PERSONALITY AND SOCIAL PSYCHOLOGY BULLETIN

Berant et al. / ATTACHMENT AND MENTAL HEALTH

Attachment Style and Mental Health:

A 1-Year Follow-Up Study of Mothers
of Infants With Congenital Heart Disease

Ety Berant
Mario Mikulincer
Victor Florian
Bar-Ilan University

The longitudinal contribution of attachment style to mental
health was examined among mothers of infants with Congenital
Heart Disease (CHD). Eighty-five mothers of newborns with
CHD completed self-report scales tapping attachment style,
appraisal of motherhood, ways of coping with motherhood tasks,
and mental health 2 weeks after the infant’s CHD diagnosis and
1 year later. Mothers’ attachment anxiety and avoidance at
Time 1 were related to poor mental health at the same point of
time. In addition, attachment avoidance at Time 1 predicted
further deterioration of mental health from Time 1 to Time 2.
Attachment style at Time 1 also predicted the ways mothers
appraised and coped with motherhood tasks, which, in turn,
were related to mental health changes. The theoretical implica-
tions of the data were discussed.
One of the most intriguing questions in personality
research is why certain people deal successfully with life
problems, whereas others succumb to these stressful
conditions. In the past decade, Bowlby’s (1973) attach-
ment theory has been successfully implemented in deal-
ing with this question, and attachment style is viewed as a
basic individual difference factor that contributes to cop-
ing and adjustment to stress (Mikulincer & Florian,
1998). However, very little is known about the longitudi-
nal effects of attachment style on the way people adjust
to a real-life stressful period. In filling in this gap, we
focused on mothers experiencing a major traumatic
event—the diagnosis of Congenital Heart Disease
(CHD) in their infants—and examined whether self-
reports of attachment style at the diagnosis predict
changes in the process of coping and mental health
1 year after this diagnosis.
Adult Attachment Style, Distress
Regulation, and Mental Health
One of the major tenets of Bowlby’s (1973) theory is
that the attachment system is an affect regulation device,
leading people to maintain proximity to significant oth-
ers who can assist in managing distress. When others are
available and supportive, distress is alleviated, support
seeking is reinforced as a proper coping strategy, and a
sense of attachment security is formed. Bowlby (1988)
claimed that this sense may enhance feelings of self-
efficacy, foster the development of constructive coping
strategies, and result in improved mental health. In con-
trast, when others are unavailable in times of need, dis-
tress is not properly managed, other defensive strategies
rather than support seeking are developed, a sense of
attachment security is broken, and emotional problems
may follow.
The above ideas have been examined in adulthood by
studies that have focused on a person’s attachment
style—stable patterns of relational cognitions and behav-
iors—and have adopted Hazan and Shaver’s (1987)
typology of secure, avoidant, and preoccupied style.
Recently, Brennan, Clark, and Shaver (1998) concluded
that this typology reflects two basic dimensions: avoid-
ance and anxiety. Persons scoring low on these two
dimensions correspond to the secure style and are char-
acterized by a positive history of interactions with signifi-
Authors’ Note: Address correspondence to Mario Mikulincer, Ph.D.,
Department of Psychology, Bar-Ilan University, Ramat Gan 52900, Is-
rael; e-mail: mikulm@mail.biu.ac.il.
PSPB, Vol. 27 No. 8, August 2001 956-968
© 2001 by the Society for Personality and Social Psychology, Inc.

956
 Berant et al. / ATTACHMENT AND MENTAL HEALTH
cant others, confidence in others’ availability in times of
need, and comfort with closeness. Persons scoring high
on attachment avoidance correspond to the avoidant
style, which is defined by insecurity in others’ goodwill
and preference for emotional distance. Persons scoring
high on attachment anxiety correspond to the preoccu-
pied style, which is defined by insecurity in others’
goodwill, compulsive need for closeness, and fear of
being rejected. Bartholomew and Horowitz (1991) dis-
tinguished a subgroup of insecure persons who score
high on both anxiety and avoidance dimensions (fear-
ful persons).1
Most adult attachment studies focus on a person’s
attachment style across different relationships (see
Shaver & Hazan, 1993, for a review). However, some
studies have focused on attachment orientation within a
specific relationship (e.g., Kobak & Hazan, 1991). In our
study, we conceptualize attachment style as a global
individual difference factor. This variable has been
found to be associated with several interpersonal and
intrapersonal phenomena (see Shaver & Hazan, 1993,
for a review). In addition, although somewhat related to
neuroticism and sociability, attachment style has been
found to be a unique construct, to have unique effects on
mental health (e.g., Shaver & Brennan, 1992), and to
regulate the process of coping with stress (Mikulincer &
Florian, 1998).
Adult attachment research has provided extensive
support to Bowlby’s ideas about the contribution of
attachment style to affect regulation. Findings show that
persons who score high on either attachment anxiety or
avoidance tend to appraise stressful events and them-
selves in negative terms, to avoid support seeking, and to
report high levels of distress in stressful conditions (see
Mikulincer & Florian, 1998, for a review). There is also
evidence on the defensive strategies that may result from
attachment insecurity. Whereas avoidant people deacti-
vate distress, suppress bad thoughts, and emphasize a
sense of self-reliance (e.g., Bartholomew & Horowitz,
1991; Fraley & Shaver, 1997), preoccupied people
hyperactivate distress, mentally ruminate on negative
thoughts, and focus on their negative emotional state
(e.g., Mikulincer & Florian, 1995; Shaver & Brennan,
1992).
Although the attachment–mental health link has
been well documented, the question of direction of cau-
sality is still open to research. Most of the studies have
used cross-sectional designs and assumed that attach-
ment style is a stable factor that may contribute to mental
health (Mikulincer & Florian, 1998). However, recent
studies have adopted Bowlby’s (1973) idea of accommo-
dation of attachment style after normative life condi-
tions (e.g., marriage) or stressful events and have found
957
fluctuations in attachment styles (e.g., Baldwin & Fehr,
1995; Davila, Burge, & Hammen, 1997). On this basis,
cross-sectional findings may be not sufficient to test the
attachment–mental health link.
To overcome the limitations of cross-sectional studies,
we adopt a longitudinal approach and examine the con-
tribution of self-reported attachment style to subsequent
changes in mental health among mothers of infants with
CHD, one of the most prevalent and distressing congeni-
tal diseases (Rae-Grant, 1985). In addition, our research
has other original contributions. First, it focuses on psy-
chological reactions to both the acute (receipt of CHD
diagnosis) and chronic phases (1 year later) of a real-life
stress. Second, it attempts to delineate the possible medi-
ators of the attachment–mental health link by focusing
on two basic components of the process of coping: the
ways mothers appraise and cope with the caring of a
chronically ill child.
The Current Study:
Rationale and Hypotheses
In the current study, we approached mothers of
infants with CHD and asked them to complete scales at
two different times tapping attachment style, mental
health, appraisal of motherhood tasks, and ways of cop-
ing with these tasks. The first time was 2 weeks after the
CHD diagnosis (Time 1) and the second time was 1 year
later (Time 2). These two points of time were selected to
represent the acute and chronic phases of the illness.
Immediately after the diagnosis (Time 1), mothers are
generally in a state of emotional shock, they are unable
to grasp the long-term implications of the illness, and
their reactions are directed toward the medical diagno-
sis (Rae-Grant, 1985). One year later (Time 2), one can
assess mothers’ reactions to the more chronic stage of
the illness because at this time the infant’s health status
becomes stabilized, and mothers should accommodate
to the daily demands imposed by the chronic illness.
