A LITERATURE REVIEW OF CHILD - PARENT/CAREGIVER ATTACHMENT THEORY AND CROSS-CULTURAL PRACTICES INFLUENCING ATTACHMENT.

By P.N. Reebye M.D. FRCPC, S.E. Ross M.Sc. RDN, K. Jamieson M.A.
With the Assistance of Jason M. Clark B.A. (Hons.)

1. INTRODUCTION
Overview of the Content of the Literature Review
Purpose of the Literature Review
The Purpose of the National Research Project
Scope of the Literature Review
Parameters and Limitations of the Review

2. ATTACHMENT THEORY AND ITS APPLICATION
A Summary of the Concept and Application of Attachment
Major Components of Attachment Theory
Types of Attachment Styles and Behaviours
Early attachment and impact on later functioning

3. CROSS - CULTURAL STUDIES OF ATTACHMENT
Cross-Cultural Studies of Attachment
Cross-Cultural Studies on Attachment Classification
Studies Conducted in Africa
Studies Conducted in Germany
Studies Conducted in Japan
Studies Conducted in China
Studies Conducted in Israel
Cross-Cultural Adoption

4. PARENTING, CARE-GIVING AND ATTACHMENT PRACTICES
Understanding the parent/caregiver in attachment relationships
Parent/Caregiver limitations in facilitating attachment relationships

5. CROSS-CULTURAL STUDIES, ATTACHMENT AND PARENTING PRACTICES
Connecting Parenting Styles to Attachment Styles
A Framework for Considering Cross-Cultural Attachment and ParentingPractices
Cultural and Cross-Cultural Studies on Parenting Practices
Ethno-Cultural Groups in Canada
Cultural Patterns of Parenting

6. CONCLUSION
Methodological Dilemmas
Gaps in the literature
Final comments and reflections on the literature from the researchers
Roles and Backgrounds of the Writers
References
Supplement

This literature review is in seven sections:
Section 1, the Introduction discusses the purpose and objectives of the review and provides an overview of the paper, its scope and its limitations.
Section 2, Attachment Theory and its Application provides a brief context for understanding the literature discussed in this report and a summary of the concepts, terms, and application of attachment. Section 3, Cross Cultural Studies of Attachment, looks at cross-cultural attachment classification, cross-cultural adoption, and studies on attachment conducted in Africa, Germany, Japan, China, and Israel.
Section 4, Parenting, Care-giving and Attachment Practices, focuses on issues in the literature related to understanding the caregiver and caregiver limitations.
Section 5, Cross-Cultural Studies, Attachment and Parenting Practices, looks at the literature on parenting and attachment styles across cultures and suggests a framework for considering cross-cultural attachment and parenting practices.
Section 6, the Conclusion, provides a critique of the state of the literature on attachment cross-culturally.
Section 7 provides a list of the sources used in this review. A supplement to this paper The History of Attachment Theory, provides a review of the historical development of attachment theory, the work of its major proponents and the evolution of their concepts. In addition, the authors provide some final comments and raise some of the questions that emerge from the review.

The purpose of this literature review is:
"To provide the national project with a summary, and critique of current research and knowledge on parent-child attachment practices - particularly within the context of ethno-cultural communities and in regards to the impact that migration may have on the practices used by women /families within these communities". [1]

The objectives of the review are to:

1. Provide the national project with a summary and critique of the current research and knowledge on parent/caregiver-child attachment across cultures;
   
   
2. Present the information in an accessible form for CAPC/CPNP staff and program participants across the country;
   
   
3. Provide a basis for critical discussion of this issue across Canada.
   
   

This review is retrospective, in that it looks back at the research on attachment that has already been done. It provides background information for a prospective study that is being conducted by the Women's Health Centre and is designed to collect and analyze new information on attachment across cultures in Canada for the CAPC program of Health Canada.

The purpose of the national research project being conducted by the Women's Health Centre SJHC/Parkdale Parents Primary Prevention Project is described in their proposal to Health Canada as being: "to acknowledge and validate parent-child attachment practices used by women/families coming from diverse backgrounds and countries abroad, and to recognize, in particular, the techniques that have proved to be critical in the healthy development and attachment of children in their first five years of life". The national project provides the context for the literature review though the review has a different purpose.

The members of the Women's Health Centre decided to conduct research in this area because of their growing awareness that women immigrants were likely to experience cultural disruption and even rejection of the familiar child-rearing practices that reinforced their roles in child development.

The literature examined for this review was derived primarily from an extensive search of Medline, PsychInfo, sociological and ethnological abstracts, Social Work, Family Studies, and Women's Studies abstracts for English language peer-reviewed literature on child-rearing, mother-child relations, parent-child relations, cross-cultural studies of parenting, attachment behavior, ethnic identity and values, cultural characteristics, and cultural diversity. The searches were limited to the years 1980-1999 in order to present a contemporary and relevant portrait of the attachment literature. Studies were deemed suitable for inclusion if they dealt with issues of attachment in infancy and early childhood (0-10 years). Studies of adult attachment were excluded from this review. One hundred and ninety-eight references were reviewed, including six critical reviews of the literature on attachment.

In addition to the above references, a number of key studies published between 1930 - 1999 that provide an overview of the development of attachment theory and learning were used.

In conducting this review of the literature on the infant/child-parent/caregiver relationship¾ known as attachment - the authors aimed to clarify how the concept is defined, described, operationalized and practiced.

Additional interconnected questions, related to the Women's Health Centre project goals and to the broad goals of the CAPC Program that the authors of this review asked, included: What if anything does the literature tell us about characteristics of the attachment relationship that better prepare a child to relate well to others, both within their family and outside their family, to be successful in school and in adult life generally? Are these characteristics the same for all mothers and children regardless of culture? What effects do different cultural and parenting practices have on the relationship between child and parent/caregiver?

