Current Developmental Disorders Reports

https://doi.org/10.1007/s40474-020-00219-5

COMORBIDITIES (DM DEWEY, SECTION EDITOR)

Associations between Neurodevelopmental Disorders

and Attachment Patterns in Preschool-Aged Children:
Systematic Review
A. Potter-Dickey 1,2 & N. Letourneau 2,3,4 & A. P. J. de Koning 5

Accepted: 25 September 2020

# Springer Nature Switzerland AG 2020

Abstract
Purpose of Review Attachment is a biological evolutionary system contributing to infant survival. In neurotypical children,
secure attachment is critical to healthy brain and organ-system development. Attachment patterns in children with
neurodevelopmental disorders (NDDs) have not been extensively explored. The purpose of this review is to appraise and
summarize the literature examining attachment in children with NDDs.
Recent Findings Children with autism spectrum disorder (ASD), intellectual disability (ID) or developmental language disorder
(DLD) displayed behavior indicative of secure attachments. Approximately 42–50% of children with NDDs were deemed
securely attached compared with 62% in neurotypical children. Factors influencing attachment patterns were autistic symptoms,
developmental level, maternal sensitivity, and maternal insightfulness/resolve.
Summary Many children with NDDs can form secure attachments; however, this is based on limited data, primarily focusing on
children with ASD. Specific challenges were identified in assessing attachment patterns in children with NDDs. This demon-
strates the need for research investigating attachment in children with various NDDs and co-occurring disorders.

Keywords Neurodevelopmental disorder . Autism . Attachment . Systematic review . Parenting . Preschool-aged children

Introduction
Attachment is a relationship between infants and their care-
givers that represents a brain-based biological evolutionary
system promoting infant survival [1, 2]. Securely attached
infants use their caregivers as a base for exploration and a
This article is part of the Topical Collection on Comorbidities
* A. Potter-Dickey
amelia.potter@ucalgary.ca
1
ACHRI Owerko Centre, Child Development Centre, 3rd Floor, 2888
Shaganappi Trail, Calgary, AB T3B 6A8, Canada
2
Faculty of Nursing, University of Calgary, Calgary, Canada
3 dren with NDDs do develop secure attachments but that sig-
Department of Pediatrics, Cumming School of Medicine, University
of Calgary, Calgary, Canada
4 ments than neurotypical children [6–8]. However, more infor-
Departments of Psychiatry and Community Health Sciences,
Cumming School of Medicine, University of Calgary,
Calgary, Canada
5
Department of Biochemistry & Molecular Biology and Medical
Genetics, University of Calgary, Calgary, Canada
haven from stress [2]. The Diagnostic and Statistical Manual
of Mental Disorders Fifth Edition (DSM-5) [3] designates
neurodevelopmental disorders (NDDs) as dyslexia, develop-
mental coordination disorder, developmental language disor-
der (DLD), autism spectrum disorder (ASD), and attention-
deficit hyperactivity disorder (ADHD) [3]. NDDs frequently
co-occur, and characteristic deficits may include delays in
reaching developmental milestones of learning, executive
function, and social interaction [3]. The limited knowledge
surrounding attachment in NDDs is from studies primarily
focusing on ASD, with very little literature addressing other
NDDs and co-occurring NDDs. Previously, it was thought
that children with ASD were unable to form secure attach-
ments given challenges with social interaction and communi-
cation [3–5]. More recently, studies have revealed that chil-
nificantly fewer children with ASD tend to form secure attach-
mation is needed to better understand the influencing factors
(e.g., caregiving quality, co-occurring NDDs) and attachment
in children with ASD and other NDDs.

