According to the MedlinePlus Encyclopedia, the complete name of this
disorder is "Reactive attachment disorder of infancy or early
childhood". I am first giving you some links to background
information, then some pages that discuss ongoing research and finally
citations and abstracts to articles on this disorder
MedlinePlus Medical Encyclopedia: Reactive attachment disorder of
infancy or early childhood
Reactive attachment disorder is a disturbance of social interaction
caused by neglect of a child's basic physical and emotional needs,
particularly during infancy.
Babies placed in orphanages at birth and raised by multiple caretakers
without primary parent-figures can also develop this disorder, even if
physical care was adequate.
Causes, incidence, and risk factors
Reactive attachment disorder is caused by neglect of an infant's needs
for physical safety, food, touching, and emotional bonds with a
primary and/or secondary caretaker.
The risk of neglect to the infant or child is increased with parental
isolation, lack of parenting skills, teen parents, or a caregiver who
is mentally retarded. A frequent change in caregivers (e.g., occuring
in orphanages or foster care) is another cause of reactive attachment
Children adopted from foreign orphanages are commonly affected,
particularly if they were removed from their birth parents during the
first weeks of life."
American Academy of Child & Adolescent Psychiatry: Reactive Attachment Disorder
?Reactive Attachment Disorder is a complex psychiatric illness that
can affect young children. It is characterized by serious problems in
emotional attachments to others and usually presents by age 5. A
parent, daycare provider or physician may notice that a child has
problems with emotional attachment by their first birthday. Often, a
parent brings an infant or very young child to the doctor with one or
more of the following concerns:
- severe colic and/or feeding difficulties
- failure to gain weight
- detached and unresponsive behavior
- difficulty being comforted
- preoccupied and/or defiant behavior
- inhibition or hesitancy in social interactions
Some children with Reactive Attachment Disorder may also be overly or
inappropriately social or familiar with strangers. The physical,
emotional and social problems associated with Reactive Attachment
Disorder may persist as the child grows older.
The cause of Reactive Attachment Disorder is not known. Most children
with this disorder have had severe problems or disruptions in their
early relationships. Many have been physically or emotionally abused
or neglected. Some have experienced inadequate care in an
institutional setting or other out-of-home placement (for example a
hospital, residential program, foster care or orphanage). Others have
had multiple or traumatic losses or changes in their primary
The RadKid.org website (http://radkid.org) has a lot of information on
this topic ? it is authored by the caregivers of a child with RAD, but
includes a wealth of links, articles, etc. The section recommending
books (http://radkid.org/books.html) is the most comprehensive I?ve
seen. I followed a number of them to get the following sites.
There are several groups involved in the diagnosis and treatment of
RAD. The most commonly known (and most controversial) treatment
involves ?rebirthing.? It doesn?t look like you?re particularly
interested in treatment of this disorder, but you might find the
following publications and information interesting:
ATTACh: Association for Treatment and Training in the Attachment of Children
?Attachment disorder is a treatable condition in which there is a
significant dysfunction in an individual's ability to trust or engage
in reciprocal loving, lasting relationships. An attachment disorder
occurs due to traumatic disruption or other interferences with the
caregiver-child bond during the first years of life. It can distort
future stages of development and impact a person?s cognitive,
neurological, social and emotional functioning. It may also increase
risk of other serious emotional and behavioral problems.?
AttachmentDisorder.net: Symptoms, Causes, and Research
This section of the Attachment Disorder website (which also bears some
looking at) includes not only brief discussions of the symptoms,
causes, and research behind RAD, but also a number of very valuable
links, several of which are included in this answer.
Evergreen Psychotherapy Center, Attachment Treatment & Training
Institute: Attachement Explained
This page has nice, comprehensive discussions of attachment,
attachment disorder, causes, and symptoms. A separate page in this
site has an extensive list of research papers, reports, and books on
attachment disorder, which I urge you to examine for further research.
Family Attachment Counseling Center: Preliminary Outcome Data for the
Intensive Outpatient Program for Children with Attachment Difficulties
at the Family Attachment and Counseling Center of Minnesota
Most children enter the intensive psychotherapy program for children
with attachment disorder with multiple diagnoses. Usually these
diagnoses are based on behavioral criteria. The common thread, and the
underlying cause of the behavior problems, is attachment difficulties.
Due to the trauma (abuse or neglect) suffered very early in life,
these children view the world, and the adults in it, very differently.
Typically, they are skilled manipulators, capable of charming people
and behaving appropriately with professionals and others outside the
family system, skills honed to cope with the traumatic environment of
their early years. In addition, the trauma frequently causes a
freezing of the emotional or developmental level of the child,
resulting in behavior and emotions that are not congruent with their
In our treatment model, attachment issues are the primary focus of
treatment. As the attachment and bond between parents and child
improves changes in behavior follow. Additionally, as attachment
improves the gap between a child's emotional/development level and
chronological age tends to narrow, producing additional improvements
in behavior. Therefore, significant and lasting improvements in
behavior are a sign of improvements in attachment. ?