It is important to note the following limitations of the study.
1) While this review is designed to provide background information for the major study that the Women's Health Centre is conducting, its purpose and objectives are different and limited to summarizing and critiquing research that has already been published. As is true of any literature review, this review can only reflect what the literature includes, and, unlike the empirical research being generated in the rest of the study by the Women's Health Centre, cannot generate hypotheses. However, wherever possible, the researchers have identified what are, in their view, biases and critical gaps in the existing research.

2) The literature on attachment and cross-cultural practices related to attachment is found primarily in the fields of social science, and medicine. Unsurprisingly, much of the language, terminology and discussion in the literature on attachment are quite technical and often abstruse. Whenever it is deemed possible to do so without losing or changing the sense, technical language and concepts are explained in plain English in this review. However, the language and concepts of a particular author sometimes have specific meanings ascribed to them that cannot be accurately explained in different words without distorting the meaning.

The term attachment means different things to different people, such as commitment, love, affection, warmth or even loyalty. Even in the scientific literature there seems to be an overlap between attachment, bonding, and affiliation. In this paper we use the term "attachment" as it is most often used to refer specifically to the relationship between an infant (and young child) and the infant/child's parent (usually mother) or preferred caregiver.

The concept was pioneered by British psychiatrist John Bowlby in the 1940's and is based in part on his observations of children in institutions. Bowlby saw attachment as being crucial to a child's personality development and to the development of healthy ways of relating to others. His theory borrows from ethology, cognitive psychology, control systems theory, and object relations theory. These multidisciplinary concepts all emphasize patterns of parent-infant relationships, and qualitative aspects within these relationships. (The historical development of attachment theory is discussed in more detail in a supplement to this report).

Bowlby described four infant behavioral systems - the exploratory system where the infant explores the world around them, the affiliative system where the infant learns to be with others, the fear/wariness system that helps the infant learn about dangers and to stay safe, and the attachment system that helps the infant to seek proximity to their attachment figure and develop a sense of security. He identified the attachment system as the most important of the four. Besides the attachment system described above, there are descriptions of attachment behaviors, attachment bonds and attachment relationships.

Attachment behaviors is the term used to refer to the actions or signals of infants, such as crying, smiling and vocalizing, which help to bring their caregiver into close proximity. In later stages, the infant/ toddler will physically approach their caregiver, by crawling and walking toward them.

Newborns arrive well equipped to play an active role in developing and maintaining an attachment relationship. Most are alert at birth, and are soon able to respond to human language (Condon & Sander, 1974) and to synchronize their movement with an adult. A two-day old infant, for example, can discriminate between their mother's face and odour, and the face and odour of others (Field et al., 1984). The emerging research on infant-caregiver relationships emphasizes this active participation on the part of infants.

The term attachment bond is normally reserved for the warm, intuitive feelings felt by the caregiver/parent towards the child. The attachment relationship is increasingly recognized as the domain of the child -parent/caregiver relationship.

The important elements in attachment theory are as follows: attachment is universal to all humans; it is not race or culture-specific; it is instinctive and biological; attachment is an 'understanding', not learned through reasoning or teaching; it is, therefore, intuitive; multiple attachments occur, but attachments are ranked and generally mother-infant is primary; it is, thus, hierarchical; attachment is about a close (usually affectionate) relationship, and its impact lasts from cradle to grave; it is, therefore, enduring and lasting.

The basic tenet of attachment theory is that the reciprocal relationship between the child/infant and the caregivers has a biological basis. The main function of this attachment relationship is to increase chances of survival for the infant by helping the infant to seek proximity to someone who will care for him or her.

The attachment relationship also takes into account the emotional aspects of infant-mother relationships. Bowlby argued that the establishment of "felt security" for the infant and development by the infant/child of "internal working models" is crucial, and that unwanted separation from the attachment figure gives rise to emotional distress.

Current concepts of attachment theory accept that the infant may form selective attachments to a number of persons. However, a hierarchical aspect among the relationships is respected. (Bowlby, 1969/1982; 1973; 1980).

It is also accepted that attachment behaviors will be exhibited according to the degree to which the attachment system is activated. Thus, the literature suggests, attachment security in a mother-infant relationship is related to her accessibility and appropriate responsiveness to the infant. Once established, the security of the mother/caregiver relationship is highly stable over time. In addition, the research suggests that attachment security predicts other aspects of a child's development such as social competence, or problem solving. (Sroufe et al., 1990; Sroufe et al., 1992).

Mary Ainsworth's work is seminal in understanding the currently accepted distinctive patterns of different attachment relationships. Her use of the so-called "strange situation" experiments allowed classification of observable attachment patterns. (Ainsworth et al., 1969; Ainsworth et al., 1971).

Ainsworth studied the behavior of young toddlers (12 to 20 months) through the use of "strange situation" experiments. This structured observation procedure focuses on the balance that the toddler achieves between attachment and exploratory behavior when moderate stress is introduced. Three classifications of attachment were described by Ainsworth: a) Secure Attachment, b) Insecure Attachment-Avoidant, and c) Insecure Attachment-Ambivalent.

The secure toddlers were those who use their mothers/caregivers as a secure base for exploration. On reunion with their mother, they greeted the parent with smiles, positive gestures and vocalizations. They sought comfort from their mother when they were separated, but were easy to soothe and comfort upon her return, and could renew their exploratory activity once comforted. Secure infants were found to be engaged in more rewarding interactions with their caregivers (Isabella and Belsky, 1990).

The insecure (often described as anxious) group of toddlers showed two different patterns of response termed avoidant and ambivalent. The avoidant pattern was characterized by little display of secure base behavior. On separation from their caregivers, toddlers exhibited minimal discomfort. On reunion with their mother/caregiver, they sought distance from the parent and showed more interest in the toy objects than the parent. The ambivalent pattern was seen in the toddlers who were either fretful or passive. They reacted in a distressed manner to separation from their mother, but on reunion, showed signs of angry rejection and were not soothed by her return.

