Reactive attachment disorder
|Reactive attachment disorder|
Children need sensitive and responsive caregivers to develop secure attachments. RAD arises from a failure to form normal attachments to primary caregivers in early childhood.
|Classification and external resources|
Reactive attachment disorder (RAD) is described in clinical literature as a severe and relatively uncommon disorder that can affect children. RAD is characterized by markedly disturbed and developmentally inappropriate ways of relating socially in most contexts. It can take the form of a persistent failure to initiate or respond to most social interactions in a developmentally appropriate way—known as the "inhibited form"—or can present itself as indiscriminate sociability, such as excessive familiarity with relative strangers—known as the "disinhibited form". The term is used in both the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD-10) and in the DSM-IV-TR, the revised fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM). In ICD-10, the inhibited form is called RAD, and the disinhibited form is called "disinhibited attachment disorder", or "DAD". In the DSM, both forms are called RAD; for ease of reference, this article will follow that convention and refer to both forms as reactive attachment disorder.
DSM-V, the fifth revised edition published in 2013, separates RAD into two separate disorders: Reactive Attachment Disorder (previously referred to as the "inhibited" form), and Social Engagement Disorder.
RAD arises from a failure to form normal attachments to primary caregivers in early childhood. Such a failure could result from severe early experiences of neglect, abuse, abrupt separation from caregivers between the ages of six months and three years, frequent change of caregivers, or a lack of caregiver responsiveness to a child's communicative efforts. Not all, or even a majority of such experiences, result in the disorder. It is differentiated from pervasive developmental disorder or developmental delay and from possibly comorbid conditions such as intellectual disability, all of which can affect attachment behavior. The criteria for a diagnosis of a reactive attachment disorder are very different from the criteria used in assessment or categorization of attachment styles such as insecure or disorganized attachment.
Children with RAD are presumed to have grossly disturbed internal working models of relationships which may lead to interpersonal and behavioral difficulties in later life. There are few studies of long-term effects, and there is a lack of clarity about the presentation of the disorder beyond the age of five years. However, the opening of orphanages in Eastern Europe following the end of the Cold War in the early-1990s provided opportunities for research on infants and toddlers brought up in very deprived conditions. Such research broadened the understanding of the prevalence, causes, mechanism and assessment of disorders of attachment and led to efforts from the late-1990s onwards to develop treatment and prevention programs and better methods of assessment. Mainstream theorists in the field have proposed that a broader range of conditions arising from problems with attachment should be defined beyond current classifications.
Mainstream treatment and prevention programs that target RAD and other problematic early attachment behaviors are based on attachment theory and concentrate on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, placing the child with a different caregiver. Most such strategies are in the process of being evaluated. Mainstream practitioners and theorists have presented significant criticism of the diagnosis and treatment of alleged reactive attachment disorder or attachment disorder within the controversial field commonly known as attachment therapy. Attachment therapy has a scientifically unsupported theoretical base and uses diagnostic criteria or symptom lists unrelated to criteria under ICD-10 or DSM-IV-TR, or to attachment behaviors. A range of treatment approaches are used in attachment therapy, some of which are physically and psychologically coercive, and considered to be antithetical to attachment theory.
Signs and symptoms
Pediatricians are often the first health professionals to assess and raise suspicions of RAD in children with the disorder. The initial presentation varies according to the child's developmental and chronological age, although it always involves a disturbance in social interaction. Infants up to about 18–24 months may present with non-organic failure to thrive and display abnormal responsiveness to stimuli. Laboratory investigations will be unremarkable barring possible findings consistent with malnutrition or dehydration, while serum growth hormone levels will be normal or elevated.
The core feature is severely inappropriate social relating by affected children. This can manifest itself in two ways:
- Indiscriminate and excessive attempts to receive comfort and affection from any available adult, even relative strangers (older children and adolescents may also aim attempts at peers).
- Extreme reluctance to initiate or accept comfort and affection, even from familiar adults, especially when distressed.
While RAD is likely to occur in relation to neglectful and abusive treatment, automatic diagnoses on this basis alone cannot be made, as children can form stable attachments and social relationships despite marked abuse and neglect.