Attachment Theory
John Bowlby initially developed attachment theory in the
1940s to explain children’s ties to their caregivers and intro-
duced one of the most influential neo-Darwinian theories of
evolutionary psychology [9, 10]. The central theme of attach-
ment theory is that a sense of security is developed when a
caregiver is available and responsive [11]. Infants anticipate
their caregivers’ responses to their distress and shape their
attachment behaviors accordingly [12]. Attachment behavior
has social-biological underpinnings promoting the proximity
of a vulnerable infant to the attachment figure, improving their
chance of survival [9, 10].
Assessing Attachment Patterns
Early childhood attachment can be evaluated using the
Strange Situation Procedure (SSP) or Attachment Q-Sort
(AQS) [2, 13, 14]. Both measures categorize attachment be-
havior into corresponding attachment patterns. The Q-Sort
was developed for neurotypical children aged 1–5 and in-
volves sorting 90 cards describing attachment behaviors
(e.g., proximity seeking, crying) in a home or laboratory to
determine a classification [14]. The cards are sorted by either
the parent or a trained observer into one of nine piles based on
the observed data, and the data can be analyzed through the
use of individual items or summary scales [14].
The SSP is the most widely used attachment assessment in
observational and experimental studies and involves a com-
plex parent-infant-stranger interaction in an unfamiliar labora-
tory setting [2, 15–17]. The SSP examines the balance be-
tween attachment and exploratory behavior in a strange
situation, which subjects the child to increasing, moderate
stress [11]. It consists of a series of separations and reunions
with the child’s caregiver [2, 11]. The purpose of this struc-
tured interaction is to activate the child’s attachment system to
display attachment behaviors [2, 11]. Attachment behavior is
coded on four scales (i.e., proximity seeking, contact mainte-
nance, proximity avoidance, and contact resistance) [2]. The
coding scale is designed for neurotypical children between 12
and 20 months of age but is commonly used up to 24 months
[2, 11, 18]. From these scales, an Overall Security Score may
be derived as a continuous rating scale [19]. Another method
of obtaining a continuous rating is through the use of the
Richters Attachment Security Scale [2, 20, 21], also derived
from the four scales [2, 20, 21].
Typically with the SSP, children are categorized as type A, B,
C, or D [2, 20]. Type B (secure) children strike a balance between
proximity to the caregiver and exploring the strange environment
[2, 20]. Type A (insecure-avoidant) pay little attention to separa-
tions and reunions with the caregiver and explore their environ-
ment, although less robustly than type B children [2, 20]. Type C
(insecure-resistant/ambivalent) children are wholly preoccupied
Curr Dev Disord Rep
with their caregiver, forgoing exploration [2, 20]. Types A, B,
and C are considered organized attachment patterns, as the chil-
dren organize their behavior around reliably predictable caregiv-
ing [2]. Disorganized attachment (type D) is observed in children
who are unable to develop and organize a display of attachment
behaviors [20]. Disorganized children may exhibit a combination
of fear or apprehension towards the caregiver, repetitive and
undirected stereotypical behavior (e.g., flapping and waving of
the arms, hand flapping, head nodding, and rocking back and
forth), and freezing or stilling of all movement for substantial
periods of time [16, 20]. Broader classifications can be
subclassified into A1, A2, B1–B4, and C1, C2 through the ex-
amination of specific attachment behaviors (e.g., B3 is very se-
cure with a well-balanced display of emotion) [2, 22].
Attachment in NDDs
NDDs are conditions characterized by early-onset develop-
mental deficits resulting in impaired functioning in specific
domains [3]. Social and affective deficits in recognizing emo-
tions and challenges in orienting towards people in a social
environment are a well-documented presentation in some
NDDs [3, 23, 24]. In the 1980s, it was thought that some
NDDs such as ASD interfered with the development of secure
attachment resulting in intrinsic difficulties with social inter-
action and communication [4, 5, 25, 26]. In addition, overlap-
ping symptoms of NDDs (e.g., inflexibility, atypical play,
poor social interaction, poor communication, deficits of emo-
tional regulation) and behavior characteristic of insecure and
disorganized attachments may lead to misclassifications [6].
Two previous systematic reviews examined associations
between NDD and attachment; however, both only focused
on ASD [7, 8]. Rutgers et al. [7••] conducted a meta-analysis
of ten studies (total n = 287) in 2004 and reported 53% (n =
72) formed secure attachments (SSP; secure vs. not secure)
[7••]. They concluded that children with ASD displayed less
attachment security than neurotypical children; however, this
effect disappeared when the sample was at a higher level of
mental development and demonstrated less severe symptoms
of ASD. More recently, Teague et al. [8••] narratively
reviewed 40 studies and updated this estimate; of the samples
(n = 7) that examined attachment, 47% of the children with
ASD were categorized as secure (n = 186). They reported that
insecure and disorganized attachment was predicted by great-
er severity of autistic symptoms and developmental delay,
difficulty in reciprocal social interaction, less maternal sensi-
tivity and insightfulness, and parents’ insecure attachment to-
wards their children.
In sum, given the need for an updated review that includes
other NDDs, and more varied measurement of attachment
classifications, this systematic narrative review aims to build
on previous work by answering the following question: What
are the associations between NDDs and attachment patterns in
Curr Dev Disord Rep

preschool-aged children (0–5 years of age)? Furthermore, this Table 1 PyscINFO search terms February 4, 2020
review sets out to examine factors influencing attachment pat- 1. exp. Attachment Behavior/or exp. Attachment Theory/
tern formation and the challenges faced in classifying attach- 2. attachment.tw,id,tm.
ment in the NDD population [24, 25]. 3. attachment q-sort.tw,id,tm.
4. “preschool assessment of attachment”.tw,id,tm.
5. (macarthur or mac arthur).tw,id,tm.
Methods 6. strange situation.tw,id,tm.
7. 1 or 2 or 3 or 4 or 5 or 6
In this systematic narrative review, we sought to synthesize
8. autism spectrum disorders/
the empirical evidence according to pre-specified eligibility
9. (autism or autistic).tw,id.
criteria and employed explicit, systematic methods to mini-
10. asperger*.tw,id.
mize bias and uncover reliable findings [27]. We employ the
11. asd.tw,id.
recommendations put forth by Preferred Reporting Items for
12. exp. Attention Deficit Disorder with Hyperactivity/
Systematic Reviews and Meta-Analyses (PRISMA) [28].
13. adhd.tw,id.
14. attention deficit disorder*.tw,id.
Search Strategy
15. exp. reading disabilities/
16. read* disability.tw,id.
Searches occurred during February 2020 in MEDLINE,
17. exp. dyslexia/
EMBASE, PsycINFO, ERIC, SocINDEX, Cumulative Index
18. (dyslexia or dyslexic).tw,id.
to Nursing & Allied Health (CINAHL), and Education
Research Complete, for published studies in the English lan- 19. exp. dyspraxia/
guage with no date limits. Relevant subject heading and text 20. development* coordination disorder*.tw,id.
words were used according to each database (see Table 1). 21. exp. developmental language disorder/
Synonymous terms were combined using the Boolean “OR” 22. development* language disorder*.tw,id.
and then combined with other concepts using a Boolean 23. 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20
or 21 or 22
“AND.” Truncation symbols were used appropriately to en-
24. (infant* or baby or babies or toddler* or pre-school* or pre-school* or
sure all variations of search terms were captured. child* or kindergarten*).tw,id.
25. 7 and 23 and 24
Study Inclusion and Exclusion Criteria 26. limit 25 to english