At a later stage, Mary Main and others (1981; 1982; 1985; 1986: 1994) built on this work and described a fourth attachment category - the disorganized or disoriented group of toddlers. These were children who did not demonstrate a characteristic or predictable attachment response to the strange situation. They reacted in disorganized way to the stranger and stress. This category of attachment was apparent in high-risk children (i.e. those with a history of neglect or abuse) on a regular basis.

Although the original attachment classifications have been described for toddlers up to 20 months, there have been several attempts to classify attachment relationships in older children and in the adult population (Bartholomew & Shaver, 1998). More recently, attachment relationships have been described using home-based measures of attachment.

Two important approaches have been used to classify attachment styles of preschool children - the picture response procedures developed by Kaplan and Main (1986) and the study of representational-based attachment security founded on observation of doll play. The Cassidy-Marvin (1992) systems and the Preschool Assessment of Attachment (PAA) have also studied attachment patterns in preschool children.

The theoretical basis of most of the attachment research is that secure attachment in infancy will predict good psycho-social outcomes in later years. However, many other factors can be expected to modify the impact of secure attachment on later functioning, including cultural variations of attachment, psychosocial circumstances, factors within the child (e.g. child temperament), and intergenerational transmission of values and beliefs.

Secure infants engage in mutually rewarding interactions with their mothers (Isabella & Belski, 1991). Main & Cassidy (1988) found a relaxed harmony in the relationships between securely attached six-year-olds and their parents. The consistent theme of research findings is that the harmony between the mother and infant in early years has benefits in the immediate post toddler phase of relationship development and in the later development of peer relationships. Securely attached children are more likely to have close friends, be more socially competent, more accepted by their peer group, have more empathy for others and be able to read emotional cues (Leiberman, 1977; Water, Whippman & Sroufe, 1979; Minnesota Parent-Child Project).

The findings from the Minnesota Parent-Child Project of Middle Class families suggest that children with secure histories were more self reliant and better problem solvers. They found that being secure did not guarantee optimal mental health and social adjustment for each individual child, but it was one the important protective factors for emotional well-being. Secure attachment is thought to be one of the protective factors involved in the development of resiliency (Sroufe, 1997; Steinhauer, 1998).

In contrast, children with (anxious) insecure attachment histories were found to be less confident and more reliant on others to have their needs met, and more at risk for psychosocial malfunctioning, such as somatic complaints, social withdrawal (Lewis et al., 1984), anxiety disorders (Warren et al., 1997). Avoidant children exhibit different forms of social incompetence - they are often identified as the bullies by their peers and are hostile and aggressive (Troy & Sroufe, 1987). The research on conduct problems in early childhood concludes that both avoidant and disorganized children are at a greater risk (Greenberg et al., 1993). Carlson, Chicchetti and other (1989) found that 82% of children who had been maltreated had a history of disorganized/disoriented attachments.

Overall, research findings to date substantiate the proposition of attachment theory that a child's attachment history does matter. There are few longitudinal studies that can inform us about the impact of attachment styles over time, but there is more concerted effort at present to examine the impact of early relationships on later functioning. Certain risk factors seem to have greater or lesser impact on specific developmental stages of a child's life. Security in early relationships for the infant to preschool child, cognitive competence and motivation for the middle childhood years, and parental norms regarding behaviour during the adolescent period (Greenberg, 1993) appear to be critical for healthy development.

An understanding of how it evolved historically facilitates any assessment of the current state of knowledge of attachment theory, its usefulness and its limitations. For readers who have not had the opportunity to study the evolution of the concept of attachment in the scientific literature, we have provided a summary from the highly regarded book written by Robert Karen (1994) as a supplement to this report.

There is an extensive literature on attachment. Key publications that might be considered essential reading in this area have been bolded in the reference section.

The idea that attachment fulfills the instinctual needs of a human baby (beyond feeding) is an important concept of attachment theory. It directs us to understand the mother-infant relationship as one that effects all humans, thus encompassing all cultural boundaries, and/or ethnic child rearing practices.

Bowlby's (1951) landmark report for the World Health Organization -"Maternal Care and Mental Health" was the result of his collection of data from different western countries such as France, Holland, Sweden, and the United States. The notion that maternal care is as important for mental health in infancy and childhood "as are vitamins and proteins for physical health" (p. 67) became commonly accepted internationally as a result of this report.

The cultural dimensions of attachment and related research have always been seen as important. As early as the 1950s, Spitz's studies on the effects of maternal deprivation on infants were critiqued for not taking cultural, racial and socio-economic factors into account (cited in Pinneau, 1955).

However, the cornerstone of the current understanding of infant-mother attachment behaviors is grounded in the cross-cultural observations of Mary Ainsworth (1963; 1967) who completed her first studies in Uganda. Her second study of American babies replicated her findings about patterns of attachment that she observed with the Ganda babies. Essentially she found that the attachment relationship was applicable to these two diverse groups, recognizing that some attachment behaviours differed (e.g. American children hugged and kissed whereas the Ganda children clapped when their 'attachment figure' returned). Several challenges have been directed to the replicability of Ainsworth's attachment classifications in different cultures. A review the literature and important studies addressing these issues follows.

One of the complexities of cross-cultural research is the recognition that infants and children learn to behave in a manner conducive to their successful adaptation within the cultural norms around them. Although, the intuitive part of the infant-mother attachment experience is well accepted, the observed relationship reflects the required patterns of their immediate social milieu. The infant behaves in a manner that responds to maternal behavior that is both intuitive and reflective of expected behaviour in their community.