Outline on the Theory of Attachment
This outline covers Bowlby?s theory of attachment of a child to its
parents, first proposed in the 1950s.
Institute for Attachment & Child Development
?Attachment Disorder results when a serious interruption occurs in the
bonding between mother and child during the child?s first 26 months of
life. Risk factors for developing the disorder include:
- genetic predisposition;
- maternal ambivalence toward pregnancy;
- a traumatic prenatal experience;
- in utero exposure to drugs or alcohol;
- birth trauma;
- sexual + physical abuse;
- sudden separation from the mother due to such factors as a child?s
illness, inconsistent or inadequate day care, chronic maternal
depression, poor parenting skills, neglect or abandonment, frequent
moves and/or placements, including foster care or failed adoptions.
When any of this occurs, the child learns not to trust anyone and has
difficulty forming loving, lasting, intimate relationships. Without
intervening treatment, the child fails to develop a conscience and
acts out without regard to the consequences. His or her behavior may
escalate to the point of violence and/or total alienation from
This site also has a list of resources, but their database appears to
be broken right now.
Here?s the definition from the Diagnostic & Statistical Manual of
Mental Disorders, 4th ed: courtesy of
http://www.behavenet.com/capsules/disorders/reactatt.htm. I am not
copying it here for copyright reasons.
I found these sites by first doing a search of the MedlinePlus
consumer health database (www.medlineplus.gov) for ?attachment
disorder?, then for ?reactive attachment?. This got me the first two
sites. From there I followed links on found pages to get additional
pages. You might also find the following search in Google helpful:
?reactive attachment disorder? research.
If you are looking for more websites with information on RAD, I
suggest you check out the 59 listings in the Open Directory category
for Attachment Disorder:
Finally, here are the citations and abstracts for 30 articles found in
the PubMed MEDLINE database of medical literature (www.pubmed.gov).
These were found using the following search:
?("Reactive Attachment Disorder/diagnosis"[MeSH] OR "Reactive
Attachment Disorder/etiology"[MeSH]) AND English[Lang] AND
For copyright reasons I cannot give you the full articles, but you
should be able to find them in your local university/medical library.
You can also order them from the National Library of Medicine using
the Loansome Doc program (which can be cumbersome to set up but is in
the end cheaper than ordering straight from the publisher):
1: Developmental Psychopathology. 2004 Spring;16(2):293-312.
Attachment in infancy and preschool in low socioeconomic status rural
Appalachian children: stability and change and relations to preschool and
Attachment classifications were obtained from the Strange Situation at 15 months
and at 4 years for a sample of 82 low socioeconomic status rural Appalachian
children. The rate of secure attachment in infancy was 50.5%, and the majority
of insecure infants were disorganized. At 4 years of age 61.2% of children were
secure; early secure relationships were likely to be maintained, and about half
of the insecure infants changed to a secure classification by 4 years. Overall,
there was low but significant stability in attachment at the level of
secure/insecure. Comparisons of (a) children who changed from insecure to secure
with those who were stable insecure and (b) stable secure children with those
who changed from secure to insecure identified contextual, child, and maternal
interaction factors associated with attaining secure attachment. Assessments of
cognitive and socioemotional competence at 4 years and kindergarten age
suggested a protective effect of secure infant attachment but little benefit
from secure preschool attachment.
2: Developmental Psychopathology. 2004 Spring;16(2):253-71.
Forming attachments in foster care: infant attachment behaviors during the first
2 months of placement.
Stovall-McClough KC, Dozier M.
This study investigated the development of attachment relationships in 38 foster
infant-caregiver dyads over the first 2 months of placement. We used the Parent
Attachment Diary to measure foster infants' daily attachment behaviors, the
Adult Attachment Interview to examine foster parents' attachment states of mind,
and Ainsworth's Strange Situation to capture attachment classifications. We
examined differences in diary scales (secure, avoidant, resistant, and
coherence) as they related to age at placement and foster parent attachment,
using hierarchical linear modeling and analyses of variance. The results
indicated infants with autonomous foster parents and infants placed at younger
ages showed higher early and overall levels of secure behavior, less avoidant
behavior, and more coherent attachment strategies compared to infants placed
with nonautonomous foster parents. Changes in attachment behaviors over time
were not predicted by the models; however, there was a significant decrease in
the daily coherence of attachment behaviors associated with Strange Situation
disorganization. Finally, we found significant concordance between the diary and
Strange Situation scales for secure and avoidant behaviors.
3: Dev Psychopathol. 2004 Spring;16(2):231-52.