There is as yet no universally accepted diagnostic protocol for reactive attachment disorder. Often a range of measures is used in research and diagnosis. Recognized assessment methods of attachment styles, difficulties or disorders include the Strange Situation Procedure (devised by developmental psychologist Mary Ainsworth), the separation and reunion procedure and the Preschool Assessment of Attachment, the Observational Record of the Caregiving Environment, the Attachment Q-sort and a variety of narrative techniques using stem stories, puppets or pictures. For older children, actual interviews such as the Child Attachment Interview and the Autobiographical Emotional Events Dialogue can be used. Caregivers may also be assessed using procedures such as the Working Model of the Child Interview.
More recent research also uses the Disturbances of Attachment Interview (DAI) developed by Smyke and Zeanah (1999). The DAI is a semi-structured interview designed to be administered by clinicians to caregivers. It covers 12 items, namely "having a discriminated, preferred adult", "seeking comfort when distressed", "responding to comfort when offered", "social and emotional reciprocity", "emotional regulation", "checking back after venturing away from the care giver", "reticence with unfamiliar adults", "willingness to go off with relative strangers", "self-endangering behavior", "excessive clinging", "vigilance/hypercompliance" and "role reversal". This method is designed to pick up not only RAD but also the proposed new alternative categories of disorders of attachment.
Although increasing numbers of childhood mental health problems are being attributed to genetic defects, reactive attachment disorder is by definition based on a problematic history of care and social relationships. Abuse can occur alongside the required factors, but on its own does not explain attachment disorder. It has been suggested that types of temperament, or constitutional response to the environment, may make some individuals susceptible to the stress of unpredictable or hostile relationships with caregivers in the early years. In the absence of available and responsive caregivers it appears that some children are particularly vulnerable to developing attachment disorders.
There is as yet no explanation for why similar abnormal parenting may produce the two distinct forms of the disorder, inhibited and disinhibited. The issue of temperament and its influence on the development of attachment disorders has yet to be resolved. RAD has never been reported in the absence of serious environmental adversity yet outcomes for children raised in the same environment vary widely.
In discussing the neurobiological basis for attachment and trauma symptoms in a seven-year twin study, it has been suggested that the roots of various forms of psychopathology, including RAD, Borderline Personality Disorder (BPD), and post-traumatic stress disorder (PTSD), can be found in disturbances in affect regulation. The subsequent development of higher-order self-regulation is jeopardized and the formation of internal models is affected. Consequently the "templates" in the mind that drive organized behavior in relationships may be impacted. The potential for "re-regulation" (modulation of emotional responses to within the normal range) in the presence of "corrective" experiences (normative caregiving) seems possible.
RAD is one of the least researched and most poorly understood disorders in the DSM. There is little systematic epidemiologic information on RAD, its course is not well established and it appears difficult to diagnose accurately. There is a lack of clarity about the presentation of attachment disorders over the age of five years and difficulty in distinguishing between aspects of attachment disorders, disorganized attachment or the consequences of maltreatment.
According to the American Academy of Child and Adolescent Psychiatry (AACAP), children who exhibit signs of reactive attachment disorder need a comprehensive psychiatric assessment and individualized treatment plan. The signs or symptoms of RAD may also be found in other psychiatric disorders and AACAP advises against giving a child this label or diagnosis without a comprehensive evaluation. Their practice parameter states that the assessment of reactive attachment disorder requires evidence directly obtained from serial observations of the child interacting with his or her primary caregivers and history (as available) of the child’s patterns of attachment behavior with these caregivers. It also requires observations of the child’s behavior with unfamiliar adults and a comprehensive history of the child’s early caregiving environment including, for example, pediatricians, teachers, or caseworkers. In the US, initial evaluations may be conducted by psychologists, psychiatrists, Licensed Marriage and Family Therapists, Licensed Professional Counselors, specialist Licensed Clinical Social Workers or psychiatric nurses.
In the UK, the British Association for Adoption and Fostering (BAAF) advise that only a psychiatrist can diagnose an attachment disorder and that any assessment must include a comprehensive evaluation of the child’s individual and family history.