There are many different ways to organize cross-cultural studies. They are grouped here according to the country of origin.

Keromoian and Leideman (1986) studied 26 families and children aged 8 to 27 months. A strange situation experiment was constructed with some modifications. An interesting finding was that the secure Guiessi babies greeted their caregivers by extending a hand, mirroring the culturally accepted behavior of adults who greet one another with a handshake. The insecure Gueissi babies avoided their caregiver and explored the surrounding environment. The study did not differentiate between the avoidant and ambivalent insecure attachment classifications.

The attachment classification found for the Gueissi dyads [2] was similar to the findings in Western studies, with 61% demonstrating secure attachment to their mothers and 54% to other non-maternal caregivers.

In this culture, the mothers carried out physical caring activities, while non-maternal caregivers were more involved in socializing and cognitive development activities. This was reflected in the finding that secure attachment with mother was related to an infant's nutritional status and secure attachment with non-maternal caregivers was related to higher cognitive task achievement by the infants.


Another study that provides important cross-cultural information is True's (1994) Dogon study. True's findings for secure attachment were comparable to other studies, and were held to provide validity for the use of the 'strange situation' methods cross-culturally. In addition, the disorganized (disoriented) attachment classification was studied in this African sample. The findings regarding insecure attachment included 23% classified as disorganized infants (compared to15% in western samples), and an absence of avoidant infants. The increased percentage of disorganized infants was attributed in the research to higher perceived stress by the infant-mother Dogon dyad resulting from the strange situation procedures.

Marvin et al's (1977) Nigerian Hausa study showed how polymatric (multiple mother figures) care of infants influences attachment behaviours. The study results were consistent with current understandings of a hierarchy of attachment relationships (cf. Bowlby) in that children formed attachment relationships with many maternal figures, but they demonstrated a preference for one relationship over all the others. The preferred maternal figure was the one who held them most frequently and had more opportunities to interact with the child.

This study also gives us insight into how parental behavior affects the measurement of attachment relationships. Hausa caregivers were sensitive to their infants' signals; however, they restricted their infants from physically moving around to explore their surroundings - an indicator of 'felt security'. This comparative restriction of physical movement has implications for use of the accepted methods of measuring attachment behaviours.

Klaus and Karin Grossman et al. (1981; 1985), studied children in Bielefeld in northern Germany and found two thirds of their sample to be insecurely attached, and one half of these children to be avoidant (two and a half times the figure for avoidant children in middle-class American studies). The avoidant nature of the children was attributed in part to the fact that independence was highly valued by northern German parents and early self-reliance was encouraged before their first birthday. However, the long-term effects of the avoidant attachment were seen in poor peer relationships and in greater rather than less dependence of the children at age ten. Secure infants were seen to be more confident, self-reliant and resilient at that age.
The same researchers carried out a second study in southern Germany and found the secure and insecure attachment classifications from this sample to be very similar to American studies.

In interpreting the two studies and comparing the results to Sroufe's sample, the researchers came to believe that the high rate of avoidant attachment should not be discounted as culturally normative. The end of the first year seems to be a critical period for babies in the development of the attachment relationship (Ainsworth, 1982), and the early requirement of babies to be emotionally independent by northern German mothers came at a cost to the child's later well being. As a result, they urged changes in some of the strongly held German opinions about child rearing (Grossman & Grossman, 1991). Their issue was that independence is found to result from continuing sensitive responsiveness on the part of the mothers, and is not realized by training or withdrawing support and expressions of love.

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Two studies using the strange situation methodology - the Tokyo study and the Sapporo study - are generally cited. The results of the Tokyo study (Durrett et al., 1984) showed distribution of the infant-mother attachment classifications consistent with other international findings. Mothers of securely attached infants in this study reported greater spousal support than mothers of insecurely (avoidant) attached infants. The Sapporo study (Takahashi, 1986) showed a different distribution of attachment classification - however both the sample selection and study procedures were modified. The different results of these two studies have raised important questions regarding the use of standardized procedures in conducting cross-cultural attachment research.

Literature on the study of attachment in the Japanese culture is complicated by the concept of amae (a relationship with emotional dependence on the caregiver akin to an attachment relationship) which is considered similar to the concept of attachment (Doi, 1989; 1992). However, scientific exploration using attachment Q-sort procedures-a participant self-report technique¾linked dependency with amae, but not attachment security with amae (ref Vaughn & Waters, 1990; Vereijken, 1996 p.724).

It is important to note that much of the research in this area had been conducted in "artificial" laboratory settings. Bornstein and colleagues (1992), however, examined, compared and discussed key characteristics of maternal responsiveness to infant activity in home settings in New York, Paris and Tokyo. Many of the predicted maternal responses were commonly seen in all three settings including appropriate response to infant's basic needs, nurturing response to infant vocalizing distress, encouraging exploration of the environment, and imitating infant's non-distress vocalization. Different culture-specific response patterns were observed, for example, in response to infant's looking rather than vocalizing, and to whether mothers encouraged others beside themselves to engage in the interactions.

Very little research on socio-emotional development or attachment has taken place in China and it is not known how representative any one study might be.

The Beijing study conducted by Gao and Wu (cited in Posada et al., 1995) attempted to explore the existence of the secure base phenomena in the Chinese population, and to develop a consensus on the profile of a typical secure child as described by Chinese mothers. They found that Chinese mothers perceived the ideal child to be one that is securely attached, and when asked to describe the profile of a securely attached child, both the experts' and mothers' profiles were in agreement.

Tang (1992) provides an overview of the psychoanalytic implications of Chinese philosophy and child-rearing practices. Ho (1994) and others suggest that Chinese culture values interdependence over independence, and that Chinese parents emphasize emotional harmony and control in relationships. A study by Lin and Fu (1990) found that the high value given interdependence within the family was totally compatible with support for independence in the wider social context external to the family, since this is generally recognized as being required for success at school and work.