The course of maternal depressive symptoms and maternal sensitivity as
predictors of attachment security at 36 months.
Campbell SB, Brownell CA, Hungerford A, Spieker SI, Mohan R, Blessing JS.
We examined the course of maternal depressive symptoms and children's attachment
security at 36 months in a large sample of mother-child pairs from 10 sites
across the country participating in the NICHD Study of Early Child Care (N =
1077). Maternal depressive symptoms predicted higher rates of insecure
attachment. Women who reported intermittent symptoms across the first 36 months
had preschoolers who were more likely to be classified as insecure C or D; women
with chronic symptoms were more likely to have preschoolers who were classified
as insecure D. Symptoms reported only during the first 15 months were not
associated with elevated rates of later insecurity. After controlling for
potentially confounding demographic variables, maternal sensitivity (observed at
6, 15, 24, and 36 months) did not meaningfully account for links between
attachment security and patterns of depressive symptoms. However, the course and
timing of maternal depressive symptoms interacted with maternal sensitivity to
predict insecurity. Women with late, intermittent, or chronic symptoms who were
also low in sensitivity were more likely to have preschoolers who were insecure,
in contrast to symptomatic women who were high in sensitivity. These data have
implications for understanding the combined impact of maternal depressive
symptoms and maternal sensitivity on children's socioemotional development.
4: Child Abuse and Neglect. 2004 Aug;28(8):877-88.
Reactive attachment disorder in maltreated toddlers.
Zeanah CH, Scheeringa M, Boris NW, Heller SS, Smyke AT, Trapani J.
OBJECTIVE: To determine if Reactive Attachment Disorder (RAD) can be
reliably identified in maltreated toddlers in foster care, if the two
types of RAD are independent, and to estimate the prevalence of RAD in
these maltreated toddlers. METHODS: Clinicians treating 94 maltreated
toddlers in foster care were interviewed regarding signs of attachment
disorder at intake in an intervention program. RESULTS: Using
categorical and continuous measures, both types of RAD can be reliably
identified in maltreated toddlers. Both continuous scores and
categorical diagnoses indicated that a substantial minority of
maltreated young children do exhibit signs of attachment disorders
sufficient to meet criteria in DSM-IV and ICD-10. The two types were
moderately convergent and at times co-occurred in the same child.
Prevalence of RAD in this high-risk sample was 38-40%.
Indiscriminate/disinhibited RAD was identified in children with and
without an attachment figure. Within this maltreated group, toddlers
whose mothers had a history of psychiatric disturbance were more
likely to be diagnosed with attachment disorders. CONCLUSIONS: RAD may
be reliably identified in maltreated toddlers. Emotionally
withdrawn/inhibited and indiscriminate/disinhibited types of RAD are
not entirely independent.
5: Child Maltreatment. 2004 May;9(2):154-60.
Recognizing and treating uncommon behavioral and emotional disorders in children
and adolescents who have been severely maltreated: reactive attachment disorder.
Haugaard JJ, Hazan C.
This article explores reactive attachment disorder, a disorder that
has been linked to severe and chronic maltreatment. The fundamental
concepts of attachment theory are reviewed briefly, and the two types
of behaviors associated with reactive attachment disorder in children
and adolescents are discussed. Treatment strategies are explored,
including the controversial holding or rebirthing strategies.
6: The Future of Children. 2004 Winter;14(1):30-47.
Safety and stability for foster children: a developmental perspective.
Children in foster care face a challenging journey through childhood. In
addition to the troubling family circumstances that bring them into state care,
they face additional difficulties within the child welfare system that may
further compromise their healthy development. This article discusses the
importance of safety and stability to healthy child development and reviews the
research on the risks associated with maltreatment and the foster care
experience. It finds: Family stability is best viewed as a process of caregiving
practices that, when present, can greatly facilitate healthy child development.
Children in foster care, as a result of exposure to risk factors such as
poverty, maltreatment, and the foster care experience, face multiple threats to
their healthy development, including poor physical health, attachment disorders,
compromised brain functioning, inadequate social skills, and mental health
difficulties. Providing stable and nurturing families can bolster the resilience
of children in care and ameliorate negative impacts on their developmental
outcomes. The author concludes that developmentally-sensitive child welfare
policies and practices designed to promote the well-being of the whole child,
such as ongoing screening and assessment and coordinated systems of care, are
needed to facilitate the healthy development of children in foster care.
7: Journal of Clinical Child & Adolescent Psychology. 2004 Mar;33(1):32-41.
Temperament and attachment disorders.
Zeanah CH, Fox NA.
Reviewed in this article is research on children with reactive attachment
disorder (RAD) who exhibit specific patterns of socially aberrant behavior
resulting from being maltreated or having limited opportunities to form
selective attachments. There are no data explaining why 2 different patterns of
the disorder, an emotionally withdrawn-inhibited pattern and an
indiscriminate-disinhibited pattern, arise from similarly aberrant environments.