Our first research issue deals with the contribution of
mothers’ attachment style to changes in mental health
during the follow-up period. The professional literature
has documented that mothers of infants reported high
levels of distress (e.g., Kazak, Reber, & Snitzer, 1988;
Walker, Epstein, Taylor, Crocker, & Tuttle, 1989). How-
ever, few studies have dealt with changes in mothers’
mental health over time, and their findings were some-
what contradictory. On one hand, Rodrigue et al. (1997)
found that, as compared to a pretransplant measure,
mothers reported higher distress 2 months after the
transplantation of organs in their chronically ill chil-
dren, and this distress remained stable 6 months later.
Accordingly, Timko, Stovel, and Moos (1992) found that
depression reactions of mothers of children with Juve-
958 PERSONALITY AND SOCIAL PSYCHOLOGY BULLETIN
nile Rheumatic Disease remained stable over a 1-year
period. On the other hand, mothers’ initial distress reac-
tions to the diagnosis of insulin-dependent diabetes
mellitus in their children were found to decline after
1 year, and this improvement remained stable after
6 years (Kovacs et al., 1985, 1990). Similar findings were
reported by Dahlquist, Czyzewski, and Jones (1996), who
showed that mothers’ anxiety to children’s cancer
decreased after 2 years.
In our view, the above contradictory findings may
reflect individual differences in mothers’ attachment
style. On one hand, their optimistic and constructive
approach to life (Bowlby, 1988; Mikulincer & Florian,
1998) may allow mothers who score low in attachment
anxiety and avoidance to maintain adequate mental
health immediately after the CHD diagnosis and to
adapt to the permanent demands of this chronic illness.
On the other hand, the emotional problems and chronic
distress of mothers scoring high on attachment anxiety
or avoidance (Mikulincer & Florian, 1998) may be mani-
fested in poor mental health immediately after the CHD
diagnosis. Moreover, the erosion of their poor resources
during the follow-up period resulting from the accumu-
lation of daily demands imposed by the illness and their
inability to mobilize support may further deteriorate
mental health. On this basis, we made the following
hypothesis:
Hypothesis 1: The higher the mothers’ attachment avoid-
ance or anxiety at Time 1, the worse their mental health
at this point of time and the higher the deterioration of
their mental health from Time 1 to Time 2.
Our second research issue deals with the possible
mediators of the attachment–mental health link. In this
context, we adopted Mikulincer and Florian’s (1998)
integration of attachment theory with Lazarus and
Folkman’s (1984) model of stress and coping. According
to Lazarus and Folkman, people differ in the appraisal of
a stressful event as a threat or a challenge and the
appraisal of themselves as capable of coping. They also
claimed that people differ in the extent to which they
direct coping efforts to solve the problem (problem-
focused coping) or to ease inner tension using either
strategies that focus on the emotional state (emotion-
focused coping), distancing/repressive strategies, or
support seeking. These patterns of appraisal and coping
are considered to be affected by individual difference
factors, to affect mental health, and to mediate the link
between these individual difference factors and mental
health.
In support of Lazarus and Folkman’s (1984) hypothe-
ses, patterns of appraisal and coping with stress have
been found to be affected by individual difference fac-
tors, such as locus of control and attachment style (e.g.,
Mikulincer & Florian, 1998; Solomon, Avitzur, &
Mikulincer, 1988). Studies also have found that the
appraisal of stressful events in challenging terms, the
appraisal of one’s coping abilities, and the reliance on
problem-focused coping and support seeking have posi-
tive effects on mental health (e.g., Griffin & Rabkin,
1998; Heijmans, 1998; Scharloo et al., 1998). In contrast,
the reliance on emotion-focused and distancing strate-
gies have been found to have a detrimental impact on
mental health (e.g., Bombardier, D’Amico, & Jordan,
1990; McCaul et al., 1999).
Of importance, the above pattern of associations
between appraisal, coping strategies, and mental health
has been replicated among mothers of chronically ill
children (e.g., Davis, Brown, Bakeman, & Campbell,
1998; McCubbin et al., 1983). Moreover, there are two
studies that addressed these issues using longitudinal
designs. Timko et al. (1992) reported that mothers’
instrumental coping with Juvenile Rheumatic Disease in
their children has a positive impact on their mental
health 1 year later. Affleck and Tennen (1991) found
that attempts to seek meaning for the problem among
mothers who had their infant in a Newborn Intensive
Care Unit (NICU) had positive effects on mental health
18 months later. In contrast, instrumental actions and
distancing coping had negative effects.
Although the above studies provided information
about the long-term contribution of appraisal and cop-
ing to mental health, they could not examine some
important issues. First, they measured appraisal and cop-
ing only once and could not examine changes in these
factors over time. Second, they did not examine the con-
tribution of individual difference factors to the adjust-
ment process. In contrast, we analyze changes in
appraisal and coping during a stressful period and incor-
porate an individual difference factor—attachment
style.
In the current study, we follow Mikulincer and
Florian’s (1998) assumption that appraisal and coping
mediate the effects of attachment style on mental health.
In their view, attachment security facilitates the appraisal
of stressful events in less threatening terms, the appraisal
of one’s abilities to cope with stress, and the reliance on
problem solving and support seeking. These patterns of
appraisal and coping have been found to have a positive
effect on mental health (see the review presented
above); therefore, they mediate the positive effects of
attachment security on mental health. Mikulincer and
Florian (1998) also hypothesized that attachment inse-
curity favors the appraisal of stress as an overwhelming
threat, raises doubts about coping abilities, and leads
people to rely on emotion-focused coping or distancing
strategies. These patterns of appraisal and coping have
been found to be related to poor mental health (see
 Berant et al. / ATTACHMENT AND MENTAL HEALTH
above review); therefore, they mediate the negative
impact of attachment anxiety and avoidance on mental
health.
In our terms, Mikulincer and Florian’s (1998) theo-
retical integration, which has been validated in various
stressful contexts (see Mikulincer & Florian, 1998, for a
review), can be applied in examining mothers’ reactions
to infant’s CHD. Our hypotheses are as follows:
Hypothesis 2: The higher the mothers’ attachment avoid-
ance or anxiety at Time 1, the higher their appraisal of
motherhood tasks as a threat and the appraisal of them-
selves as incapable of dealing with these tasks. These as-
sociations would be found immediately after the CHD
diagnosis (Time 1) and become more prominent 1 year
later (Time 2).
Hypothesis 3: The higher the mothers’ attachment avoid-
ance or anxiety at Time 1, the lower the reliance on prob-
lem solving and support seeking in dealing with
motherhood tasks. In addition, whereas attachment
avoidance would be positively related to distancing cop-
ing, attachment anxiety would be positively related to
emotion-focused coping. These associations would be
observed at Time 1 and would become more prominent
at Time 2.
Hypothesis 4: Whereas positive appraisal of coping abilities
and the reliance on problem solving and support seek-
ing would be positively related with mental health, the
appraisal of motherhood tasks as a threat and the reli-
ance on emotion-focused coping and distancing strate-
gies would be related to poor mental health.
Hypothesis 5: Appraisal and coping factors would mediate
the link between attachment style at Time 1 and changes
in mental health from Time 1 to Time 2.
METHOD
Participants
The sample consisted of 85 mothers of infants with
CHD who were diagnosed during the first year of life and
referred to treatment and follow-up in heart institutes in
different hospitals in the central area of Israel. Mothers
participated in the study without any monetary reward.
Mothers whose infants died during the study, mothers of
CHD infants who suffered from other medical condi-
tions at the time of the diagnosis (e.g., mental retarda-
tion, brain dysfunction), or mothers who were known as
substance abusers were excluded from the sample. The
most frequent congenital heart defects were ventricular
septal defect (N = 37), atrial septal defect (N = 12), and
transposition of great arteries (N = 8). Based on medical
files, two senior pediatric cardiologists independently
rated the CHD severity of each infant on a 7-point scale,
ranging from 1 (not severe at all) to 7 (very severe, life-threat-
959
ening defect). These two ratings, which were highly corre-
lated (r = .91, p < .01), revealed a normal distribution
with an average of 3.65 and standard deviation of 1.24.