The articles retrieved were uploaded into Covidence, a web-

based tool for article screening organization [29]. Two re-
viewers screened titles and abstracts for studies that met the comparison groups, mean chronological age of participants,
inclusion criteria, including articles from peer-reviewed and results (see Table 2).
journals utilizing an observational cohort study design that
examined the relationship between NDDs and attachment
Plan for Analysis
using the SSP or AQS, coded for infants or preschoolers (0–
5 years of age). Snowball sampling was also undertaken using
A best evidence narrative systematic review was chosen to
literature reviews, previously conducted systematic reviews,
synthesize the findings to ensure that the range of research
and bibliographies. The exclusion criteria were qualitative
exploring attachment in children with NDDs was presented
studies, editorials, and non-peer-reviewed articles.
appropriately. A meta-analysis was not appropriate given the
range of research topics, research designs, sample composi-
Study Selection and Data Extraction
tion, sample sizes, and measurement scores.
A total of 1529 articles were identified through the search.
After removing duplicates (n = 222), titles and abstracts were
screened (n = 1307). Full texts were obtained on 52 articles Results
that met the inclusion criteria. A total of 12 articles met all
inclusion criteria and addressed the research question (see Description of the Literature
Fig. 1). Each article was appraised and scored by the two
reviewers according to the Newcastle-Ottawa Scale (NOS) The 12 articles reviewed included a total of 387 children and
for assessing the quality of cohort studies [41]. Data were were published between 1987 and 2018. Four studies were
extracted and summarized relating to diagnoses, sample size, from the USA [24, 30, 31, 40], four from Israel [28, 35, 37,
 Curr Dev Disord Rep

Fig. 1 PRISMA procedural flow

diagram

Identification
Records identified through Additional records identified through
database searching other sources
(n = 1528) (n = 1)

Records after duplicates removed

(n = 222)

Screening
Records screened Records excluded
(n = 1307) (n = 1255)

Full-text articles assessed Full-text articles excluded,

Eligibility

for eligibility with reasons

(n = 52) (n = 40)

Resons for exclusion:

Wrong Study Design (n = 12)

Not a published study (n = 6)
Does not include
neurodevelopmental/behaviour
Included

Studies included in al disorders (n = 5)

narrative synthesis Does not Include attachment
(n = 12) measures: Attachment Q-sort,
Strange Situation Procedure
(SSP), Preschool Assessment
of Attachment (PAA),
MacArthur (n = 4)
Children are not of preschool
age (n = 5)
Does not answer research
question (n = 4)
Does not measure attachment
in children (n = 4)

38], three from the Netherlands [32, 34, 42], and one from
Italy [39•]. All studies primarily examined ASD and attach-
ment patterns. Of the articles that reported on sex distribution
(n = 351), 273 children were males and 78 were females, and
only one article did not report sex distribution of their sample
(n = 36) [24]. Eleven studies concurrently discussed pervasive
developmental disorder (PDD) [24, 30, 32, 34–40, 42], which
is any class of disorder characterized by severe and wide-
spread impairment in social interaction and communication
[43]. In the DSM-5, PDD has been subsumed under the
ASD diagnosis [44]. Five studies examined DLD and intel-
lectual disability (ID), previously referred to as mental retar-
dation (MR) [24, 30, 32, 34, 42]. The SSP was conducted with
mothers in nine studies, while three looked at unspecified
caregivers [32, 40, 42]. The SSP was modified in four studies
to accommodate the needs of some children and decrease
distress from the change of routine [24, 30, 31, 39]. Some
studies adapted the SSP coding scale for age and overlapping
symptoms [30–32, 39, 40]. NOS scores for these articles
ranged from seven to nine stars out of nine, suggesting high
quality overall with a 92% inter-rater agreement (see Table 2).
Scoring of the SSP
The Shapiro et al. [24•] study used Ainsworth’s (type A, B, C)
classification for the SSP [2, 24]. At the time of publication,
Main and Solomon had not yet suggested disorganized (type
D) as a fourth classification [20]. Eight studies utilized the
four-fold attachment classification system for the SSP (type
A, B, C, D) [2, 20, 31, 32, 35–40]. Rogers et al. [30•] used the
Overall Security Score [2, 19]. Similarly, two studies [34, 42]
assigned each child a Richters Attachment Security Score in
addition to classifying them as type A, B, or C [2, 20, 21].
Attachment Classifications in Children with NDDs
Eight studies did not utilize a neurotypical comparison group.
Four separate publications from the Oppenheim and Koren-
Table 2 Summary of articles included for the review

Authors Country Total Sample description Comparison Method Attachment Attachment Attachment pattern results Additional findings/remarks Quality
of origin sample groups figure classification score
size (number
of stars)
Curr Dev Disord Rep