In this article, we consider whether temperamental differences might contribute
to the different manifestations of reactive attachment disorder (RAD) in the
context of adverse environments. Although the association between attachment and
temperament has been studied extensively and has been the subject of spirited
debate within the field of child development, there are no extant data on the
influence of temperament on the development of attachment disorders. We consider
possible directions for research efforts designed to explore the biological
underpinnings of the complex phenomenon of attachment disorders.
8: Annals of the New York Academy of Science. 2003 Dec;1008:22-30.
Attachment relationship experiences and childhood psychopathology.
Zeanah CH, Keyes A, Settles L.
Human infants form attachments to their caregivers gradually over the course of
the first year of life. Qualitatively different types of attachments, which can
be identified by the end of the first year, are broadly predictive of subsequent
adaptive outcomes for young children. "Disorganized" patterns of attachment have
the strongest links to concurrent and subsequent psychopathology, and
considerable research has demonstrated both within-the-child and environmental
correlates of disorganized attachment. Clinical disorders of attachment have
been demonstrated to arise under conditions of social deprivation, such as
institutionalization and maltreatment. An emotionally withdrawn/inhibited
pattern and an indiscriminate/disinhibited pattern both have been described.
Although these clinical types arise under similar conditions of environmental
adversity, they tend to have different courses over time. We describe recent
findings and highlight areas of emerging consensus and areas of continuing
controversy regarding both disorganized patterns of attachment and clinical
disorders of attachment in young children.
9: Developmental Psychology. 2004 Jan;40(1):81-94.
Are there biological programming effects for psychological development? Findings
from a study of Romanian adoptees.
Rutter M, O'Connor TG; English and Romanian Adoptees (ERA) Study Team.
Associations between experiences and outcomes could be due to (a) continuation
of adversity or (b) organismic changes, including experience-expectant and
experience-adaptive developmental programming. The adoption into British
families of children who had been reared in profoundly depriving institutions in
Romania presented an opportunity to test mechanisms. Romanian children reared
from infancy in very depriving institutions for periods up to 42 months were
compared with 52 nondeprived UK-born children placed into adoptive families
before the age of 6 months. The results at 6 years of age showed substantial
normal cognitive and social functioning after the provision of family rearing
but also major persistent deficits in a substantial minority. The pattern of
findings suggests some form of early biological programming or neural damage
stemming from institutional deprivation, but the heterogeneity in outcome
indicates that the effects are not deterministic. (c) 2003 APA
10: Attachment & Human Development. 2003 Sep;5(3):297-301.
A clinical/research dialogue on Reactive Attachment Disorder.
Minnis H, Keck G.
11: Journal of Psychology. 2003 Mar;137(2):145-62.
Behavioral and personality characteristics of children with reactive attachment
Hall SE, Geher G.
The authors compared behavioral and personality characteristics of children with
reactive attachment disorder (RAD) with non-RAD children. Participants included
parents of children with RAD (n = 21), parents of non-RAD children (n = 21), and
some of the children (n = 20). The parents completed questionnaires regarding
behavioral and personality characteristics of their children. Parents were also
given the option of asking their children to participate in the study by
completing self-report measures. Several significant findings were obtained.
Children with RAD scored lower on empathy but higher on self-monitoring than
non-RAD children. These differences were especially pronounced based on parent
ratings and suggest that children with RAD may systematically report their
personality traits in overly positive ways. Their scores also indicated
considerably more behavioral problems than scores of the control children.
Previous research has been generally qualitative in nature. The current research
represents some of the first quantitative, empirical work documenting specific
behaviors associated with the diagnosis of RAD. The findings of this study have
implications for better understanding and dealing with reactive attachment
12: Neurotoxicology & Teratology. 2003 Jan-Feb;25(1):23-38.
Level of prenatal cocaine exposure and infant-caregiver attachment behavior.
Beeghly M, Frank DA, Rose-Jacobs R, Cabral H, Tronick E.
The objective of this longitudinal prospective cohort study was to determine
whether level of prenatal cocaine exposure, or the interaction between level of
prenatal cocaine exposure and contextual risk variables, was associated with a
higher rate of infant-caregiver insecure attachment and disorganized attachment,
or with alterations in infant crying or avoidant behavior, after controlling for
prenatal exposure to alcohol, tobacco, and marijuana, the quality of the
proximal caregiving environment, and other covariates. Subjects were 154
full-term 12-month-old infants (64 unexposed, 61 with lighter cocaine exposure,
29 with heavier cocaine exposure) and their primary caregivers from low-income,
urban backgrounds. Exposure status was determined in the maternity ward by
biologic assay (infant meconium and/or maternal or infant urine) and maternal
self-report. At the 12-month follow-up visit, infants were videotaped with their
primary caregiver in Ainsworth's Strange Situation. Reliable coders masked to
exposure status scored videotapes for attachment variables, amount of crying,
and level of avoidance. Contrary to popular perceptions, level of prenatal
cocaine exposure was not significantly related to secure/insecure attachment
status, disorganized attachment status, or rated level of felt security. Foster
care status also was not associated with attachment status. However, heavier
prenatal cocaine exposure, in interaction with maternal contextual variables
(public assistance or multiparity) was associated with alterations in infant
socio-affective behavior, including a higher level of behavioral
disorganization, more avoidance of the caregiver, and less crying.