No significant association was found between these rat-
ings and attachment style, and the statistical control of
these ratings did not affect the pattern of the results.2
All 85 mothers (M age = 30.3, SD = 5.38) were Jewish,
residing in the central urban area of the country. All of
them were married, lived in intact families, and had, on
average, 1.62 children. Of the mothers, 29% completed
high school, whereas 62% of them have studied in differ-
ent professional programs. At the time of CHD diagno-
sis, infants were 3 months old on average, and 53% were
boys.
Materials and Procedure
The data were collected in two stages during 24 con-
secutive months. The data represented all the infants
who were diagnosed with CHD in five hospitals in the
central area of Israel during the study period. Mothers
were contacted by a pediatric cardiologist who diag-
nosed the CHD in their infants. After explaining the
meaning of the illness and expected prognosis, the car-
diologist asked mothers to participate in the research to
understand how mothers of CHD infants feel and the
best way to help these women. They also were told that a
psychologist would contact them within 2 weeks; ano-
nymity was assured. Mothers signed an informed con-
sent and a psychologist visited them at their home after
their infant’s discharge from the hospital (Time 1).
Refusal rate from those mothers who were initially
approached (N = 121) was low (101/121: 18%).
After completing questionnaires at Time 1, the psy-
chologist asked for the mothers’ consent to meet them
again a year later (Time 2) to understand their feelings
after taking care of their infant during this period. All of
these infants were still being followed up at cardiology
institutes. Of the 101 mothers who participated at Time 1,
85 also participated in the study at Time 2 (85%). The 16
mothers who did not participate at Time 2 consisted of 3
mothers whose infants died during heart surgery, 1
mother who lost her husband, 4 mothers whose infants
were diagnosed as suffering from brain damage, 4 moth-
ers who refused to participate, and 4 mothers who were
impossible to locate due to address changes. No signifi-
cant difference was found in Time 1 measures between
mothers who participated at both points of time and
those who participated only at Time 1.
At both Time 1 and Time 2, mothers were requested
to fill out self-report scales. These scales were presented
in a random order and were filled out individually in
the presence of the psychologist. All the scales were
Hebrew versions of English scales that were translated
960 PERSONALITY AND SOCIAL PSYCHOLOGY BULLETIN
in previous studies using usual and valid back-translation
techniques.
Mothers’ attachment style was assessed via Miku-
lincer, Florian, and Tolmacz’s (1990) Adult Attachment
Style Scale. This scale taps the two basic dimensions of
attachment avoidance and anxiety (five items per
dimension). Items were constructed based on Hazan
and Shaver’s (1987) descriptions of how people feel in
close relationships. Participants were asked to think
about their close relationships, without focusing on a
specific partner, and to rate the extent to which each
item described their feelings and cognitions in close
relationships on a 7-point scale ranging from not at all
(1) to very much (7).
The decision to use this continuous attachment scale
was based on Fraley and Waller’s (1998) findings that
categorical measures of attachment style do not provide
a complete picture of attachment organization. Further-
more, Brennan et al. (1998) have shown that a two-
dimensional model of individual differences underlies
most measures of adult attachment style. In fact, our anx-
iety items (e.g., “I often worry that my partner does not
love me,” “I find that other persons are reluctant to get as
close as I would like”) corresponded to Brennan et al.’s
relevant items. Accordingly, our avoidance items (e.g.,
I’m somewhat uncomfortable being close to other per-
sons,” “I find it difficult to trust other persons in close
relationships”) corresponded to Brennan et al.’s items.
The Cronbach’s alpha coefficients indicated ade-
quate internal consistency for both anxiety items (.71 at
Time 1, .82 at Time 2) and avoidance items (.72 at Time 1,
.73 at Time 2). On this basis, we computed two scores for
each mother at each point of time by averaging the rele-
vant items. Pearson correlations revealed weak and
nonsignificant associations between anxiety and avoid-
ance scores at both points of time (.18 at Time 1, .11 at
Time 2), supporting the orthogonality of these dimen-
sions. In addition, Pearson correlations revealed signifi-
cant associations between the two points of time (.36 for
anxiety, .47 for avoidance), reflecting temporal stability
of the attachment scores.3
Mothers’ mental health was assessed via the Mental
Health Inventory (MHI) (Florian & Drory, 1990; Veit &
Ware, 1983). The MHI included 38 items, each answered
on a 6-point scale ranging from complete confirmation (6)
to complete rejection (1) of applicability of the item to the
participant over the preceding 2 weeks. The MHI con-
sists of 14 positive-state items that define psychological
well-being (e.g., “I feel relaxed and calm,” “I enjoy things
that I do”). It also includes 24 negative-state items that
define distress (“I feel depressed,” “I feel tense”).
Cronbach’s alphas indicated adequate internal consis-
tency for the 38 items (.93 at Time 1, .95 at Time 2) after
reversing the scale of the distress items. On this basis, we
computed a total mental health score at each point of
time by averaging the 38 items (as recommended by Weit
and Ware [1983]). Pearson correlations yielded a signifi-
cant association between the two points of time, r(83) =
.58, p < .01.
The cognitive appraisal of motherhood was assessed
by a Hebrew version of Folkman and Lazarus’s (1985)
scale, which was tailored to motherhood tasks. This 17-
item scale taps Lazarus and Folkman’s (1984) appraisal
components of the coping process. Specifically, the 17
items tapped three theoretical factors: threat appraisal,
challenge appraisal, and the appraisal of abilities to deal
with a stressful event. Mothers rated the extent to which
they appraised motherhood tasks in the way described in
each item. Ratings were made on a 5-point scale ranging
from not at all (1) to very much (5).
In our sample, factor analyses with Varimax rotation
validated the three-factor structure of the scale. The
analyses yielded three main factors (eigenvalue > 1) that
explained 58% of the variance at Time 1 and 60% at
Time 2. Factor 1 (35% of explained variance at Time 1
and 31% at Time 2) included seven items (loading > .40)
that resembled Lazarus and Folkman’s (1984) threat
appraisal (e.g., “taking care of this infant seems difficult
to me,” “taking care of this infant threatens my mar-
riage”). Factor 2 (13% at Time 1, 20% at Time 2)
included five items that corresponded to Lazarus and
Folkman’s (1984) challenge appraisal (e.g., “this infant
makes my life meaningful,” “taking care of this infant is a
real challenge”). Factor 3 (10% at Time 1, 9% at Time 2)
included five items that resembled Lazarus and
Folkman’s (1984) appraisal of coping abilities (e.g., “I
can effectively care for this baby,” “I have adequate skills
for taking care of this infant”). Cronbach’s alphas were
reasonable for the three factors (from .75 to .84 at Time 1
and from .76 to .87 at Time 2). Three scores were com-
puted at each point of time by averaging items that
loaded high on a factor. Pearson correlations yielded sig-
nificant associations between the two points of time (r s
from .46 to .58), reflecting temporal stability of cognitive
appraisal.
Ways of coping were assessed with Parkes’s (1984)
shortened version of Folkman and Lazarus’s (1985)
Ways of Coping Checklist. This questionnaire was trans-
lated into Hebrew by Solomon et al. (1988) and adapted
in the current study to motherhood tasks. Originally, this
scale consisted of 41 items, but we dropped 8 items that
were found to overlap in content with items from the
other assessed scales.4 Participants indicated on a 5-point
scale ranging from not at all (1) to very much (5) the
extent to which they act in the way described in each
item when confronted with their motherhood tasks.