Shapiro, T., Sherman, USA n = 36 ASD (DSM 3); n = 15; Other Modified Mother Type A, B, C - 34 of the children were able to be - Quality of attachment not Reviewer
M., Calamari, G., and 30–63 months psychiatric SSP classified associated with diagnosis, 1: 8
Koch, D. [24•] Mean age and SD not diagnosis - 42% of children with a diagnosis of developmental quotients, mood Reviewer
provided (PDD, ID, DLD, ID, ASD displayed reunion change, or behavior change 2: 8
Sex not indicated DLD) behavior and were classified as
n = 21 securely attached
- Secure attachment breakdown: DLD
(12.5%), ID (33.3%), ASD (53.3%),
PDD (50%)
Rogers, S. J., Ozonoff, USA n = 32 ASD (DSM 3); n = 21; Other Modified Mother Overall Security - 50% of the children demonstrated - Developmental level rather than the Reviewer
S., and Maslin-Cole, mean age of psychiatric SSP Score (accounting secure attachment (i.e., proximity severity of ASD was the strongest 1: 8
C. [30•] 46.3 months diagnosis for overlapping seeking, contact seeking, and contact predictor of attachment security Reviewer
(SD = 11.5) (PDD, ID, symptoms) maintenance) (mental age, r = 0.49, p ≤ 0.01; 2: 8
Age range not provided DLD) - No children who were “unattached” chronological age, r = 0.48,
Males: n = 25 n = 11 (i.e., demonstrated neither positive or p ≤ 0.01; language r = 0.39,
Females: n = 7 negative behaviors towards mother, p ≤ 0.05)
compared with a stranger at reunion)
Capps, L., Sigman, M., USA n = 19 ASD (DSM 3); age No comparison Modified Mother Type A, B, C, D - Primary classification: n = 4 not able to - Attachment security is associated Reviewer
and Mundy, P. [31•] range group SSP (accounting for classify; n = 15 disorganized with greater sensitivity in mothers 1: 7
36–72 months; overlapping - Secondary classifications: 20% (n = 3) (t = 3.33, df = 13, p < 0.01) and Reviewer
mean age of 48.6 symptoms) could not be secondarily classified, more social initiatives in children 2: 8
(SD = 12.4; 40% (n = 6) securely attached (B), (t = 2.52, df = 8.36, p < 0.02)
classified children) 13% (n = 2)
Males: n = 16 insecure-ambivalent/resistant (C), 7%
Females: n = 3 (n = 1) insecure-avoidant (A), 20%
(n = 3) truly disorganized (D)
Willemsen-Swinkels, S. The n = 70 ASD (DSM 4; PDD), Normally SSP Not Specified Type A, B, C, D - No differences between clinical and - Having disorganized attachment Reviewer
H. N., Netherl- ID, and DLD n = 51; developing (accounting for non-clinical groups in proportions of does not simply reflect the 1: 9
Bakermans-Kranenb- ands 36–84 months children overlapping insecurely attached children presence of autistic behavior Reviewer
urg, M. J., Buitelaar, Mean age and SD not n = 19 symptoms) (multinomial test, p ≥ 0.05) 2: 9
J. K., van Ijzendoorn, provided - ASD and ID were found to be more
M. H., and van Males: n = 52 Females: often classified as disorganized
Engleland, H. [32•] n = 18 Fisher’s exact test, p = 0.018)
van Ijzendoorn, M. H., The n = 55 ASD (DSM 4; PDD), Normally SSP Not specified Richters Scale of - NDD had lower security score F(1, - A MANCOVA revealed a Reviewer
Rutgers, A. H., Netherl- ID, and DLD developing Attachment 53) = 4.36, p = 0.04, and more significant relationship between 1: 8
Bakermans-Kranenb- ands Mean age of children attachment disorganization, F(1, diagnosis, parental sensitivity F(1, Reviewer
urg, M. J., Swinkels, 28.4 months n = 15 53) = 8.93, p < 0.01, than 42) = 6.48, p = 0.02, children 2: 8
S. H. N., Van Daalen, (SD = 4.9) n = 40 neurotypical children without ASD parental sensitivity
E., Dietz, C., Van Age range not provided - ID scored lower on attachment, F(1, was associated with attachment
Engeland, H. [33] Males: n = 35 Females: 53) = 4.44, p = 0.04 and displayed security r(31) = 0.49 p < 0.01
n = 20 more attachment disorganization, F(1, - Higher parental sensitivity
53) = 11.56, p < 0.01 demonstrated more secure
- ASD showed more attachment children; two covariates that were
disorganization F(1, 53) = 4.46, associated with attachment
p = 0.04 disorganization are Richters
security F(1, 48) = 6.21, p = 0.02
and developmental level F(1,
48) = 6.11, p = 0.02
Naber, F. B. A., n = 80 ASD (DSM 4; PDD), Normally SSP Mother Richters Scale of - In a hierarchical regression, there Reviewer
Swinkels, S. H. N., ID, and DLD; developing Attachment was a significant result in adding 1: 8
Table 2 (continued)

Authors Country Total Sample description Comparison Method Attachment Attachment Attachment pattern results Additional findings/remarks Quality
of origin sample groups figure classification score
size (number
of stars)