13: Psychopathology. 2002 Nov-Dec;35(6):347-54.
Attachment and panic disorder.
Pacchierotti C, Bossini L, Castrogiovanni A, Pieraccini F, Soreca I,
A dysfunctional relationship between parents and children can influence
cognitive and emotional development and contribute to the development of
psychiatric disorders, particularly panic disorder (PD). With the aim of
exploring childhood experiences of parenting in PD patients, we compared
subjectively perceived climate and objective recall by administering the
Parental Bonding Instrument and 10 adjunctive items to 22 out-patients and 22
matched controls. Our analysis showed that DSM-III-R-diagnosed PD patients
reported their parents to be significantly less caring than did the control
group, while there was no significant difference in objective recall of
parenting experiences. Copyright 2002 S. Karger AG, Basel
14: Journal of the American Academy of Child & Adolescent Psychiatry.
Attachment disturbances in young children. II: Indiscriminate behavior and
Zeanah CH, Smyke AT, Dumitrescu A.
OBJECTIVE: To assess convergence among three different measures of
indiscriminate behavior and to assess the relationship of indiscriminate
behavior to having an attachment figure and to aggressive behavior among young
children living in a Romanian institution. METHOD: Caregivers in the institution
were interviewed with semistructured interviews regarding the behavior of 61
children with special emphasis on indiscriminate behavior. The study was
conducted in Bucharest, Romania (1999). RESULTS: Substantial convergence among
measures of indiscriminate behavior was demonstrated. Indiscriminate behavior
was common whether or not these children had a preferred attachment figure.
Indiscriminate behavior was independent of aggressive behavior. CONCLUSIONS:
Differing explanations for indiscriminate behavior in young children derive from
differing interpretations of similar findings rather than different findings
with different measures. Indiscriminate behavior was largely independent of
aggression in these institutionalized young children. Indiscriminate behavior
may represent an independent problem rather than a type of reactive attachment
disorder as suggested by DSM-IV criteria.
15: Journal of the American Academy of Child & Adolescent Psychiatry.
Attachment disturbances in young children. I: The continuum of caretaking
Smyke AT, Dumitrescu A, Zeanah CH.
OBJECTIVE: To determine whether signs of disordered attachment were greater in
young children being reared in more socially depriving caregiving environments.
METHOD: Three groups of children were studied by means of structured interviews
with caregivers that were administered over several months in Bucharest,
Romania, in 1999: (1) 32 toddlers living in a typical unit (standard care) in a
large institution in Bucharest; (2) 29 toddlers living in the same institution
on a 'pilot unit" designed to reduce the number of adults caring for each child;
and (3) 33 toddlers living at home who had never been institutionalized.The
presence of attachment disorders and other behavioral problems was assessed by
caregiver/ parent report. RESULTS: Children on the typical unit (standard care)
had significantly more signs of disordered attachment than children in the other
two groups. Both the emotionally withdrawn and the indiscriminately social
pattern of attachment disorder were apparent in these children, but cluster
analysis suggested that mixed patterns are more typical. CONCLUSIONS: The
continuum of caretaking casualty is reflected by increasing signs of disordered
attachment in toddlers living in more socially depriving environments.
16: Child Development. 2002 Jul-Aug;73(4):1166-86.
Shedding further light on the effects of various types and quality of early
child care on infant-mother attachment relationship: the Haifa Study of Early
Sagi A, Koren-Karie N, Gini M, Ziv Y, Joels T.
The Haifa Study of Early Child Care recruited a large-scale sample (N = 758)
that represented the full SES spectrum in Israel, to examine the unique
contribution of various child-care-related correlates to infant attachment.
After controlling for other potential contributing variables--including mother
characteristics, mother-child interaction, mother-father relationship, infant
characteristics and development, and the environment--this study found that
center-care, in and of itself, adversely increased the likelihood of infants
developing insecure attachment to their mothers as compared with infants who
were either in maternal care, individual nonparental care with a relative,
individual nonparental care with a paid caregiver, or family day-care. The
results suggest that it is the poor quality of center-care and the high
infant-caregiver ratio that accounted for this increased level of attachment
insecurity among center-care infants.