The first study of attachment in China using the strange situation methods was conducted by Hu and Meng (1996) from Peking University in Beijing with 31 mothers and infants. There were 15 girls and 16 boys in the sample, each being an only child. Grandmothers played a key role as substitute caregivers. The distribution of attachment classifications was similar to the international comparisons with 68% being classified as secure, and 32% classified as insecure attachments. The results were similar for female and male infants. The researchers were not confident about their findings and interpretation, particularly with regard to the avoidant classification. However, the findings seemed to support the relevance of caregiver sensitivity in attachment development. Mothers of secure infants were more involved in child care than mothers of avoidant infants.

Sagi et al (1985) found important differences in the attachment security of Kibbutz infants who sleep in a collective sleeping arrangement at night versus infants who returned to their parents to sleep for the night - the latter being more secure. Inconsistent responsiveness (mother/caregiver during the day; unfamiliar person at night) is suggested as the reason for the higher proportion of insecure attachment among the communally sleeping infants. Several Israeli studies (Sagi et al., 1985, 1994, 1997) have consistently shown an over-representation of ambivalent and an under-representation of avoidant insecure attachment classifications when compared to international norms. Studies to pursue the reason for this occurrence have not been completed.

In the Netherlands, 80 mothers and infants adopted from Sri Lanka, South Korea and Colombia were observed at home at 6 and 12 months to assess the adoptive mother's sensitivity, and in a 'strange situation' at 12 and 18 months to assess infant-mother attachment (Juffer & Rosenboom, 1997). All interracially adopted infants were placed before 6 month of age (mean age of 11 weeks) in adoptive families. Using Ainsworth's classification, 74% demonstrated secure attachment relationships. The adoptive mother's sensitivity seems comparable to that of non-adoptive parents. The author's suggest these results might be attributable to adoption at a young age. This would concur with the maternal deprivation studies cited earlier.

Marcovitch et al. (1997) assessed developmental status, attachment and behavioural problems in 56 Romanian orphans (aged 3-5 years) adopted in Ontario. The group as a whole was functioning in the normal range and was considered well adjusted, but children who had experienced less than 6 month of institutional care had better outcomes than the rest on developmental measures. Secure attachment was less frequent than normally expected and avoidant attachment was not observed. Children who had more institutional experience, those who were developmentally less competent, and those who were insecurely attached had more parent-reported behaviour problems.

Mainemer, Gilman and Ames (1998) evaluated parenting stress in 39 families that adopted 43 Romanian orphans. Predictors of stress included attachment security and the number of behaviour problems as well as family factors.

In summary, the distribution of secure attachment classification in different countries shows a striking similarity. For example 67% U.S. (21 samples); Western Europe, 66% (9 samples); Africa (3 studies) 57-69%; China, 68% (1 study); Japan, (2 studies) 61-68%
(van IJzendoorn &.Sagi, 1999). The distribution of types of insecure (avoidant and ambivalent) and disorganized attachment classifications, if measured, are less consistent. Differences have been attributed to the over-riding expression of a cultural value, such as dependency or independence, and to differences in perceived stress generated by the strange situation methods between mother-infant dyads with different cultural experiences.

The concept of a 'good enough' mother/parent that the human baby needs to exist is an important one. To talk about a 'good enough parent" is to absolve parents from having to be a 'super parent'. What is expected is that parents support, understand and respond to their infant in distress, or otherwise.

Bowlby speculated that when infants are separated from their attachment figures they would show emotional reactions in a particular manner. He elaborated these concepts in his trilogy entitled Loss in three phases: protest, despair and detachment. Bowlby thus enhanced our understanding of the phenomenology of grief. He offered explanations of normative reactions to loss of an attachment figure and also atypical forms of mourning. Chronic mourning is of particular interest to the understanding of parenting practices. It may be inferred from this that unresolved grief might be an issue for new immigrants and refugees, and "good enough" parenting may become challenging for parents faced with an unfamiliar milieu and experiencing grief.

However, studies that capture the interaction between good enough parenting, attachment, and parental psychopathology show mixed results. Children of mothers who had bipolar depression show high rates of insecurity and the majority of these were disorganized/ disorientated. Maternal anxiety similarly predicts a high percentage of insecure children (Cassidy et al, 1992). Of importance are the findings that the rates of child insecurity in groups of mildly depressed mothers did not differ from those of the control groups (Radke-Yarrow et al, 1985). As maternal depression and anxiety appear to be fairly common conditions in new immigrants, these studies seem relevant.

The substance-abusing parent poses a complicated parenting situation. The physical absence of the parent due to medical or emotional disability, hospitalizations, and transient lifestyle all contribute to inconsistent, erratic parenting. In addition, the effects of gestational substance use may adversely effect the fetal development. The parent's capacity to look after the infant when abstaining may not be in question, but the unpredictable pattern of care-giving is not comprehensible to an infant and results in insecure attachment patterns.

Adolescent caregivers have been a focus for researchers in understanding issues of attachment and parenting practices (East et al., 1994; McAnarney & Lawrence, 1986; Teberg et al., 1983)

A full literature review of parental psychopathology is beyond the scope of this review. Examples are chosen that are relevant to mainstream and prominent Canadian cultural groups.

Relationship development begins with the core/primary relationships upon which increasingly more complex relationships are built - affective development, cognitive development, social problem solving, peer relationships and 'conscious formation' (the development of morals and ethics). Parenting practices influence this hierarchy of development, and in turn these practices are influenced by social, cultural practices and beliefs (see diagram 1). Of critical importance is the understanding that the core/primary relationships are affected by a combination of attachment and parenting practices.