Buitelaar, J. K., The n = 62; mean age children Type A, B, C, D - NDD children were less securely the number of autistic symptoms Reviewer
Bakermans-Kranenb- Netherl- 27.65 months n = 18 attached than neurotypical children, to attachment security, F(2, 2: 8
urg, M. J., van ands (SD = 6.04) χ2 (1, n = 80) = 8.18 p < 0.01 57) = 3.87, p = 0.03 explaining
Ijzendoorn, M. H., Age range not provided - No differences found in different 12% of variance
Dietz, C., van Males: n = 57 Females: diagnostic groups (ASD PDD, ID, - Developmental level significantly
Engeland, H. [34•] n = 23 DLD) predicted disorganized attachment
- Only the DLD group showed no in the children with an ASD
differences in attachment pattern diagnosis F(1, 57) = 5.56,
distribution; ASD versus control χ2 p = 0.02 explaining 9% of the
(1, n = 38) = 9.08 p < 0.01; ASD variance
(PDD) versus control χ2 (1,
n = 32) = 5.72 p = 0.02; ID versus
control χ2 (1, n = 30) = 7.75 p < 0.01
- Disorganized attachment was
overrepresented in clinical groups
versus control groups, χ2 (1,
n = 80) = 7.74 p < 0.01, ASD versus
control χ2 (1, n = 38) = 12.21
p < 0.01; ASD (PDD) versus control
χ2 (1, n = 32) = 4.26 p = 0.04; ID
versus control χ2 (1, n = 30) = 6.92
p < 0.01; DLD versus control χ2 (1,
n = 34) = 3.70 p = 0.05
Oppenheim, D., Israel n = 45 ASD (DSM 4; PDD) No comparison SSP Mother Type A, B, C, D - 42.2% (n = 19) were classified as - Examined if insightfulness or Reviewer
Koren-Karie, N., n = 45; age group securely attached (type B), 20% resolution was associated with 1: 8
Dolev, S., and range = 32–69 (n = 9) insecure-avoidant (type A), secure attachment. 83% of Reviewer
Yirmiya, N. [35•] months; mean age 15.6% (n = 7) were classified as mothers who were both resolved 2: 8
49.35 months insecure-ambivalent (type C), 22.2% and insightful were securely
(SD = 9.56) (n = 10) were classified at attached compared with 20% just
Males: n = 45 Females: disorganized (type D) insightful or resolved, or 30%
n=0 neither insightful nor resolved
Marcu, I., Oppenheim, Israel n = 45 ASD (DSM 4; PDD) No comparison SSP Mother Type A, B, C, D - 42.2% (n = 19) were classified as Reviewer
D., Koren-Karie, N., n = 45; age group securely attached (type B), 20% 1: 8
Dolev, S., and range = 32–69 (n = 9) insecure-avoidant (type A), Reviewer
Yirmiya, N. [36•] months; mean age 15.6% (n = 7) were classified 2: 8
49.35 months insecure-resistant/ambivalent (type C),
(SD = 9.56) 22.2% (n = 10) were classified at
Males: n = 45 Females: disorganized (type D)
n=0
Koren-Karie, N., Israel n = 45 ASD (DSM 4; PDD) No comparison SSP Mother Type A, B, C, D - 42.2% (n = 19) were classified as - The findings support the notion that Reviewer
Oppenheim, D., n = 45; age group securely attached (type B), 20% securely attached children had 1: 8
Dolev, S., and range = 32–69 (n = 9) insecure -avoidant (type A), mothers that displayed more Reviewer
Yirmiya, N. [37] months; mean age 15.6% (n = 7) were classified as sensitivity towards their children 2: 8
49.35 months insecure-resistant/ambivalent (type C), F(2, 39) = 3.74, p = 0.03, effect
(SD = 9.56) 22.2% (n = 10) were classified at size 0.16
Males: n = 45 Females: disorganized (type D)
n=0
Oppenheim, D., Israel n = 45 ASD (DSM 4; PDD) No comparison SSP Mother Type A, B, C, D - 42.2% (n = 19) were classified as - Predictor (insightfulness and Reviewer
Koren-Karie, N., n = 45; age group securely attached (type B), 20% resolution) and outcome 1: 8
Curr Dev Disord Rep

range = 32–69 (n = 9) insecure -avoidant (type A),

Table 2 (continued)

Authors Country Total Sample description Comparison Method Attachment Attachment Attachment pattern results Additional findings/remarks Quality
of origin sample groups figure classification score
size (number
of stars)
Curr Dev Disord Rep

Dolev, S., and months; mean age 15.6% (n = 7) were classified as (attachment) was significant, Reviewer
Yirmiya, N. [38•] 49.35 months insecure-resistant/ambivalent (type C), β = 0.4, t = 2.91, p = 0.006 2: 8
(SD = 9.56) 22.2% (n = 10) were classified at - Predictor and mediator (maternal
Males: n = 45 Females: disorganized (type D) sensitivity) was significant,
n=0 β = 0.54, t = 4.37, p < 0.001
- Mediator and outcome were
significant controlling for the
predictor, β = 0.58, t = 4.00,
p < 0.001
- Predictor and outcome became
insignificant when controlling for
the mediator, suggesting the
indirect effect of
insightfulness/resolution on
attachment was mediated through
sensitivity
Filippello, P., Marino, F., Italy n = 20 ASD (DSM 4; PDD) Normally Modified Mother Ainsworth interactive - Attachment did not differ between the - No differences in secure/insecure Reviewer
Chila, P., and n = 10; age developing SSP subscale (A1, A2, ASD and non-ASD group overall. In classification; the only difference 1: 8
Sorrenti, L. [39•] range = 35–54 children B1–B4, and C1, subgroups, only in B3 (very secure) emerged in how secure Reviewer
2
months; mean age n = 10 C2) and Overall was there a difference (χ attachment was expressed 2: 8
43.2 months Security Score 1(n = 15) = 8.07 p = 0.02) in that it did
(SD = 15,13) (accounting for not exist in ASD but was present in
Males: n = 10 Females: overlapping 67% of ND children
n=0 symptoms)
Rozga, A., Hesse, E., USA n = 30 ASD (DSM 5; PDD); No comparison SSP Mothers and 1 Type A, B, C, D - Children were classified into primary - Based on these classifications, 45% Reviewer
Main, M., n = 30; mean age group father (accounting for secure (n = 7), relationally were classified as secure (n = 13) 1: 8
Duschinsky, R., 47 months (SD = 9) overlapping disorganized (n = 5), D-autism and 55% as insecure (n = 16) Reviewer
Beckwith, L., and Age range not provided symptoms) (n = 17), and one child could not be 2: 8
Sigman, M. [40•] Males: n = 23 Females: classified because of a mixture of
n=7 avoidant, resistant/ambivalent, and
disorganized behaviors
-Of the children who were relationally
disorganized, they received secondary
classifications of secure (type B;
n = 3), insecure-resistant/ambivalent
(type C; n = 1), and insecure-avoidant
(type A; n = 1). Of the children who
received a D-autism classification, 16
received secondary classifications
(one child was dropped due to coders
being unable to differentiate between
D-autism and relational
disorganization) of secure (type B;
n = 6), insecure-resistant/ambivalent
(type C; n = 1), insecure-avoidant
(type A; n = 5), and relationally
disorganized (n = 4; within the
primary classification of D-autism)