17: Developmental Psychopathology. 2002 Spring;14(2):293-310.
Infant-mother attachment security, contextual risk, and early development: a
Belsky J, Fearon RM.
In light of evidence that the effects of attachment security on subsequent
development may be contingent on the social context in which the child continues
to develop, we examined the effect of attachment security at age 15 months,
cumulative contextual risk from 1 to 36 months, and the interaction of
attachment and cumulative risk to predict socioemotional and cognitive
linguistic functioning at age 3 years, using data from the National Institute of
Child Health and Human Development Study of Early Child Care. Results indicated
that early attachment predicts both socioemotional development and language
skills, but not cognitive functioning as indexed by a measure of school
readiness, and that the effect of attachment on socioemotional development and
expressive language varied as a function of social-contextual risk.
Insecure-avoidant infants proved most vulnerable to contextual risk, not
children classified as secure or insecure more generally, although in one
instance security did prove protective with respect to the adverse effects of
cumulative contextual risk. Findings are discussed in terms of risk and
resilience and in light of the probabilistic nature of the relation between
early attachment and later development.
18: Developmental Psychopathology. 2002 Spring;14(2):279-91.
Joint attention and disorganized attachment status in infants at risk.
Claussen AH, Mundy PC, Mallik SA, Willoughby JC.
The development of joint attention skills is a major milestone of infancy.
Recent research suggests that the development of these skills may be affected by
disorganized (D) attachment. This hypothesis was examined in a longitudinal
study of attachment and joint attention skill development in a sample of infants
at risk for developmental-behavioral morbidity. The results revealed that
toddlers with D classifications initiated joint attention with an experimenter
significantly less often than did secure, or even other insecure, toddlers.
However, no group differences in the capacity to respond to the joint attention
bids of others were observed in this study. These data suggest that a
disturbance in the tendency to initiate episodes of joint attention with others
may be indicative of early social-cognitive and social-emotional disturbance
among infants affected by disorganized attachment status. Theory and research is
reviewed to suggest that an early impairment in joint attention facility may
make a significant contribution to risk for negative cognitive and emotional
outcomes among these infants.
19: Developmental Psychopathology. 2002 Spring;14(2):253-78.
Mother-infant and father-infant attachment among alcoholic families.
Eiden RD, Edwards EP, Leonard KE.
This study examined the association between fathers' alcoholism and other risk
factors such as parental depression, family conflict, infant temperament, and
parent-infant attachment. The quality of parent-infant interactions was
hypothesized to be a proximal mediator of the associations among alcoholism and
other risk factors and attachment. The participants were 223 families (104
nonalcoholic families and 119 alcoholic families) with 12-month-old infants
recruited through birth records. Infants in families with two parents with
alcohol problem had significantly higher rates of insecure attachment with both
parents. Structural Equations Modeling indicated that the fathers' alcohol
problem was associated with lower paternal sensitivity (higher negative affect,
lower positive engagement, and lower sensitive responding) during father-infant
play interactions, and this in tum was associated with higher risk for infant
attachment insecurity with fathers. The association between the fathers' alcohol
problem and infant attachment security with the mother was mediated by matemal
depression, and matemal alcohol problems and family conflict were associated
with maternal sensitivity during play interactions. These results indicate that
the fathers' alcoholism is associated with higher family risk including the
quality of the parent-infant relationship; infant attachment develops in a
family context; and this context has a significant association with attachment
20: Journal of the American Academy of Psychoanalysis. 2001 Winter;29(4):551-63.
Cluster B personality traits and attachment.
Bender DS, Farber BA, Geller JD.
21: Child and Adolescent Psychiatric Clinics of North America. 2001
Attachment and depression. Implications for family therapy.
Sexson SB, Glanville DN, Kaslow NJ.
The preceding discussion highlights the use of attachment theory in
conceptualizing the interface between normal development and the manifestation
of depression from infancy through adolescence. Additional research is needed to
delineate better the specific nature of the association between attachment
relationships and depression, particularly with regard to factors that mediate
and moderate the link. The extant literature informs family-oriented clinical
interventions with depressed young people with comorbid attachment problems,
with or without a depressed parent. These family interventions are most likely
to be effective if they incorporate developmentally informed conceptualizations
and techniques and are targeted specifically to the problems of depressed youth
and their families. The efficacy of such interventions remains to be determined
through the implementation of treatment efficacy and effectiveness studies.
22: Psychoanal Study Child. 2000;55:145-79.
Little orphan Anastasia. The analysis of an adopted Russian girl.
It is becoming commonplace for analysts to hear about or encounter in their
clinical work adopted children from Korea, China, Eastern Europe, or Russia.