Parenting styles or care-giving practices can be reviewed in a variety of ways. The key factors that influence 'good enough' parenting will inevitably have an influence on attachment relationships. The factors such as parental intuition, parental attitudes, attributions and beliefs, learned parenting skills, accepted cultural and societal parenting norms, family factors, and environmental factors such as extended family support, poverty or unemployment - are the most influential ones. Each of these, or all collectively, can be considered from a cross-cultural perspective.

There are many definitions of 'culture', the following two definitions, however, reflect our understanding of the term. Culture is the "knowledge, experience, beliefs, values, attitudes, meanings, hierarchies, religion, notions of time, roles, spatial relations, concepts of the universe, and material objects and possessions acquired by a group of people in the course of generations through individual and group striving" (Samovar and Porter, 1994). Anderson and Fenichel (1989) write about culture being a framework that guides and bounds life practices - not a rigidly prescribed set of behaviours or characteristics, but rather a framework through which actions are filtered or checked as individuals go about daily life. These cultural frameworks are constantly evolving and being reworked.

When the cultural aspects of immigrants' parenting are taken into account the issues to be considered are complex. In most cultures there is some change from one generation to another in parenting styles, often as a result of global changes in society and the family environment (e.g. single parenting, dual family parenting, acceptance of assisted parenting from extra-familial persons, inter-racial adoptions, parenting by same sex couples, use of surrogate mothers). These changes may accelerate in a new country.

There is an emerging scholarly interest in cross-cultural aspects of attachment behaviours. This interest is triggered by the increased global movement between countries and the increasing diversity of immigrants settling in countries like Canada. Many complex attachment behaviours and styles have become evident in studies observing infant-caregiver relationships. These studies are complex for a number of reasons. The concept of uniformity of attitude, beliefs and practices in any given culture is challenged by the fact that all cultures are dynamic. There is always an influx of new ideas. Even in countries of origin where certain cultures are predominant, there may not be a consistent and uniform pattern of parenting or attachment.

The questions that then arise are: In what ways do cultural parenting patterns change in Canada where many cultures live side-by-side? If ethnic minorities in Canada retain certain attitudes, beliefs, values and practices from their native culture, what exactly will they retain? How do changes in family networks and situations affect these practices?

Unfortunately, studies measuring the influence of culture-specific parenting practices, attitudes or beliefs on attachment formulation, are limited in number and scope.

The following diagram attempts to summarize from the literature the ways in which socio-cultural norms and parenting practices affect attachment relationships. The diagram offers a schematic framework for exploring how the complex interplay of cultural values, beliefs, parenting practices and other factors influence attachment and relationship development. It shows the primary relationship as the building block for the child's further development in affective and cognitive development spheres, for social problem solving, for the creation of peer relationships, and for conscious formation.

The mother-infant relationship does not exist in a vacuum. In any given culture this relationship is bound by accepted parenting practices and socio-cultural influences. The focus of this section of the paper is on how social and cultural aspects from non-dominant cultures continue to effect parenting practices, which in turn influence core or primary relationships.

In developing a cross-cultural framework or approach it is important to identify similar and differing values, beliefs, and parenting practices between and within different cultural groups. Current work in attachment theory, focusing on the development of the core/primary parent-child relationship, is useful in understanding 'good enough' parenting practices from a cultural perspective. This perspective can draw from cultural influences seen within the country of origin as well as the way cultural influences are expressed within another dominant culture over time, and for new immigrant or refugee families.

A number of cross-cultural studies exploring differences and similarities in attachment related parenting practices are reported in the literature and are noted in the reference section. Unfortunately, it is not clear how generalizable these findings are to the study of attachment practices of different cultures in Canada. However, the studies may provide some insights that are useful in developing hypotheses for cross-cultural studies on attachment in Canada. Some examples include:

A cross-cultural study of 409 infant-mother dyads (38 in Japan, 100 in Taiwan, and 271 in the United States) by Wang (1995) to compare the amount and type of interaction time found significant differences among the three cultural groups in the following variables: proximity, clothing, soothing, playing, reading, holding and behaviour toward the child when sleeping.

Bornstein and colleagues (1998) investigated and compared ideas about parenting in Argentine, Belgian, French, Israeli, Italian, Japanese and U.S. mothers of 20 month-old children. Mothers evaluated their competence, satisfaction, investment, and role balance is parenting and rated attributions of successes and failures in seven parenting tasks to their own ability, effort or mood to the difficulty of the task, or to child behaviour. Few cross-cultural similarities emerged. Parents' self-evaluations and attributions help to explain how and why parents parent and provide insight into the broader cultural contexts of children's development.

Fernald and Morikawa (1993) explored the universal features and cultural variation between American and Japanese mothers' speech to infants at 6, 12 and 19 month in a cross-cultural study of 60 dyads observed playing at home. Mothers' speech in both cultures shared characteristics such as linguistic simplification, frequent repetition, and adjustments over the ages. The researchers found cultural differences in interactional style and beliefs about child rearing influenced the structure and content of speech to infants. An example is that American mothers labeled objects more frequently and consistently than Japanese mothers, whereas Japanese mothers used the objects to engage infants in social routines more often than American mothers did. Minami et al. (1995) looked at differences in narrative patterns between Japanese and American families.

Cheung & Liu (1997) developed and tested a model to explain the reciprocal relationship between parental distress and children's behavioural adjustment problems and the effects of parent behaviour, acceptance and social support or pressure in single parent Hong Kong families. They found the effect of parental distress on acceptance of their child was not significant.

Kisilevsky and colleagues (1998) from Queen's University School of Nursing, conducted studies in China with forty 3-6 month-old infants and compared the results to previous studies of Canadian infants to examine cross-cultural differences using the 'still face' method. Although Chinese infants took longer to begin to smile in response to interaction with their mother, and mothers behaved somewhat differently in the interaction, the infants' response was similar for both cultures.