Karie team were identified that reported on one sample of 45
males (mean age in months = 49.35, SD = 9.56) from northern
Israel, diagnosed with ASD or PDD [35–38]. Each article
reported that 42.2% were securely attached (type B), 20%
insecure-avoidant (type A), 15.6% as insecure-resistant/am-
bivalent (type C), and 22.2% as disorganized (type D)
[35–38].
Shapiro et al. [24] conducted an American study, which
found that 42% of children with a diagnosis of DLD, ID, or
ASD (n = 36, age range = 30–63 months) demonstrated se-
cure attachment behaviors [24]. The breakdown of secure
attachment for each diagnosis indicated 12.5% in DLD,
33.3% in ID, and 53.3% in ASD. Rogers et al. [30•] studied
attachment behaviors in children with ASD (n = 32), ID, and
DLD (mean age of 46.3 months, SD = 11.5) and found that
50% of the sample demonstrated some evidence of secure
attachment; however, they did not provide a breakdown for
each diagnosis [30•].
Capps et al. [31•] examined attachment security in children
with ASD (n = 19) aged 36–72 months. Four children were
not classified due to their own or their mothers’ behaviors (i.e.,
frequent embraces, continuous running). All 15 classified chil-
dren were primarily classified as disorganized (type D).
However, in assigning a secondary classification that coded
the child while recognizing stereotypical behaviors as an at-
tribute of ASD rather than attachment disorganization, six
children (40%) were re-coded as securely attached, and nine
(60%) insecurely attached. Most recently, Rozga et al. [40•]
found that with a secondary classification accounting for over-
lapping symptoms, 45% of the children were classified as
secure (type B).
Comparison to Neurotypical Children
Four studies utilized a non-clinical, neurotypical group for
comparison. Filippello et al. [39•] found no differences be-
tween secure versus insecure classifications (type A, B, C,
D) when they explored the quality of the relationship of at-
tachments in children aged 32–54 months (mean = 43.2 ± 15,
13) with an ASD diagnosis (n = 10) in comparison with
neurotypical children (n = 10). The only difference found be-
tween children with ASD and neurotypical children was how
secure attachment was expressed in the subgroup classifica-
tion (χ2 1(n = 15) = 8.07 p = 0.02). None of the children with
ASD fell into the very secure subclassification (B3), whereas
67% of neurotypical children fit into this category.
Willemsen-Swinkels et al. [32•] studied children (n = 70)
diagnosed with DLD (mean age = 63 ± 9 months), PDD
(mean age = 69 ± 12 months), ID (mean age = 67 ± 16), as
well as neurotypical children (mean age = 54 ± 15 months).
No differences in insecure attachment distribution were iden-
tified between the neurotypical and NDD groups (multinomial
test, p ≥ 0.05). However, children diagnosed with both PDD
Curr Dev Disord Rep
and ID were more frequently disorganized (Fisher’s exact test,
p = 0.018).
In contrast, van Ijzendoorn et al. [42] examined children
(n = 55) with a mean age of 28.4 months (SD = 4.9). They
looked at ASD, ID, ASD with ID, and DLD (n = 40) in rela-
tion to neurotypical children (n = 15). Overall, children with
NDD tended to score lower on the Richters Attachment
Security Scale (F(1, 53) = 4.36, p = 0.04), and displayed more
attachment disorganization (F(1, 53) = 8.93, p < 0.01) than
neurotypical children. In looking at the breakdown of attach-
ment for ASD, ID, ASD with ID, and DLD, only children with
ASD showed more disorganization (F(1, 53) = 4.46, p =
0.04), whereas children with ID scored lower on the security
scale (F(1, 53) = 4.44, p = 0.04) and displayed more disorga-
nization (F(1, 53) = 11.56, p < 0.01).
Naber et al. [34•] assessed children (n = 80) with a mean
age of 27.65 months (SD = 6.04) diagnosed with ASD, PDD,
ID, and/or DLD, and a non-clinical control group (n = 18;
Richters Attachment Security Scale and type A, B, C, or D)
[2, 20, 21]. Children with NDDs were less often securely
attached than neurotypical children (χ2 (1, n = 80) = 8.18
p < 0.01); however, there were no differences identified in
the distribution of attachment patterns among diagnostic
groups (ASD PDD, ID, DLD). When comparing each diag-
nostic group to the non-clinical control group, only the DLD
group showed no differences in attachment distribution be-
tween secure and insecure (ASD versus control χ2 (1, n =
38) = 9.08 p < 0.01; ASD (PDD) versus control χ2 (1, n =
32) = 5.72 p = 0.02; ID versus control χ2 (1, n = 30) = 7.75
p < 0.01).
Predictors of Attachment
Several studies (n = 8) examined factors that predicted attach-
ment in children with NDDs. Three studies examined if spe-
cific NDDs impacted attachment. Shapiro et al. did not find
any association between the quality of attachment and the
severity of NDDs [24]. Rogers et al. [30•] reported that devel-
opmental level (measured through Merrill-Palmer Test of
Mental Abilities [45], Leiter International Performance
Scale [46], the Bayley Scales of Infant Development Mental
Scale [47], and the language subscale of Early Intervention
Profile and Preschool Profile on the Early Intervention [48])
was the strongest predictor of attachment. However, in a hier-
archical regression performed by Naber et al. [34•], more au-
tistic symptoms predicted a lower score on the Richters
Attachment Security Scale, explaining 12% of the variance
[21]. In addition, developmental level, assessed through lan-
guage, motor, and perceptual abilities on the Mullen Scales of
Early Learning [49], significantly predicted disorganized at-
tachment explaining 9% of the variance [34•].
The association between parental qualities and attachment