 Berant et al. / ATTACHMENT AND MENTAL HEALTH 961

TABLE 1: Cross-Sectional Pearson Correlations and Regression Analyses of Attachment Scores at Time 1 as Predicting Mental Health, Cogni-
tive Appraisal, and Coping Strategies at Time 1
2
Measure r Anxiety r Avoidance Anxiety Avoidance Interaction R (%) F

Mental health –.36** –.25* –.32** –.23* –.09 20 6.58**

Appraisal scores
Threat .28* .07 .30** –.04 .10 10 3.03*
Challenge –.05 –.04 –.06 .05 .08 1 0.13
Coping abilities –.37** –.18 –.35** –.13 –.13 19 6.53**
Coping strategies
Problem-focused –.03 –.01 .01 –.02 .01 1 0.02
Emotion-focused .28* .11 .23* .05 –.02 8 2.89*
Distancing –.25* –.11 –.27* –.20* –.12 11 3.02*
Support-seeking –.26* –.25* –.22* –.32** –.07 10 2.86*

*p < .05. **p < .01.

The current version of the Ways of Coping Checklist
was designed to tap Lazarus and Folkman’s (1984) cop-
ing strategies of problem solving, focus on emotional
state, distancing, and support seeking. These four major
coping strategies are highly relevant for attachment the-
ory because problem solving and support seeking are
theoretically related to attachment security, distancing
coping to attachment avoidance, and emotional focus to
attachment anxiety (Mikulincer & Florian, 1998). Previ-
ous factor analyses conducted on this Hebrew version
indeed revealed these four coping categories (Solomon
et al., 1988). Twelve items tap problem solving (e.g., “I
simply concentrate on my tasks,” “I analyze the situation
in order to solve the problem”), 9 items tap emotional
focus (e.g., “Somehow I ventilate and express my feel-
ings,” “I think about why it happened to me”), 6 items tap
support seeking (e.g., “I talk to someone to find more
about the situation,” “I look for emotional support and
understanding from others”), and 6 items tap distancing
coping (e.g., “I try to forget the whole matter,” “I avoid
thinking about the problem”). Cronbach’s alphas for
items in each of the four strategies ranged from .71 to .78
at Time 1 and from .72 to .82 at Time 2, implying reason-
able internal consistency. Four scores were then calcu-
lated at each point of time by averaging the relevant
items. Pearson correlations yielded significant associa-
tions between the two points of time (r s from .34 to .49).
RESULTS
Changes in Mental Health
From Time 1 to Time 2
In this section, we examine the contribution of attach-
ment style to mental health at Time 1 and Time 2
(Hypothesis 1). In the first step, we computed cross-
sectional Pearson correlations between attachment
scores at Time 1 and mental heath at the same point of
time. In addition, we computed a hierarchical regression
examining the unique and interactive contributions of
attachment scores to mental health at Time 1. In Step 1,
we introduced the two attachment scores as predictors.
In Step 2, we added the interactive (product) term of
anxiety and avoidance as another predictor. This interac-
tion allowed us to examine possible differences between
mothers who scored high on either anxiety or avoidance
and those who scored high on both dimensions. Table 1
shows that the two attachment scores were significantly
correlated with, and made a significant unique contribu-
tion to, mental health. The higher the mothers’ anxiety
and avoidance at Time 1, the worse their mental health
at this time. The interaction effect was not significant.
The second step consisted of a hierarchical regression
examining the unique and interactive contributions of
attachment scores at Time 1 to changes in mental health
from Time 1 to Time 2. In Step 1, we introduced mental
health at Time 1 to remove that portion of variance of
mental health at Time 2 explained by mental health at
Time 1. In Step 2, we added the two attachment scores at
Time 1 as predictors of mental health at Time 2. In Step 3,
we added the interactive (product) term of these attach-
ment scores as another predictor. Table 2 shows that
mothers’ attachment scores at Time 1 made a significant
contribution to mental health at Time 2. However, only
attachment avoidance at Time 1 made a significant
unique contribution (see betas in Table 2): The higher
the mothers’ attachment avoidance at Time 1, the worse
their mental health at Time 2. The effect of attachment
anxiety as well as the interaction term was not significant.
The findings provided partial support for Hypothe-
sis 1. As expected, the higher the attachment anxiety or
avoidance at the time of the CHD diagnosis, the poorer
the mental health at this point of time. Accordingly, the
higher the attachment avoidance at Time 1, the higher
the deterioration of mental health from Time 1 to Time 2.
Unexpectedly, attachment anxiety did not predict
changes in mental health during the follow-up period.
962 PERSONALITY AND SOCIAL PSYCHOLOGY BULLETIN

TABLE 2: Longitudinal Hierarchical Regression Analyses of Attach- However, attachment avoidance was not significantly
ment Scores at Time 1 as Predicting Changes in Mental related to any appraisal score. On the other hand, 1 year
Health, Cognitive Appraisal, and Coping Strategies From later, mothers’ attachment avoidance at Time 1 was
Time 1 to Time 2
related to a deterioration in coping abilities appraisal
Unique Contributions to from Time 1 and Time 2. At this time, Time 1’s attach-
Changes From Time 1 to Time 2 ment anxiety had no effect.
2
R (%)
Measure Anxiety Avoidance Interaction Change Changes in the Reported Use of
Coping Strategies From Time 1 to Time 2
Mental health –.03 –.37** –.09 13.8**
Appraisal scores In this section, we examine the contribution of moth-
Threat .03 .14 .09 3.9 ers’ attachment style to ways of coping at Time 1 and
Challenge –.01 –.02 –.03 0.4
Time 2 (Hypothesis 3). A canonical correlation revealed
Coping abilities –.09 –.37** .12 14.5**
Coping strategies a significant association between the set of attachment
Problem-focused –.02 –.01 .05 0.6 scores at Time 1 and the four coping strategies at Time 1,
Emotion-focused .08 .39** .04 14.1** R2 = .13, F(8, 158) = 2.48, p < .05. Cross-sectional regres-
Distancing .23* –.07 .06 8.5* sions yielded that attachment scores at Time 1 made sig-
Support-seeking .25* –.08 .10 9.6*
nificant predictions of emotion-focused coping, distanc-
*p < .05. **p < .01. ing coping, and support seeking at this time (see Table 1).
Attachment anxiety was significantly correlated with,
and made a significant unique contribution to, the three
Changes in the Cognitive Appraisal coping scores (see Table 1). The higher the anxiety at
of Motherhood From Time 1 to Time 2 Time 1, the higher the reliance on emotion-focused cop-
ing and the lower the reliance on distancing coping and
In this section, we examine the contribution of moth-
support seeking. Attachment avoidance was significantly
ers’ attachment style to appraisal of motherhood at Time
related to support seeking but made a significant unique
1 and Time 2 (Hypothesis 2). A canonical correlation
contribution to both distancing coping and support
yielded a significant association between the set of
seeking (see Table 1). The higher the avoidance at Time
attachment scores at Time 1 and the set of appraisal
1, the lower the reliance on distancing coping and sup-
scores at Time 1, R2 = .18, F(6, 160) = 3.02, p < .05. Cross-
port seeking at this time. The interaction was not signifi-
sectional regressions showed that attachment scores
cant in any of the regressions.
