, it is important to note that we do not have any data about mother’s
attachment style before the CHD diagnosis. Although attachment style
is considered to be a relatively stable personal characteristic, we do not
know whether and how the receipt of a CHD diagnosis can influence
mother’s attachment orientation. Therefore, it is important to conduct
follow-up longitudinal studies, which may allow us to provide more
valid information about the causal links between attachment style, cog-
nitive appraisal, coping strategies, and psychological distress.
Before ending the discussion, we note some limitations of the current
study that may limit the validity and generalizability of its findings and
conclusions. First, all the variables were assessed through self-report
measures, which might have been affected by social desirability and de-
fensive strategies. In this context, the shared method variance resulting
from single-method measurement may further limit the validity of the
ATTACHMENT AND MENTAL HEALTH 229

findings. Future studies should use observational techniques and adopt

a multimethod measurement approach. Second, although the study and
control groups were matched across sociodemographic variables, one
should be aware that the final sample comprised limited demographic
strata in terms of ethnic affiliation and socioeconomic background. Fur-
ther studies should be conducted among mothers of diverse socioeco-
nomic, ethnic, and cultural backgrounds before generalizing our find-
ings. Third, our study exclusively focused on mother’s attachment style.
However, future studies should take into consideration the possible
contribution of mother’s attachment to specific figures (husband, par-
ents, newborn). Studies should also examine the impact of other
sociopsychological factors (family dynamics, dyadic adjustment) on
mother’s adjustment to chronic childhood illness and the possible inter-
actions between these factors and attachment style in shaping maternal
coping and adjustment. Despite these limitations, our study provides
initial and important data about the contribution of mothers’ attachment
style to their reactions to the diagnosis of a severe infant’s health condi-
tion.

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