was examined in several studies (n = 5). Three studies found
Curr Dev Disord Rep
that securely attached children with NDDs had caregivers that
displayed higher degrees of sensitivity [31, 37, 42].
Oppenheim et al. [35•] found that mothers who were more
insightful and resolved had more securely attached children.
Maternal insightfulness is the capacity to see things from the
child’s point of view; insightful mothers interpret and accu-
rately respond to their child’s signals, which, in neurotypical
children, fosters the development of a secure attachment
[50–53]. With NDDs, insightfulness should be considered
with resolution as it accounts for the child’s point of view
while accepting and understanding the challenges with the
diagnosis [35, 54]. In 2012, Oppenheim et al. [38•] deter-
mined that maternal sensitivity mediated the association be-
tween combined maternal insightfulness and resolution and
attachment; that is, mothers with higher sensitivity in the con-
text of maternal insightfulness/resolve were more likely to
have securely attached children [38•].
Discussion
Attachment in NDDs appears to serve the same essential
functions as in neurotypical children, including providing
them with a sense of safety and security [8]. Eight studies
identified secure attachment in approximately 42–50% of
children with NDDs [24, 30, 31, 35–38, 40]. In studies
with a neurotypical comparison group (n = 4), there were
conflicting findings [32, 34, 39, 42]. Two studies reported
no differences in proportions of children classified as se-
curely attached when compared with neurotypical chil-
dren [32, 39], while others suggested that children with
NDDs were less often securely attached than neurotypical
children [34, 42]. Of the studies examining other NDDs in
addition to ASD [24, 32, 34, 42], only three conducted
statistical analyses to determine if differences existed in
attachment pattern distribution among ASD, ID, and DLD
[32, 34, 42]; two of the studies found that children with
ID tend to be less secure and more disorganized [32, 42],
similar to the findings of studies that have included chil-
dren with ASD [34, 42]. This review adds further support
for the suggestion that children with NDDs display behav-
ior indicative of secure attachment, which was found in
the previous narrative [8] and meta-analytic reviews [7].
In addition, this review identified two additional studies
[39, 40] not included in the most recent 2017 systematic
review [8]. Both these studies also presented findings that
support the capacity of children with ASD to develop
secure attachment patterns [39, 40]. Finally, this review
provides further support that there remains a minimal
amount of research with regard to NDDs and attachment,
and identifies concerns with the varying degrees in which
the SSP is conducted and scored when assessing children
with NDDs.
Comparison of Children with NDDs to Neurotypical
Children
To examine the broad-scale distribution of attachment in
neurotypical children using the four-fold A, B, C, and D clas-
sification, van Ijzendoorn et al. [16] conducted a meta-
analysis with data from nearly 80 studies (n = 2104). Of the
neurotypical, middle-class samples, approximately 15% were
disorganized (type D) [16]. Our review found that 22.2%
[35–38] to 100% of children [31•] with ASD were disorga-
nized. Furthermore, in examining secure attachment (type B),
the distribution in neurotypical children is approximately
62%. In comparison, approximately 42% in DLD, ID, or
ASD are secure upon primary classification [24, 35–38], and
60% receive a secondary classification of secure attachment
[31•]. Children with ASD were most likely to be securely
attached, followed by children with ID and DLD [24•]. Only
five studies [31, 35–38] examined insecure types A and C.
While van Ijzendoorn et al. [16] found that 15% of
neurotypical children were insecure-avoidant (type A), 6 to
20% of children with NDDs received the same classification
[31, 35–38]. Finally, 9% of neurotypical children were inse-
cure-resistant/ambivalent (type C) [16], whereas 13–15.6% of
children with ASD [31, 35–38]. This suggests that children
with ASD are more frequently classified as disorganized and
less secure than neurotypical children. These results build on
and support the previous reviews by Rutgers et al. [7] and
Teague et al. that found that 47–53% of ASD children were
securely attached versus insecurely attached not taking into
account the classification of disorganized. The consensus of
replicated studies on ASD children suggests that approximate-
ly half form secure attachments; additional research is needed
on ID and DLD to determine if findings to date can be
replicated.
However, with the continuous scoring of the SSP using the
Richters Scale of Attachment, there were conflicting findings,
with two of four studies suggesting that children with NDDs
were scored less securely than neurotypical children [34, 42].
At the same time, two studies reported no differences in at-
tachment security scores between neurotypical children and
children with NDDs [32, 39]. Additional work validating
these measures for children with NDDs may address these
conflicting results.
Predictors of Attachment in Children with NDDs and
Neurotypical Children
Factors predicting attachment in preschool children with
NDDs included the number of autistic symptoms, develop-
mental level, maternal sensitivity, and maternal insightfulness
and resolve [30, 31, 34]. Naber et al. [34] reasoned that asso-
ciations between either developmental level, autistic symp-
toms, and attachment could stem from the child not