According to the AACAP Practice Parameter (2005) the question of whether attachment disorders can reliably be diagnosed in older children and adults has not been resolved. Attachment behaviors used for the diagnosis of RAD change markedly with development and defining analogous behaviors in older children is difficult. There are no substantially validated measures of attachment in middle childhood or early adolescence. Assessments of RAD past school age may not be possible at all as by this time children have developed along individual lines to such an extent that early attachment experiences are only one factor among many that determine emotion and behavior.
ICD-10 describes reactive attachment disorder of childhood, known as RAD, and disinhibited attachment disorder, less well known as DAD. DSM-IV-TR also describes reactive attachment disorder of infancy or early childhood divided into two subtypes, inhibited type and disinhibited type, both known as RAD. The two classifications are similar and both include:
- markedly disturbed and developmentally inappropriate social relatedness in most contexts (e.g., the child is avoidant or unresponsive to care when offered by caregivers or is indiscriminately affectionate with strangers);
- the disturbance is not accounted for solely by developmental delay and does not meet the criteria for pervasive developmental disorder;
- onset before five years of age (there is no age specified before five years of age at which RAD cannot be diagnosed);
- a history of significant neglect;
- an implicit lack of identifiable, preferred attachment figure.
ICD-10 states in relation to the inhibited form only that the syndrome probably occurs as a direct result of severe parental neglect, abuse, or serious mishandling. DSM states in relation to both forms there must be a history of "pathogenic care" defined as persistent disregard of the child's basic emotional or physical needs or repeated changes in primary caregiver that prevents the formation of a discriminatory or selective attachment that is presumed to account for the disorder. For this reason, part of the diagnosis is the child's history of care rather than observation of symptoms.
In DSM-IV-TR the inhibited form is described as persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hypervigilant, or highly ambivalent and contradictory responses (e.g., the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting or may exhibit "frozen watchfulness", hypervigilance while keeping an impassive and still demeanour). Such infants do not seek and accept comfort at times of threat, alarm or distress, thus failing to maintain "proximity", an essential element of attachment behavior. The disinhibited form shows diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures). There is therefore a lack of "specificity" of attachment figure, the second basic element of attachment behavior.
The ICD-10 descriptions are comparable save that ICD-10 includes in its description several elements not included in DSM-IV-TR as follows:
- abuse, (psychological or physical), in addition to neglect;
- associated emotional disturbance;
- poor social interaction with peers, aggression towards self and others, misery, and growth failure in some cases (inhibited form only);
- evidence of capacity for social reciprocity and responsiveness as shown by elements of normal social relatedness in interactions with appropriately responsive, non-deviant adults (disinhibited form only).
The first of these is somewhat controversial, being a commission rather than omission and because abuse of itself does not lead to attachment disorder.
The inhibited form has a greater tendency to ameliorate with an appropriate caregiver, while the disinhibited form is more enduring. ICD-10 states the disinhibited form "tends to persist despite marked changes in environmental circumstances". Disinhibited and inhibited are not opposites in terms of attachment disorder and can coexist in the same child. The question of whether there are two subtypes has been raised. The World Health Organization acknowledges that there is uncertainty regarding the diagnostic criteria and the appropriate subdivision. One reviewer has commented on the difficulty of clarifying the core characteristics of and differences between atypical attachment styles and ways of categorizing more severe disorders of attachment.
As of 2010[update], the American Psychiatric Association has proposed to redefine RAD into two distinct disorders in the DSM-V. Corresponding with the inhibited type, one disorder will be reclassified as Reactive Attachment Disorder of Infancy and Early Childhood.
In regards to pathogenic care, or the type of care in which these behaviors are present, a new criterion for Disinhibited Social Engagement Disorder now includes chronically harsh punishment or other types of severely inept caregiving. Relating to pathogenic care for both proposed disorders, a new criterion is rearing in atypical environments such as institutions with high child/caregiver ratios that cut down on opportunities to form attachments with a caregiver.