made significant predictions of threat appraisal and cop- The longitudinal hierarchical regressions revealed
ing abilities appraisal but failed to significantly contrib- significant contributions of attachment scores in Time 1
ute to challenge appraisal (see Table 1). Only attach- to changes in emotion-focused coping, distancing cop-
ment anxiety was significantly correlated with, and made ing, and support seeking from Time 1 to Time 2 (see
a significant unique contribution to, these appraisal Table 2). Attachment avoidance made a significant
scores (see Table 1). The higher the anxiety at Time 1, unique contribution only to emotion-focused coping
the higher the appraisal of motherhood as a threat and (see Table 2): The higher the mothers’ attachment
the lower the appraisal of coping abilities at Time 1. avoidance at Time 1, the more frequent the use of emo-
Effects of avoidance and the interaction term were not tion-focused coping at Time 2. Attachment anxiety
significant. made a significant unique contribution only to distanc-
The three-step hierarchical regressions examining ing coping and support seeking (see Table 2): The
the contribution of attachment scores at Time 1 to higher the mothers’ attachment anxiety at Time 1, the
changes in appraisal from Time 1 to Time 2 yielded a sig- higher the reliance on distancing coping and support
nificant effect of these scores only on changes in coping seeking at Time 2. The interaction term was not
abilities appraisal (see Table 2). Only avoidance at Time 1 significant.
made a significant unique contribution to changes in The findings partially supported Hypothesis 3. On
coping abilities appraisal (see Table 2): The higher the one hand, as expected, both attachment anxiety and
mothers’ avoidance at Time 1, the lower their appraisal avoidance at Time 1 were significantly related to lower
of coping abilities at Time 2. Effects of anxiety and the reliance on support seeking at this time. In addition,
interaction term were not significant. attachment anxiety at Time 1 was positively related to
The findings partially supported Hypothesis 2. On emotion-focused coping and inversely related to distanc-
one hand, immediately after the diagnosis, mothers’ ing coping at this time. On the other hand, unexpect-
attachment anxiety was significantly related to higher edly, attachment avoidance at Time 1 was inversely
threat appraisal and lower coping abilities appraisal. related to distancing coping at this time. Accordingly,
 Berant et al. / ATTACHMENT AND MENTAL HEALTH
whereas attachment avoidance at Time 1 was related to
increased use of emotion-focused coping at Time 2,
attachment anxiety at Time 1 was related to increased
use of distancing coping and support seeking at Time 2.
Associations Between Appraisal,
Coping Strategies, and Mental Health
In this section, we examine Hypothesis 4 concerning
the associations between appraisal, coping strategies,
and mental health. First, we conducted cross-sectional
Pearson correlations and multiple regressions separately
for Time 1 and Time 2 (see correlations in Table 3). To
avoid problems of multicollinearity, we excluded threat
and challenge appraisals from the regressions because
they were strongly related to coping abilities appraisal5
(see Table 3). The regressions yielded significant contri-
butions of appraisal and coping scores to mental health
at Time 1, R2 = .42, F(5, 78) = 11.43, p < .01; and Time 2,
R2 = .30, F(5, 78) = 6.75, p < .05. Coping abilities appraisal
and emotion-focused coping made significant unique
contributions to mental health at both Time 1 and Time 2
(betas of .31 and .23 for coping abilities appraisal, –.39
and –.36 for emotion-focused coping). The higher the
coping abilities appraisal and the lower the reliance on
emotion-focused coping, the higher the level of mental
health. Distancing coping made a significant positive
contribution to mental health at Time 1 (β = .26), and
problem-focused coping made a significant positive con-
tribution to mental health at Time 2 (β = .25).
In the second step, we conducted a hierarchical
regression examining the longitudinal contribution of
appraisal and coping at Time 1 to changes in mental
health during the follow-up period. In Step 1, we intro-
duced mental health at Time 1 to control for its associa-
tion with mental health at Time 2. Then, in Step 2, we
added coping abilities appraisal and the four coping
scores at Time 1 as the predictors of mental health at
Time 2. These scores made a significant contribution
to changes in mental health over time, F(5, 278) = 4.54,
p < .05, and explained 12.7% of the variance. Beta coef-
ficients showed that coping abilities appraisal (.29),
emotion-focused coping (–.24), and distancing coping
(.25) had significant unique effects. Mental health
improvement was related to higher appraisal of coping
abilities and higher reliance on distancing coping at
Time 1. Mental health deterioration was related to
higher reliance on emotion-focused coping at Time 1.
The findings were in line with Hypothesis 4. They
emphasize the positive effects of coping abilities
appraisal and problem solving as well as the negative
effects of emotion-focused coping. Interestingly, the
findings also emphasize the positive cross-sectional and
longitudinal effects of reliance on distancing coping
immediately after the CHD diagnosis.
963
The Mediating Role of Cognitive
Appraisal and Coping Strategies
In this section, we examine Hypothesis 5 concerning
the mediating role of appraisal and coping. In examin-
ing this hypothesis, we adopted Baron and Kenny’s
(1986) analytical strategy. In their terms, a variable func-
tions as a mediator if (a) variations in the independent
variable account for variations in the mediators (path a),
(b) variations in the mediator significantly account for
variations in the dependent variable (path b), and
(c) when paths a and b are controlled, a previously signif-
icant relation between independent and dependent
variables is no longer significant. In applying these crite-
ria to our data, we could only analyze the mediating role
of coping abilities appraisal and emotion-focused cop-
ing to the significant association between attachment
avoidance at Time 1 and changes in mental health from
Time 1 to Time 2. Attachment anxiety and the interac-
tion term made no significant contribution to changes in
mental health (see Table 2). Moreover, from all the
appraisal and coping factors (see Table 2), avoidance at
Time 1 was significantly related only to coping abilities
appraisal and emotion-focused coping at Time 2 (path
a), which, in turn, were significantly related to mental
heath at Time 2 (path b, see Table 3). Other coping
scores did not meet criteria a and b.
Technically, we conducted two hierarchical regres-
sions, each examining the possible mediation of a spe-
cific factor (coping abilities appraisal or emotion-
focused coping). In Step 1, we introduced mental health
at Time 1 to remove that part of the variance of mental
health at Time 2 explained by mental health at Time 1.
In Step 2, we added attachment avoidance at Time 1 as a
predictor of mental health at Time 2. In Step 3, we added
coping abilities appraisal or emotion-focused coping at
Time 2 as a predictor. Then, we compared the beta of
avoidance in Step 2 to the beta of avoidance in Step 3
(after controlling for the presumed mediator) using
Sobel’s (1982) test for mediation.
The findings indicated that both coping appraisal
abilities and emotion-focused coping at Time 2 acted as
significant mediators of the link between attachment
avoidance at Time 1 and changes in mental health from
Time 1 to Time 2. Attachment avoidance at Time 1 sig-
nificantly contributed to deterioration in mental health
(β = –.41, p < .01), as found in Step 2 of the regression. In
addition, both coping abilities appraisal and emotion-
focused coping at Time 2 had significant unique and
direct effects on mental health at Time 2 after control-
ling for attachment avoidance in Step 3 of the regression
(βs of .48 and –.32, respectively). However, the most
important finding was that the unique contribution of
attachment avoidance to changes in mental health was
no longer significant when either coping abilities
964 PERSONALITY AND SOCIAL PSYCHOLOGY BULLETIN
TABLE 3: Cross-Sectional Pearson Correlations Between Mental Health, Appraisal, and Coping Scores
1 2 3 4
1. Mental health –.34** .26*
2. Threat appraisal –.68** –.60**
3. Challenge appraisal –.18 –.35**
4. Ability appraisal .44** –.57** .56**
5. P-F coping –.18 .01 .04
6. E-F coping –.41** .46** –.13
7. Distancing .36** –.33** .01
8. Support-seeking .28* .32** –.22*
NOTE: Below diagonal are correlations between variables at Time 1. Above diagonal are correlations between the same variables at Time 2. P-F =
problem-focused, E-F = emotion-focused.
*p < .05. **p < .01.
appraisal or emotion-focused coping were controlled for
in Step 3 of the regression (βs of –.04 and –.08, respec-
tively). In addition, Sobel’s (1982) test for mediation
revealed a significant difference in the contribution of
attachment avoidance before and after the statistical
control for coping abilities appraisal or emotion-focused
coping (Z = –3.03, p < .05; Z = –2.74, p < .05, respectively).