In a study of the crying pattern of 160 Korean infants between the ages 1 to 6 months, and comparing the results with Western studies, Lee (1994) found the duration of crying by Korean infants was shorter and the time held and/or in close contact with mothers longer. Colic was not seen in the Korean study.

Kong et al. (1988), from the National University of Singapore, examined child-rearing practices of Chinese parents and their relationship to behavioural problems in a sample of 401 toddlers. Although consistent with cultural expectations, both low child-rearing involvement of fathers and punitive types of discipline were significantly related to the identified behaviour problems of toddlers.

Chen et al. (1998) from the University of Western Ontario studied behaviour inhibition in Chinese and Canadian toddlers and the child-rearing attitudes of their mothers. They concluded that Chinese toddlers were significantly more inhibited than Canadian toddlers. They found that inhibition was positively associated with Chinese mother's warm and accepting attitudes but negatively associated with the mother's acceptance in Canada suggesting different adaptational meanings of behaviour inhibition across the two cultures.

Odebiyi (1985) reported on the different child-rearing practices among educated and non-educated nursing mothers in Ile-Ife, Nigeria. Following four years of fieldwork, Riesman (1983) differentiates between child-rearing practices and parental practices in examining character formation between two communities (the Fulbe of the Upper Volta, and their ex-slaves the Riimaaybe). Child-rearing practices were seen to be identical in both communities and not related to the development of different personality types.

Studies reviewed for other cultures include: Malay (Banks, 1989), Turkish (Bengi-Arslan et al, 1997), Pakistani (Burton-Jeangros, 1995), African (Campinha-Bacote, 1991; Chase-Lansdale et al, 1994; Skuy et al, 1997; Wakschlag et al, 1996; Wolfe & Ikeogu, 1996), Chinese (Chao, 1983,1994), Mexican (Corral-Verdugo et al, 1995; Fox & Solis-Camara, 1997), Haitian/Cuban (DeSantis & Thomas, 1994), Guayanese (DeYoung & Zigler, 1994), Egyptian (Wachs et al, 1993), Greek (Diareme et al, 1997), British (Field & Pawlby, 1980), Israeli (Goshen-Gottstein, 1980; Oppenheim, 1998), Sudan (Grotberg et al, 1987), Puerto Rican (Harwood, 1992; 1996), Hispanic (Lequerica & Hermosa, 1995; Schachter et al, 1989), Inuit (MacDonald-Clark & Boffman, 1995), N.American Aboriginal (Phillips & Lobar, 1990; Seideman et al, 1994 ), Palestinian (Merizian, 1991), Indian (Sharma & LeVine, 1998), and more general cultural factors (Choi, 1986; Fernand et al, 1989; Levinson et al, 1984; McKenna et al, 1993; Nihira et al, 1994; Nicci, 1997; Pfeiffer & Aylward, 1990; Reyes et al, 1991; Roe & Drivas, 1993; Roll, 1998; Shand, 1981; Van Der Zwaard, 1992; Wasserman et al., 1990; Sameroff et al, 1982; Laroche, 1996).

The dilemmas with this literature are mentioned in several studies:

1) There is a lack of validation of a core set of measurement tools and methods. Drawing inferences from the wide variety of within cultures and cross-cultural studies of parenting practices, attitudes or beliefs, and the influence on attachment relationships is therefore problematic.

2) The majority of measures have been developed for Euro-American parent and child studies and may or may not be valid for other cultural groups (Judith & Solomon, 1999; De Wolff & van IJzendoorn, 1997; Nugent, Lester, & Brazelton, 1991; Akaragian & Dewa, 1992; Hayes, 1996; Stevenson-Hinde, 1998).

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The largest ethno-cultural groups in Canada, based on the 1996 Canadian population census [3], are as follows:

a) The 'pre-dominant' Canadian cultural group - i.e. the mix of early immigrant Western European/British cultures which form the population majority, now primarily English and French-speaking;

b) The primary ethno-cultural groups - Chinese, South Asian [4] and Blacks [5] represent 60% of the national 'visible minority' population of 3.2 million persons;

c) The First Nations population - approximately 1 million families of Aboriginal ancestry live in Canada;

d) Other ethno-cultural groups, each representing at least two to eight percent of the 'visible minority' population of just under 1 million, are Arab/West Asian [6], Filipino, Latin American, Southeast Asian [7], Japanese, and Korean.

Cultural values are the core conceptions of what is desirable within the individual and the larger society of a given group of peoples (Gollnick & Chinn, 1990); they are a major factor in contributing to a sense of identity and characteristic ways of perceiving, thinking, feeling, and behaving. An often-cited cultural value for North Americans, for example, is the importance of individualism, while in Africa, Asia, Latin America, and the Pacific, the collective is more important than the individual (Triandis, Brislin, & Hui, 1988).

Without mentioning acculturation, the dynamic nature of any culture cannot be fully appreciated.
Acculturation "involves the conflict-ridden, decision-making process in which an immigrant trades off his or her indigenous attitudes, values, and behaviours for those of the host group, until he or she achieves a mixture of old and new that is deemed optimal" (Salgado de Snyder, 1987). Exposure to school or employment for some members of the family may result in uneven acculturation levels among other family members and create transitional stress. Uncovering how immigration and acculturation influence attachment is a key challenge for the Women's Health Centre.

This review of the literature on child-parent/caregiver attachment across cultures shows that there is an extensive literature on attachment in general and many studies that relate to different cultures and ethno-cultural groups. However, it is not clear whether the results of any of these studies are generalizable to a Canadian context.

There are two fundamental methodological dilemmas or problems evident in the literature on attachment:

1) There is a lack of validation of a core set of measurement tools and methods and much of the research has been conducted in artificial settings. Making inferences from the wide variety of within cultures and cross-cultural studies of parenting practices, attitudes or beliefs, and the influence on attachment relationships is, therefore, problematic.