The diagnostic complexities of RAD mean that careful diagnostic evaluation by a trained mental health expert with particular expertise in differential diagnosis is considered essential. Several other disorders, such as conduct disorders, oppositional defiant disorder, anxiety disorders, post traumatic stress disorder and social phobia share many symptoms and are often comorbid with or confused with RAD, leading to over and under diagnosis. RAD can also be confused with neuropsychiatric disorders such as autism spectrum disorders, pervasive developmental disorder, childhood schizophrenia and some genetic syndromes. Infants with this disorder can be distinguished from those with organic illness by their rapid physical improvement after hospitalization. Children with an autistic disorder are likely to be of normal size and weight and often exhibit a degree of intellectual disability. They are unlikely to improve upon being removed from the home.
In the absence of a standardized diagnosis system, many popular, informal classification systems or checklists, outside the DSM and ICD, were created out of clinical and parental experience within the field known as attachment therapy. These lists are unvalidated and critics state they are inaccurate, too broadly defined or applied by unqualified persons. Many are found on the websites of attachment therapists. Common elements of these lists such as lying, lack of remorse or conscience and cruelty do not form part of the diagnostic criteria under either DSM-IV-TR or ICD-10. Many children are being diagnosed with RAD because of behavioral problems that are outside the criteria. There is an emphasis within attachment therapy on aggressive behavior as a symptom of what they describe as attachment disorder whereas mainstream theorists view these behaviors as comorbid, externalizing behaviors requiring appropriate assessment and treatment rather than attachment disorders. However, knowledge of attachment relationships can contribute to the etiology, maintenance and treatment of externalizing disorders.
The Randolph Attachment Disorder Questionnaire or RADQ is one of the better known of these checklists and is used by attachment therapists and others. The checklist includes 93 discrete behaviours, many of which either overlap with other disorders, like conduct disorder and oppositional defiant disorder, or are not related to attachment difficulties. Critics assert that it is unvalidated and lacks specificity.
Assessing the child's safety is an essential first step that determines whether future intervention can take place in the family unit or whether the child should be removed to a safe situation. Interventions may include psychosocial support services for the family unit (including financial or domestic aid, housing and social work support), psychotherapeutic interventions (including treating parents for mental illness, family therapy, individual therapy), education (including training in basic parenting skills and child development), and monitoring of the child's safety within the family environment
In 2005 the American Academy of Child and Adolescent Psychiatry laid down guidelines (devised by N.W. Boris and C.H. Zeanah) based on its published parameters for the diagnosis and treatment of RAD. Recommendations in the guidelines include the following:
- "The most important intervention for young children diagnosed with reactive attachment disorder and who lack an attachment to a discriminated caregiver is for the clinician to advocate for providing the child with an emotionally available attachment figure."
- "Although the diagnosis of reactive attachment disorder is based on symptoms displayed by the child, assessing the caregiver's attitudes toward and perceptions about the child is important for treatment selection."
- "Children with reactive attachment disorder are presumed to have grossly disturbed internal models for relating to others. After ensuring that the child is in a safe and stable placement, effective attachment treatment must focus on creating positive interactions with caregivers."
- "Children who meet criteria for reactive attachment disorder and who display aggressive and oppositional behavior require adjunctive (additional) treatments."
Mainstream prevention programs and treatment approaches for attachment difficulties or disorders for infants and younger children are based on attachment theory and concentrate on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, placing the child with a different caregiver. These approaches are mostly in the process of being evaluated. The programs invariably include a detailed assessment of the attachment status or caregiving responses of the adult caregiver as attachment is a two-way process involving attachment behavior and caregiver response. Some of these treatment or prevention programs are specifically aimed at foster carers rather than parents, as the attachment behaviors of infants or children with attachment difficulties often do not elicit appropriate caregiver responses. Approaches include "Watch, wait and wonder," manipulation of sensitive responsiveness, modified "Interaction Guidance", "Clinician-Assisted Videofeedback Exposure Sessions (CAVES)", "Preschool Parent Psychotherapy", "Circle of Security", "Attachment and Biobehavioral Catch-up" (ABC), the New Orleans Intervention, and parent–child psychotherapy. Other treatment methods include Developmental, Individual-difference, and Relationship-based therapy (DIR, also referred to as Floor Time) by Stanley Greenspan, although DIR is primarily directed to treatment of pervasive developmental disorders.
The relevance of these approaches to intervention with fostered and adopted children with RAD or older children with significant histories of maltreatment is unclear.