There is wide variation in the orphanage experience from one area to another and
also in the manner in which the transitional phase from orphanage to adoptive
parents is carried out. Not surprisingly, the experience of being an orphan
carries with it lifelong implications and repercussions, particularly in the
area of self/object relations. Some of the problems of being an orphan are
obvious at the time of adoption. Others unfold only in the course of subsequent
development. We are increasingly called upon to assist adoptive families whose
children are struggling amid much pain and confusion with the aftermath of the
threefold experience of becoming an orphan, being raised in an orphanage, and
joining a family of another culture. This essay describes in some detail the
infancy and early childhood of "Little Orphan Anastasia" as she picks through
the emotional rubble of her infancy and samples the embarrassment of rich
nurture in her current life with her adoptive parents, the Carters. This is
followed by a description of the opening phase of her analysis, in which I
sketch some of her attempts to fashion an adapted identity that is more
congruent with her life before and after her adoption.
23: Journal of Psychology. 2001 Jan;135(1):37-51.
Attachment disorders: review and current status.
Developmental research on attachment has flourished in the past 15 years (C. H.
Zeanah, 1996). However, there has been relatively scant empirical investigation
of disorders in attachment. In this article, the pertinent developmental
research on the attachment cycle is delineated and the current status of
disordered attachment is examined. A particular focus is given to the
conceptualization of the most severe form of disordered attachment, Reactive
24: Child Maltreatment. 2000 May;5(2):137-45.
Reactive Attachment Disorder: what we know about the disorder and implications
Hanson RF, Spratt EG.
In recent years, there has been an increase in the number of children diagnosed
with Reactive Attachment Disorder (RAD). There is considerable disagreement
about what this entity actually entails and, in particular, what types of
assessments and interventions to use with these children and families. Children
with a history of maltreatment (i.e., physical, sexual, emotional abuse, and/or
severe neglect) are particularly likely to receive this diagnosis, because the
behavior problems often seen in these children are presumed to stem from the
maladaptive relationships they have had with abusive caregivers. However, many
children are receiving this diagnosis because of behavior problems that clearly
extend beyond the DSM-IV criteria for RAD. Perhaps the most concerning
consequence of the RAD diagnosis is the emergence of novel treatments that lack
a sound theoretical basis or empirical support, and may potentially be
traumatizing and dangerous to the child. Thus, the purpose of this article is to
review and synthesize what is known about RAD and attachment disorders and to
discuss implications for treatment.
25: Journal of the American Psychoanalysis Association.
2000;48(4):1097-127; discussion 1175-87.
Disorganized infant, child, and adult attachment: collapse in behavioral and
Hesse E, Main M.
This presentation focuses on the disorganized/disoriented (Group D) categories
of infant, child, and adult attachment. The infant D category is assigned on the
basis of interruptions and anomalies in organization and orientation observed
during Ainsworth's strange situation procedure. In neurologically normal
low-risk samples, D attachment is not substantially related to descriptions of
infant temperament, and usually appears with respect to only one parent. At six,
former D infants are often found to be role-inverting (D-Controlling) towards
the parent, while drawings and separation-related narratives (D-Fearful) suggest
continuing states of fear and disorganization. In adults, marked lapses in
reasoning and discourse surrounding the discussion of loss or abuse during the
Adult Attachment Interview (AAI) causes a transcript to be assigned to
Unresolved/disorganized (U/d) adult attachment status, which predicts infant D
attachment. Bowlby's theory is extended, with the proposal that certain forms of
frightening parental behavior will arouse contradictory biologically channeled
propensities to approach and to take flight from the parent. Maltreated infants
are therefore highly likely to be disorganized. Also identified are subtler
forms of frightening parental behavior (including dissociative behavior and
anomalous forms of frightened behavior) that appear to lead to infant
disorganization. This suggests that infant D attachment may at times represent a
second-generation effect of the parent's own continuing unresolved responses to
trauma. Infant D attachment predicts disruptive/aggressive and dissociative
disorders in childhood and adolescence, while U/d adult attachment appears
frequently in psychiatric and criminal populations. Clinical implications are
26: Molecular Psychiatry. 2000 Nov;5(6):633-7.
Dopamine D4 receptor (DRD4) gene polymorphism is associated with attachment
disorganization in infants.
Lakatos K, Toth I, Nemoda Z, Ney K, Sasvari-Szekely M, Gervai J.