This finding was in line with Hypothesis 5 about the
mediating role of appraisal and coping.
DISCUSSION
Overall, the findings made important theoretical con-
tributions to both attachment theory and health psychol-
ogy. First, the findings showing that mothers’
attachment style predicted mental health and coping
responses after the diagnosis of infants’ CHD and 1 year
later are a strong validation of the mental health implica-
tions of attachment theory. Second, these findings were
obtained in a naturalistic setting, supporting the ecologi-
cal validity of attachment theory. Third, the longitudinal
analysis sheds new light on the attachment–mental
health link and challenges some assumptions of the
nature of the attachment anxiety dimension. Fourth,
from a health psychology viewpoint, the current study
presents a good example of how psychological theory
can inform health practice and behavioral medicine,
particularly in the context of family health prevention.
With regard to the attachment avoidance dimension,
the findings emphasized the fragile nature of the
“pseudo-safe” world of persons scoring high on this
dimension (Mikulincer & Florian, 1998). This vulnera-
bility was observed at Time 1, when attachment avoid-
ance was related to poor mental health and reluctance to
seek for social support as a way of coping with the CHD
diagnosis. Interestingly, attachment avoidance also was
related to a reluctance to rely on distancing coping. This
finding is at odds with previous results showing that per-
sons endorsing an avoidant style tend to rely on distanc-
ing coping in dealing with stress (Mikulincer & Florian,
5 6 7 8
.47** .13 –.29* .10 –.12
–.39** .11 .30** –.11 .29*
.17 –.01 –.10 –.06 –.13
.15 –.27* .07 .06
.05 –.15 –.01 .42**
–.25* –.09 –.04 .03
.27* –.11 .02 .19
–.21* .09 .17 –.08
1998). It seems that the demands imposed by a sick
infant might have drawn away the resources necessary
for activating distancing coping, leaving avoidant moth-
ers without their usual defenses against negative
feelings.
The vulnerability of avoidant mothers was more
strongly manifested in the negative changes in mental
health they reported 1 year later. Longitudinal analyses
showed that attachment avoidance at Time 1 was signifi-
cantly related to mental health deterioration from
Time 1 to Time 2. This decrease in mental health was
related to two changes avoidant mothers underwent in
the ways they appraised and coped with motherhood.
Findings indicated that attachment avoidance at Time 1
was related to a decrease in coping abilities appraisal as
well as to increased reliance on emotion-focused coping
1 year after the CHD diagnosis. Overall, the appraisal of
coping abilities and the reliance on emotion-focused
coping were found to be related to a decrease in mental
health and to mediate the association between avoidant
attachment style and changes in mental health.
Two alternative explanations can be offered to the
above pattern of findings. First, avoidant mothers’ habit-
ual ways of affect regulation may put them in a perma-
nent conflict with the overwhelming demands imposed
by a chronically ill infant. The overdependence of this
infant on their mother may contradict one basic charac-
teristic of the avoidant style—the tendency to distance
oneself from dependent relationships (Shaver & Hazan,
1993). Moreover, the need to flexibly reorganize one’s
life imposed by the chronic childhood illness may con-
tradict the habitual cognitive rigidity of the avoidant
style (Mikulincer & Florian, 1998). Accordingly, the
medical condition of the infant may demand mothers to
unwillingly face pain, suffering, and even the threat of
death, which may be contrary to the avoidant person’s
tendency to suppress distressing thoughts (Mikulincer &
Florian, 1998). All of these sources of conflict may
weaken the defenses of avoidant mothers, exposing
them to overwhelming negative thoughts as well as to
 Berant et al. / ATTACHMENT AND MENTAL HEALTH
strong feelings of helplessness. Second, avoidant moth-
ers’ inability to mobilize sources of social support may
create a real deficit in the process of coping. In the cur-
rent study, the observed tendency of avoidant mothers to
refrain from support seeking might have left them alone
in their struggle with the demands of the chronic illness,
thereby impairing their long-term adjustment.
In regard to the attachment anxiety dimension, the
findings were somewhat surprising because previous
studies have extensively documented the poor mental
health associated with this attachment dimension
(Mikulincer & Florian, 1998). Although attachment
anxiety was related to poor mental health at Time 1, it
did not significantly predict further deterioration of
mental health during the follow-up period; that is, moth-
ers scoring high on attachment anxiety showed a very
negative psychological picture at Time 1 but seemed to
undergo a different adaptation process from that of
avoidant mothers.
The above conclusion is reinforced by findings con-
cerning the patterns of appraisal and coping related to
attachment anxiety. Immediately after the CHD diagno-
sis, mothers scoring high on attachment anxiety
appraised motherhood tasks in threatening terms and
themselves as being unable to cope with these tasks.
Moreover, they tended to rely on emotion-focused cop-
ing, which might have exacerbated their negative emo-
tional state, and were reluctant to rely on support-seeking
and distancing coping, which were found to be positively
related to mental health. However, the maladaptive
responses of these mothers did not show any exacerba-
tion during the follow-up period, and some of these reac-
tions were even reduced 1 year later. First, attachment
anxiety did not significantly predict any further decrease
in coping abilities appraisal or increased reliance on
emotion-focused coping during the follow-up period.
Second, attachment anxiety was significantly related to
increased reliance on support seeking and distancing
coping 1 year later. Overall, one can observe that after 1
year of raising the infant, mothers scoring high on
attachment anxiety tend to mobilize both external
sources of support (support seeking) and internal
defenses (distancing coping) that may protect them
against overwhelming negative affect.
The discrepancy between the above findings and
those usually reported in previous studies may be
explained in two alternative ways. From a methodologi-
cal perspective, most of the previous studies were based
on cross-sectional designs and documented the negative
reactions of preoccupied persons to stressful events at a
single point of time (see Mikulincer & Florian, 1998, for
a review). In contrast, our longitudinal design revealed
that although the cross-sectional associations of attach-
ment anxiety and mental health fitted previous findings,
965
when changes over time were analyzed, attachment anxi-
ety was related to certain positive changes in coping and
did not predict any deterioration of mental health. Fur-
ther studies should take into consideration these differ-
ences between cross-sectional and longitudinal data
when analyzing the effects of attachment anxiety.
From a theoretical perspective, it is possible that the
caring of a chronically ill infant might have attenuated
the negative mental health effects of attachment anxiety.
This positive impact may be due to the legitimacy that
mothers scoring high on attachment anxiety may receive
to their habitual worries, which can be channeled to the
real threat that the illness poses to infants’ lives. In addi-
tion, these mothers may feel that, despite their negative
self-image, they are needed and valued because the life
of their infant depends on them. These self-enhancing
experiences may underlie the fact that attachment anxi-
ety did not produce any deterioration in mental health
during the follow-up period. However, although this
interpretation may be reasonable, it is still speculative
and some questions remain unanswered; for example,
whether these changes relate to motherhood in general
or are characteristic of mothers of chronically ill infants
and whether these changes are limited to the first year of
an infant’s life or remain stable over time.
The current findings also provide some support for
Lazarus and Folkman’s (1984) stress-coping model. In
line with this theory, optimistic beliefs about one’s cop-
ing abilities were positively related to mental health at
both Time 1 and Time 2. Accordingly, the reliance on
emotion-focused coping was associated with poor men-
tal health at the two points of time. More important,
appraisal of coping abilities and emotion-focused cop-
ing had longitudinal contributions to changes in mental
health during the follow-up period and mediated the
attachment–mental health link. Overall, the data
emphasized the basic role that appraisal and coping play
in explaining attachment-style differences in mental
health.