Outside the mainstream programs is a form of treatment generally known as attachment therapy, a subset of techniques (and accompanying diagnosis) for supposed attachment disorders including RAD. In general, these therapies are aimed at adopted or fostered children with a view to creating attachment in these children to their new caregivers. The theoretical base is broadly a combination of regression and catharsis, accompanied by parenting methods which emphasize obedience and parental control. There is considerable criticism of this form of treatment and diagnosis as it is largely unvalidated and has developed outside the scientific mainstream. There is little or no evidence base and techniques vary from non-coercive therapeutic work to more extreme forms of physical, confrontational and coercive techniques, of which the best known are holding therapy, rebirthing, rage-reduction and the Evergreen model. These forms of the therapy may well involve physical restraint, the deliberate provocation of rage and anger in the child by physical and verbal means including deep tissue massage, aversive tickling, enforced eye contact and verbal confrontation, and being pushed to revisit earlier trauma. Critics maintain that these therapies are not within the attachment paradigm, are potentially abusive, and are antithetical to attachment theory. The APSAC Taskforce Report of 2006 notes that many of these therapies concentrate on changing the child rather than the caregiver. Children may be described as "RADs", "Radkids" or "Radishes" and dire predictions may be made as to their supposedly violent futures if they are not treated with attachment therapy. The Mayo Clinic, a well known U.S. non-profit medical practice and medical research group, cautions against consulting with mental health providers who promote these types of methods and offer evidence to support their techniques; to date, this evidence base is not published within reputable medical or mental health journals.
The AACAP guidelines state that children with reactive attachment disorder are presumed to have grossly disturbed internal models for relating to others. However, the course of RAD is not well studied and there have been few efforts to examine symptom patterns over time. The few existing longitudinal studies (dealing with developmental change with age over a period of time) involve only children from poorly run Eastern European institutions.
Findings from the studies of children from Eastern European orphanages indicate that persistence of the inhibited pattern of RAD is rare in children adopted out of institutions into normative care-giving environments. However, there is a close association between duration of deprivation and severity of attachment disorder behaviors. The quality of attachments that these children form with subsequent care-givers may be compromised, but they probably no longer meet criteria for inhibited RAD. The same group of studies suggests that a minority of adopted, institutionalized children exhibit persistent indiscriminate sociability even after more normative caregiving environments are provided. Indiscriminate sociability may persist for years, even among children who subsequently exhibit preferred attachment to their new caregivers. Some exhibit hyperactivity and attention problems as well as difficulties in peer relationships. In the only longitudinal study that has followed children with indiscriminate behavior into adolescence, these children were significantly more likely to exhibit poor peer relationships.
Studies of children who were reared in institutions have suggested that they are inattentive and overactive, no matter what quality of care they received. In one investigation, some institution-reared boys were reported to be inattentive, overactive, and markedly unselective in their social relationships, while girls, foster-reared children, and some institution-reared children were not. It is not yet clear whether these behaviors should be considered as part of disordered attachment.
There is one case study on maltreated twins published in 1999 with a follow-up in 2006. This study assessed the twins between the ages of 19 and 36 months, during which time they suffered multiple moves and placements. The paper explores the similarities, differences and comorbidity of RAD, disorganized attachment and post traumatic stress disorder. The girl showed signs of the inhibited form of RAD while the boy showed signs of the indiscriminate form. It was noted that the diagnosis of RAD ameliorated with better care but symptoms of post traumatic stress disorder and signs of disorganized attachment came and went as the infants progressed through multiple placement changes. At age three, some lasting relationship disturbance was evident.
In the follow-up case study when the twins were aged three and eight years, the lack of longitudinal research on maltreated as opposed to institutionalized children was again highlighted. The girl's symptoms of disorganized attachment had developed into controlling behaviors—a well-documented outcome. The boy still exhibited self-endangering behaviors, not within RAD criteria but possibly within "secure base distortion", (where the child has a preferred familiar caregiver, but the relationship is such that the child cannot use the adult for safety while gradually exploring the environment). At age eight the children were assessed with a variety of measures including those designed to access representational systems, or the child's "internal working models". The twins' symptoms were indicative of different trajectories. The girl showed externalizing symptoms (particularly deceit), contradictory reports of current functioning, chaotic personal narratives, struggles with friendships, and emotional disengagement with her caregiver, resulting in a clinical picture described as "quite concerning". The boy still evidenced self-endangering behaviors as well as avoidance in relationships and emotional expression, separation anxiety and impulsivity and attention difficulties. It was apparent that life stressors had impacted each child differently. The narrative measures used were considered helpful in tracking how early attachment disruption is associated with later expectations about relationships.