About 15% of one-year-old infants in non-clinical, low-risk and up to 80% in
high-risk (eg maltreated) populations show extensive disorganized attachment
behavior(1,2) in the Strange Situation Test.(3) It has also been reported that
disorganization of early attachment is a major risk factor for the development
of childhood behavior problems.(4) The collapse of organized attachment strategy
has been explained primarily by inappropriate caregiving, but recently, the
contribution of child factors such as neurological impairments and neonatal
behavioral organization(6) has also been suggested. Here we report an
association between the DRD4 III exon 48-bp repeat polymorphism and attachment
disorganization. Attachment behavior of 90 infants was tested in the Strange
Situation and they were independently genotyped for the number of the 48-bp
repeats by polymerase chain reaction (PCR). The 7-repeat allele was represented
with a significantly higher frequency in infants classified as disorganized
compared to non-disorganized infants: 12 of 17 (71%) vs 21 of 73 (29%) had at
least one 7-repeat allele (chi2 = 8.66, df = 1, P < 0.005). The estimated
relative risk for disorganized attachment among children carrying the 7-repeat
allele was 4.15. We suggest that, in non-clinical, low-social-risk populations,
having a 7-repeat allele predisposes infants to attachment disorganization.
27: Journal of Developmental and Behavioral Pediatrics. 2000 Jun;21(3):230-6.
Disturbances of attachment in young children adopted from institutions.
In this article, the author describes a discrepancy between popular media
accounts of reactive attachment disorder (RAD) and its clinical and scientific
description. The literature on serious disturbances of attachment in children
adopted out of institutions is reviewed. The author concludes that children
adopted from institutions are at dramatically increased risk for disturbances,
although the majority of such children do not demonstrate problems. Both the
duration of deprivation and the postinstitutional caregiving environment seem to
be importantly related to outcome. Inhibited/withdrawn RAD is exceedingly
uncommon in children adopted from institutions (at least after 1 or more years),
but disinhibited/indiscriminate RAD is quite persistent. Long after children
become attached to adoptive parents, a number of them continue to exhibit
indiscriminate sociability. Three explanations for this divergence of recovery
curves are considered. It is likely that future systematic studies will
illuminate many areas that are unclear at this time.
28: Journal of the American Academy of Adolescent & Child Psychiatry.
Attachment disorder behavior following early severe deprivation: extension and
longitudinal follow-up. English and Romanian Adoptees Study Team.
O'Connor TG, Rutter M.
OBJECTIVE: To examine attachment disturbances and disorder in a sample of
children adopted into the U.K. following severe early privation and in a
comparison sample of nondeprived, within-country, early-placed adoptees. METHOD:
The subjects, 165 children adopted from Romania and 52 adoptees from the U.K.,
were assessed at age 6 years; longitudinal data (at ages 4 and 6 years) were
available on the 111 Romanian adoptees placed in U.K. homes before 24 months of
age and on all U.K. adoptees. Information on attachment disorder was derived
from a semistructured interview with the parent; in addition, data on children's
cognitive and social development were assessed using standardized assessments.
RESULTS: Analyses revealed a close association between duration of deprivation
and severity of attachment disorder behaviors. In addition, attachment disorder
behaviors were correlated with attentional and conduct problems and cognitive
level but nonetheless appeared to index a distinct set of symptoms/behaviors.
Finally, there was marked stability in individual differences in attachment
disorder behaviors and little evidence of a mean decrease over this 2-year
period. CONCLUSIONS: The findings offer construct validation for the attachment
disorder construct and highlight clinical and conceptual questions that require
29: Journal of Consulting & Clinical Psychology. 1999 Feb;67(1):54-63.
Frightening maternal behavior linking unresolved loss and disorganized infant
Schuengel C, Bakermans-Kranenburg MJ, Van IJzendoorn MH.
Main and Hesse's (1990) model in which frightening (threatening, frightened, or
dissociated) parental behavior explains why infants of parents with unresolved
loss develop disorganized attachment relationships was tested. Unresolved loss
using the Adult Attachment Interview in a nonclinical middle-class sample of 85
mothers who had experienced the loss of someone important was assessed.
Disorganized attachment was examined in the Strange Situation. Parental behavior
was recorded during 22-hr home visits. The model applied to mothers with
currently insecure attachment representations. Secure mothers with unresolved
loss displayed less frightening behavior than other mothers, and unresolved loss
in secure mothers did not predict disorganized attachment of their infants.
Frightening behavior predicted infant disorganized attachment irrespective of
30: Current Opinion in Pediatrics. 1998 Aug;10(4):365-8.
Clinical disturbances of attachment in infancy and early childhood.
Boris NW, Zeanah CH.
The development of the attachment behavioral system in infancy has been the
focus of a wide range of research in the past 30 years. The clinical
significance of disturbances in this area of development is currently a major
focus for this research. Research on patterns of attachment in infancy has
informed understanding of the development of psychopathology in later childhood;
insecure-disorganized attachment is recognized as an important risk factor in
this regard. The clinical features of reactive attachment disorder in early
childhood are also becoming more clear. Finally, knowledge about the
intersection between attachment and various risk conditions is growing and
should inform clinical judgement about infants and young children requiring
intervention. Primary care physicians can use these findings to identify
children in need of intervention.
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