With regard to coping strategies, two findings were at
odds with our hypotheses. First, whereas previous studies
have found that distancing coping was associated with
attachment avoidance and poor mental health (see
Mikulincer & Florian, 1998, for a review), our study
failed to replicate these associations. One possibility is
that the Ways of Coping Checklist did not tap distancing
strategies in the same way as they are defined theoreti-
cally. However, this argument can be easily dismissed,
because the above-reported associations have been
found in previous studies using the same coping scale
(e.g., Mikulincer & Florian, 1995). Another, more plausi-
ble possibility is that distancing strategies may be benefi-
cial in the assessed stressful situation. In fact, distancing
strategies were found to positively contribute to mental
966 PERSONALITY AND SOCIAL PSYCHOLOGY BULLETIN
health at Time 1 but not 1 year later. It is possible that
immediately after the CHD diagnosis, when mothers
may be in a state of shock, distancing may serve an adap-
tive function. These strategies may allow mothers to dis-
miss the traumatic meaning of the CHD, maintain posi-
tive appraisals of the situation, and mobilize resources to
cope with the demands of the chronic illness.
The second finding concerns the reliance on prob-
lem-focused coping. Although this coping strategy was
positively related to mental health at Time 2, it had no
significant association with mental health at Time 1 as
well as with attachment style. Although difficult to
explain, one may speculate that the fact that all the
mothers received similar guidance regarding how to
manage the needs of their child might have blurred
attachment-style differences in problem solving. In addi-
tion, problem solving as a strategy may be more relevant
for mothers’ mental health at Time 2 than at Time 1,
because immediately after the CHD diagnosis the infant
is still under the treatment of the professional staff. One
year later, mothers themselves care for the child’s prob-
lems; therefore, proper use of problem-focused coping
may have a beneficial impact on mental health.
Similar to other field studies, some notes of caution
are required. In the current study, all of the data were
collected via self-report measures; therefore, they may
be affected by social desirability and other response set
biases. For example, social desirability might have
skewed the findings concerning the attachment anxiety
dimension. It is possible that mothers scoring high on
attachment anxiety may be sensitive to social cues and
therefore may change their responses over time in a
more socially desirable direction. However, mothers
scoring high on attachment avoidance become more
negative over time, and it does not seem likely that social
desirability could account for this shift. Moreover, the
different patterns of coping and appraisal obtained for
the two attachment dimensions suggest that the findings
do not reflect a simple response bias relating attachment
insecurity with negativity. In fact, insecure individuals
did not always respond more negatively than secure indi-
viduals. Of course, other complex biases may be operat-
ing and, then, further studies should use measures that
are not solely based on self-report.
Another possible limitation of the study may be
related to the measurement of appraisal and coping.
First, we focus on Lazarus and Folkman’s (1984) primary
and secondary appraisal dimensions because they are
based on a sound theoretical and empirical background.
However, one may recognize the existence of other dif-
ferent appraisal dimensions, which were not assessed in
the current study. Future studies should assess different
appraisal dimensions and compare their associations
with attachment style and mental health. Second, our
measurement of coping was based on the assumption
that people may have a habitual coping style, which may
not dramatically change on a daily basis. On this basis, we
used the Ways of Coping Checklist, which requested par-
ticipants to recall problematic situations and to arrive at
a retrospective overall estimate of their coping strate-
gies. However, this instrument does not provide any
information on the ways people arrive at their overall
estimate of coping (e.g., averaging on the most recent
instances, focusing on the most affectively charged
events, etc.). Moreover, their judgments may not corre-
spond well with those made close to the real-time occur-
rence of the problematic situations. Further studies
should focus on these issues, using different method-
ological approaches (e.g., daily reports of coping).
The assessment of mothers’ responses at the two
selected points of time may raise other unaddressed
issues. First, we did not have any data on mothers’ attach-
ment style and mental health before the CHD diagnosis;
therefore, we still did not know whether and how the
actual receipt of the CHD diagnosis might have affected
attachment style. Moreover, one should recognize the
possibility that participants at Time 1 might have experi-
enced a decrease in mental health and have recovered to
their “normal” levels at Time 2. Second, the lack of a
third wave of measurement prevents us from delineating
the trajectory of mental health changes. In fact, we do
not know whether the changes over time were linear and
cannot predict whether participants would show even
more improvement 2, 3, or 5 years after the CHD diagno-
sis. Future studies should attempt to conduct multiple
waves of measurement to improve our knowledge of the
long-term adaptation process to life adversities.
The current study focuses on mother’s global attach-
ment style and did not collect data on mothers’ specific
attachment style within their marital relationship. This
within-relationship attachment orientation may be
extremely important for understanding the dynamics
between the husband and wife, which, in turn, may affect
subsequent coping and adjustment. For example, preoc-
cupied mothers may be more able to solicit and accept
support from their husbands than are avoidant mothers,
and this process might reduce mothers’ distress. In addi-
tion, although the focus of our study was the long-term
process of adjustment among mothers of infants with
CHD, the lack of a control group of mothers of healthy
babies prevents us from discerning whether our findings
are specific to the coping with chronic childhood illness
or can be extended to motherhood in general.
Despite the above limitations, our study may provide
important and original information about the long-term
process of maternal coping and adjustment to chronic
childhood illness as well as to the crucial role that moth-
ers’ attachment style plays in explaining this process. In
 Berant et al. / ATTACHMENT AND MENTAL HEALTH
practical terms, the current finding might help mental
health professionals to early identify mothers who are at
risk for developing emotional problems due to their
attachment avoidance. Moreover, the findings might be
implemented in the counseling process, where these
mothers may be encouraged to avoid maladaptive
appraisal and coping patterns and to adopt those beliefs
and strategies (e.g., coping abilities appraisal, support
seeking) that were found to be beneficial to adaptation.
NOTES
1. In our study, we did not focus on the fearful subgroup because
these persons do not possess a unique coping strategy. In fact, fearful
persons seem to indiscriminately move between avoidant strategies
and anxious strategies. Moreover, findings indicated that all the inter-
actions between attachment avoidance and attachment anxiety were
not significant, implying that persons scoring high on avoidance and
anxiety did not significantly differ from those scoring high only in
either anxiety or avoidance.
2. With the exception of 12 infants whose health status was
improved due to a surgery intervention, no notable change in CHD
severity (as rated by cardiologists) was found in infants between Time 1
and Time 2. Again, no significant association was found between these
ratings and mothers’ attachment style, mental health, cognitive
appraisal, and coping scores at Time 2. The statistical control of these
ratings at Time 2 did not affect the associations reported in the Results
section.
3. Participants also answered Hazan and Shaver’s (1987) categori-
cal measure of attachment style, in which they were asked to endorse
the attachment style that fit their feelings in close relationships. Statisti-
cal analyses using this categorical scale replicated the findings
obtained with the continuous attachment scores and were not
reported in the Results section.
4. We conducted a detailed analysis to examine overlap in content
between items of the various scales. With the exception of eight items
in the Ways of Coping Scale that tapped emotion-focused coping and
somewhat overlapped in content with distress items from the Mental
Health Inventory (MHI), no notable overlap was found between other
items. We dropped the overlapping items from the Ways of Coping
Scale so that the scores used in the statistical analyses were derived
from nonoverlapping items.
5. Beyond the strong association between the various appraisal fac-
tors, statistical tests revealed no notable problem of multicollinearity in
all the reported regressions.
REFERENCES
Affleck, G., & Tennen, H. (1991). Appraisal and coping predictors of
mother and child outcomes after newborn intensive care. Journal
of Social and Clinical Psychology, 10, 424-447.
Baldwin, M. W., & Fehr, B. (1995). On the instability of attachment
style ratings. Personal Relationships, 2, 247-261.
Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator vari-
able distinction in social psychological research: Conceptual, stra-
tegic, and statistical considerations. Journal of Personality and Social
Psychology, 51, 1173-1182.
Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among
young adults: A test of a four-category model. Journal of Personality
and Social Psychology, 61, 226-244.
Bombardier, C. H., D’Amico, C., & Jordan, J. S. (1990). The relation-
ship of appraisal and coping to chronic illness adjustment. Behav-
ioral Research and Therapy, 28, 297-304.
Bowlby, J. (1973). Attachment and loss: Separation, anxiety, and anger.
New York: Basic Books.
Bowlby, J. (1988). A secure base: Clinical applications of attachment theory.
London: Routledge.
967
Brennan, K. A., Clark, C. L., & Shaver, P. R. (1998). Self-report mea-
surement of adult attachment: An integrative overview. In J. A.
Simpson & W. S. Rholes (Eds.), Attachment theory and close relation-
ships (pp. 46-76). New York: Guilford.
Dahlquist, L. M., Czyzewski, D. I., & Jones, C. L. (1996). Parents of
children with cancer: A longitudinal study of emotional distress,
coping style, and marital adjustment two and twenty months after
diagnosis. Journal of Pediatric Psychology, 21, 541-554.
Davila, J., Burge, D., & Hammen, C. (1997). Why does attachment
style change? Journal of Personality and Social Psychology, 73, 826-838.
Davis, C. G., Brown, R. T., Bakeman, R., & Campbell, R. (1998). Psy-
chological adaptation and adjustment of mothers of children with
congenital heart disease: Stress, coping and family functioning.
Journal of Pediatric Psychology, 23, 219-228.
Florian, V., & Drory, Y. (1990). The Mental Health Inventory:
Psychometric characteristics and normative data from Israeli pop-
ulation. Psychologia, 2, 26-35.
Folkman, S., & Lazarus, R. S. (1985). If it changes it must be a process:
Study of emotion and coping during three stages of a college
examination. Journal of Personality and Social Psychology, 48, 150-
170.
Fraley, R. C., & Shaver, P. R. (1997). Adult attachment and the sup-
pression of unwanted thoughts. Journal of Personality and Social Psy-
chology, 73, 1080-1091.
Fraley, R. C., & Waller, N. G. (1998). Adult attachment patterns: A test
of typological model. In J. A. Simpson & W. S. Rholes (Eds.),
Attachment theory and close relationships (pp. 77-114). New York:
Guilford.
Griffin, K. W., & Rabkin, J. G. (1998). Perceived control over illness,
realistic acceptance, and psychological adjustment in people with
AIDS. Journal of Social and Clinical Psychology, 17, 407-424.
Hazan, C., & Shaver, P. R. (1987). Romantic love conceptualized as an
attachment process. Journal of Personality and Social Psychology, 52,
511-524.
Heijmans, M.J.W. (1998). Coping and adaptive outcome in chronic
fatigue syndrome: Importance of illness cognitions. Journal of Psy-
chosomatic Research, 45, 39-51.
Kazak, A. E., Reber, M., & Snitzer, L. (1988). Chronic childhood dis-
ease and family functioning: A study of phenylketonuria. Pediat-
rics, 81, 224-230.
Kobak, R. R., & Hazan, C. (1991). Attachment in marriage: Effects of
security and accuracy of working models. Journal of Personality and
Social Psychology, 60, 861-869.
Kovacs, M., Finkelstein, R., Feinberg, T. L., Crouse-Novak, M.,
Paulauskas, S., & Pollock, M. (1985). Initial psychological
responses of parents to the diagnosis of insulin-dependent diabe-
tes mellitus in their children. Diabetes Care, 8, 568-575.
Kovacs, M., Iyengar, S., Goldston, D., Obrosky, D. S., Stewart, J., &
Marsh, J. (1990). Psychological functioning among mothers of
children with insulin-dependent diabetes mellitus: A longitudinal
study. Journal of Consulting and Clinical Psychology, 58, 189-195.
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal and coping. New
York: Springer.
McCaul, K. D., Sandgren, A. K., King, B., O’Donell, S., Branstetter, A., &
Foreman, G. (1999). Coping and adjustment to breast cancer.
Psychooncology, 8, 230-236.
McCubbin, H. I., McCubbin, M. A., Patterson, J. M., Cauble, A. E.,
Wilson, L. R., & Warwick, W. (1983). CHIP—Coping Health
Inventory for Parents: An assessment of parental coping patterns
in the care of the chronically ill child. Journal of Marriage and the
Family, 45, 359-370.
Mikulincer, M., & Florian, V. (1995). Appraisal and coping with a real-
life stressful situation: The contribution of attachment styles. Per-
sonality and Social Psychology Bulletin, 21, 408-416.
Mikulincer, M., & Florian, V. (1998). The relationship between adult
attachment styles and emotional and cognitive reactions to stress-
ful events. In J. Simpson & S. W. Rohles (Eds.), Attachment theory
and close relationships (pp. 143-165). New York: Guilford.
Mikulincer, M., Florian, V., & Tolmacz, R. (1990). Attachment styles
and fear of personal death: A case study of affect regulation. Jour-
nal of Personality and Social Psychology, 58, 273-280.
968 PERSONALITY AND SOCIAL PSYCHOLOGY BULLETIN
Parkes, K. S. (1984). Locus of control, cognitive appraisal and coping
in stressful episodes. Journal of Personality and Social Psychology, 46,
655-668.
Rae-Grant, O. (1985). Psychological problems in the medically ill
child. Pediatric Clinics of North America, 32, 653-663.
Rodrigue, J. R., McNaughton, K., Hoffmann, R. G., Graham-Pole, J.,
Andres, J., Novak, D., & Fenell, R. (1997). Transplantation in chil-
dren: A longitudinal assessment of mothers’ stress, coping, and
perceived family functioning. Psychosomatics, 38, 478-486.
Scharloo, M., Kaptein, A. A., Weinman, J., Hazes, J. M., Willems, L.,
Bergman, W., & Rooijmans, H. G. (1998). Illness perceptions,
coping and functioning in patients with rheumatoid arthritis,
chronic obstructive pulmonary disease, and psoriasis. Journal of
Psychosomatic Research, 44, 573-581.
Shaver, P. R., & Brennan, K. A. (1992). Attachment style and the Big-5
personality traits: Their connections with each other and with
romantic relationships outcomes. Personality and Social Psychology
Bulletin, 18, 536-545.
Shaver, P. R., & Hazan, C. (1993). Adult romantic attachment: Theory
and evidence. In D. Perlman & W. Jones (Eds.), Advances in per-
sonal relationships (pp. 29-70). London: Jessica Kingsley.
Sobel, M. E. (1982). Asymptotic confidence intervals for indirect
effects in structural equation models. In S. Leinhart (Ed.), Socio-
logical methodology (pp. 290-312). San Francisco: Jossey-Bass.
Solomon, Z., Avitzur, E., & Mikulincer, M. (1988). Coping, locus of
control, social support, and combat-related posttraumatic stress
disorder. Journal of Personality and Social Psychology, 55, 279-285.
Timko, C., Stovel, K. W., & Moos, R. H. (1992). Functioning among
mothers and fathers of children with Juvenile Rheumatic Disease:
A longitudinal study. Journal of Pediatric Psychology, 17, 705-724.
Veit, C. T., & Ware, J. E. (1983). The structure of psychological stress
and well-being in general populations. Journal of Counseling and
Clinical Psychology, 51, 730-742.
Walker, D. K., Epstein, S. G., Taylor, A. B., Crocker, A. C., & Tuttle,
G. A. (1989). Perceived needs of families with children who have
chronic health conditions. Children Health Care, 18, 196-201.
Weit, C. T., & Ware, J. E. (1983). The structure of psychological stress
and well-being in general populations. Journal of Counseling and
Clinical Psychology, 51, 730-742.
Received August 17, 1999
Revision accepted July 8, 2000