understanding what happens during the separations and re-
unions of the SSP, and therefore, they may experience confu-
sion rather than stress, leading to a misclassification [34•].
This review further supports the notion that children with
greater severity of ASD symptoms and developmental delays
are more likely to demonstrate less secure attachments. This
finding suggests that possessing co-occurring NDDs (e.g., ID)
may place a child at a greater risk for an insecure or disorga-
nized attachment [7, 8, 30, 33, 55]. As this review was limited
to literature on preschool-aged children, and so few studies
were found, future work should examine attachment and co-
occurring NDDs in both preschool and school-aged children
[7, 8].
The findings regarding maternal insightfulness, resolve,
and sensitivity in predicting secure attachment in children
with NDDs are consistent with the findings in neurotypical
children and with previous reviews [7, 8]. Unfortunately, the
reviewed studies only focused on ASD, not the other NDDs.
Insightful mothers interpret and accurately respond to their
child’s signals, which, in neurotypical children, fosters the
development of secure attachment [50–53]. Fonagy et al.
[52] found that mothers with greater insight showed less
avoidant behavior and more contact maintenance (r = − 0.37
and − 0.30, respectively). As previously mentioned in NDDs,
insightfulness and resolution should be considered together
[35, 54]. Like maternal insightfulness and resolve, maternal
sensitivity can be variable. In the neurotypical population,
children whose caregivers are less sensitive tend to develop
secure attachment less frequently [56–58].
Strengths and Limitations
While a strength of this review includes the measures
used by the studies included, a limitation is that attach-
ment measurement modifications were not standardized or
validated for NDDs, potentially limiting generalizability
[16, 31]. In nine studies, attachment was studied with
mothers, while in three, it was unclear who the caregivers
were or if they were primary caregivers [32, 40, 42]. As
attachment patterns may differ between caregivers (e.g.,
mothers versus fathers, primary caregiver versus not) [59,
60], findings may be limited by this lack of information.
None of the studies considered differences in attachment
behaviors between male and female children in both
neurotypical and NDD populations. This consideration is
significant, as neurotypical females tend to seek proximity
more than males in threatening situations, leading to an
overestimation of security in females [61]. Finally, the
inclusion criteria for the measurement tools and age range
used in this review may limit the NDDs being examined
as some diagnoses (e.g., dyslexia, ADHD) typically are
not diagnosed until a child is of school-age (i.e., 6–
12 years) [3].
Curr Dev Disord Rep
Clinical and Research Implications
Secure caregiver-child attachment appears to be equally im-
portant for preschool-aged children with NDDs as it is for
neurotypical children. The lack of standardization with regard
to measurement tools and the presence of overlapping symp-
toms with disorganization in some NDDs make it difficult to
know whether children with NDDs are accurately coded [62].
These concerns identify a need to conduct research to high-
light behaviors that may reflect NDD-related neurological dif-
ferences rather than attachment behavior and develop and val-
idate standardized tools or modifications to existing tools to
assess attachment patterns in children with NDDs reliably.
When examining the impact of NDDs and co-occurring
NDDs examining school-aged children in addition to
preschool-aged children, future research is needed to develop
tailored, standardized measures of attachment in children with
NDDs.
This review reveals the limited research examining factors
that may influence attachment in children with NDDs. Despite
being regarded as an important predictor of attachment, in
neurotypical children, maternal sensitivity accounts for only
one-third of the association between maternal-infant attach-
ment, leaving a large gap of unexplained variance [63–65].
In a neurotypical population, factors such as genetics or ma-
ternal mental health may influence attachment [66–68]. For
example, the dopamine receptor D4 gene (DRD4) genotype
has been associated with increased risk for disorganization
[69, 70]. Also, higher levels of maternal depressive symptoms
are consistently associated with disorganization in young chil-
dren [71]. This review has identified that predictors of attach-
ment, such as maternal sensitivity, appear to be just as impor-
tant in children with NDDs. Therefore, it would be important
to examine the role of other predictors of attachment, such as
genetics or maternal mental health in children with NDDs.
Nonetheless, in neurotypical children, interventions designed
to promote maternal sensitivity and insightfulness are found to
be effective in promoting secure attachment [57, 72, 73]. The
promise of interventions built on a range of factors that may
influence attachment patterns for children with NDDs remains
to be explored.
Conclusion
This systematic review demonstrates that many young chil-
dren with NDDs can develop a secure attachment with their
caregiver. Understanding the developmental stages and be-
havioral nuances of children with NDDs will improve the
ability to apply assessments and predict attachment in this
population. Secure attachment is linked to lifespan health
and reduced morbidity [74]; thus, continued emphasis on fac-
tors predicting attachment in children with NDDs is
Curr Dev Disord Rep
warranted. Investigating attachment patterns in children with
NDDs could lead to understanding and improving parent-
child relationships and wellbeing for children with NDDs.
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