2) As many studies note, the majority of measures have been developed for Euro-American parent and child studies and may or may not be valid for other cultural groups (Judith & Solomon, 1999; De Wolff & van IJzendoorn, 1997; Nugent, Lester, & Brazelton, 1991; Akaragian & Dewa, 1992; Hayes, 1996; Stevenson-Hinde, 1998).
For all areas of research and theory development, it is important to recognize that what is, and what is not, measured, observed and studied is dependent upon the 'lens' through which an individual, and/or a discipline sees the world, and their particular area of study. The same principle applies to those who interpret or review the collective body of information generated by any set of studies. Politics, philosophy, gender, societal and cultural norms can all influence researchers and the research process in obvious and subtle ways. Whether funding is available for certain types of research is also a key factor. So too is the level of cultural competence associated with any research or review in cross-cultural fields of investigation.

The majority of work on attachment theory, measurement development, and practice has been done through the cultural lens of researchers from the United States or Europe and through the disciplinary lens of Psychiatry, Psychology and Paediatrics. It is impossible to assess the varying effects of these different lenses, particularly in research done with other cultures. While acknowledging the value of the work that has been done in other cultures than North America, it is, nonetheless, important to be cautious about its application.

Major gaps are evident in the literature. There is, for example, limited discussion in the literature relevant to this review about the potential influence on attachment of the gender of children, the education and social status/income of parents, the status of women in a society, families with multiple caregivers, families with more than one infant/small child, the locale, and the changing definition of the family. The concern in the literature about using measurement instruments developed from observations on Euro-American infants and families with infants and families from other cultures is unresolved. However, it is only in the last ten years that attachment theory has become generally accepted, and attempts are now being made to integrate this learning into a broader understanding of child development and family systems.

This literature review provides an understanding of the primacy of attachment relationships and the essential value of attachment in healthy child development. To understand more fully the ways in which various social and cultural influences effect parenting practices, which in turn influence the quality of the attachment relationship, is of critical importance to the future well-being of all families and communities in Canada. But, clearly much research remains to be done.

In the literature reviewed for this paper on the theory and application of attachment and the attachment-related influence of variations in care-giving practices in different cultures, there was general agreement that secure attachment between a mother and infant is the ideal first relationship. This relationship develops in the first months and years. Feeling secure (feeling loved) and having a safe base to explore from, and return to, are ongoing needs met by the parent/care-giver relationship within all cultures as a child progresses through the early formative years.

One implication of this finding is that in order to facilitate secure attachment, the infant/ child must be able to build on this primary relationship for successful adaptation to living in Canada. Primary relationships exist within social networks but it is likely that those networks that existed in the immigrant parents' childhood are fragmentary or non-existent in Canada. The social protection that they were entitled to in their culture of origin then needs to be recreated in a different way in their new country. Many immigrant families re-create this social support by utilizing available formal and informal support systems to replace their absent families and social networks.

The literature suggests that beliefs and attitudes towards parenting change little, but that overt parenting practices begin to conform to the accepted norms of the mainstream culture.

In Canada, long- time residents and recent immigrants can choose to adopt the values of the dominant or mainstream culture partially or fully. They also require the opportunity to practice and share intuitive parenting skills or learned parenting skills of the countries/cultures of their origin. However, cultural values, and variations in family and parenting practices between and within cultural groups, have the potential to influence attachment in positive or negative ways.

Besides the fundamental methodological problems and the major gaps in the literature, the existing literature on attachment leaves us with many other unanswered technical questions. For example, there is no straightforward answer to questions such as: Does the secure attachment classification capture 'felt security'? Secure attachment relationships are not necessarily 'secure' from day one throughout childhood. What is a healthy balance? What are the critical periods, and are they different between cultures

With many new immigrants from diverse cultures entering Canada annually, an infant's parenting has important future implications for the well-being of all individuals, communities and the whole country.

Considerations for the future include:

1) Given that Canadians value equality of opportunity for all, all children in Canada need to be able to function optimally in physical, psychological and cognitive domains

2) There may be much to be learned from adaptive secure dyads who have brought to Canada healthy ways of interacting with their infant that are not yet popularized in North American society.

3) Learned ways may not be adaptive to a new cultural milieu or changing times.

4) Today's infants are the decision-makers of our future society. There is considerable speculation and concern in the literature about the number of 'avoidant' citizens in North America. Preventing rather than adopting some patterns of mainstream attachment may, therefore, also seem an appropriate approach.

5) Critical periods of change in the sensitivity responsiveness and or continuity of the care-giving from an infant's primary attachment figure (usually mother) may differ between cultural groups. These critical periods can cause stress in an infant's felt security. Much remains to be learned from cross-cultural practices used to sustain an infant's sense of love and safety during these periods.

The two principal researchers for this paper were Dr Pratibha Reebye and Susan Ross:

Dr. Pratibha Reebye is a psychiatrist who works with the Infant Mental Health Clinic at BC Children's Hospital in Vancouver. She is a consultant for the BC Ministry for Children and Families and teaches courses on attachment at the University of British Columbia. Dr. Reebye is of East Indian descent. She spent her early years in India and Mauritius and grew up in Canada. With her three-generation household, and siblings living in other countries around the world, she has experienced first hand many of the cross-cultural issues that are background to this paper.

Susan Ross is a fourth generation Canadian of British ancestry with western pioneer roots, and a background in nutrition, healthcare and epidemiology.

Kathleen Jamieson, SPARC Program Director, who edited this review, came to Canada as an adult, having lived and worked in several other countries. She has a background in sociology, anthropology and social policy research. All three of the researchers are mothers and/or grandmothers.

Jason M. Clark, a graduate student in Psychology and Social Work, provided technical and editing assistance.