One paper using questionnaires found that children aged three to six, diagnosed with RAD, scored lower on empathy but higher on self-monitoring (regulating your behavior to "look good"). These differences were especially pronounced based on ratings by parents, and suggested 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.
Epidemiological data are limited, but reactive attachment disorder appears to be very uncommon. The prevalence of RAD is unclear but it is probably quite rare, other than in populations of children being reared in the most extreme, deprived settings such as some orphanages. There is little systematically gathered epidemiologic information on RAD. A cohort study of 211 Copenhagen children to the age of 18 months found a prevalence of 0.9%.
Attachment disorders tend to occur in a definable set of contexts such as within some types of institutions, in the presence of repeated changes of primary caregiver or of extremely neglectful identifiable primary caregivers who show persistent disregard for the child's basic attachment needs, but not all children raised in these conditions develop an attachment disorder. Studies undertaken on children from Eastern European orphanages from the mid-1990s showed significantly higher levels of both forms of RAD and of insecure patterns of attachment in the institutionalized children, regardless of how long they had been there. It would appear that children in institutions like these are unable to form selective attachments to their caregivers. The difference between the institutionalized children and the control group had lessened in the follow-up study three years later, although the institutionalized children continued to show significantly higher levels of indiscriminate friendliness. However, even among children raised in the most deprived institutional conditions the majority did not show symptoms of this disorder.
A 2002 study of children in residential nurseries in Bucharest, in which the DAI was used, challenged the current DSM and ICD conceptualizations of disordered attachment and showed that inhibited and disinhibited disorders could coexist in the same child.
There are two studies on the incidence of RAD relating to high risk and maltreated children in the U.S. Both used ICD, DSM and the DAI. The first, in 2004, reported that children from the maltreatment sample were significantly more likely to meet criteria for one or more attachment disorders than children from the other groups, however this was mainly the proposed new classification of disrupted attachment disorder rather than the DSM or ICD classified RAD or DAD. The second study, also in 2004, attempted to ascertain the prevalence of RAD and whether it could be reliably identified in maltreated rather than neglected toddlers. Of the 94 maltreated toddlers in foster care, 35% were identified as having ICD RAD and 22% as having ICD DAD, and 38% fulfilled the DSM criteria for RAD. This study found that RAD could be reliably identified and also that the inhibited and disinhibited forms were not independent. However, there are some methodological concerns with this study. A number of the children identified as fulfilling the criteria for RAD did in fact have a preferred attachment figure.
It has been suggested by some within the field of attachment therapy that RAD may be quite prevalent because severe child maltreatment, which is known to increase risk for RAD, is prevalent and because children who are severely abused may exhibit behaviors similar to RAD behaviors. The APSAC Taskforce consider this inference to be flawed and questionable. Severely abused children may exhibit similar behaviors to RAD behaviors but there are several far more common and demonstrably treatable diagnoses which may better account for these difficulties. Further, many children experience severe maltreatment and do not develop clinical disorders. Resilience is a common and normal human characteristic. RAD does not underlie all or even most of the behavioral and emotional problems seen in foster children, adoptive children, or children who are maltreated and rates of child abuse and/or neglect or problem behaviors are not a benchmark for estimates of RAD.
There are few data on comorbid conditions, but there are some conditions that arise in the same circumstances in which RAD arises, such as institutionalization or maltreatment. These are principally developmental delays and language disorders associated with neglect. Conduct disorders, oppositional defiant disorder, anxiety disorders, post-traumatic stress disorder and social phobia share many symptoms and are often comorbid with or confused with RAD. Attachment disorder behaviors amongst institutionalized children are correlated with attentional and conduct problems and cognitive levels but nonetheless appear to index a distinct set of symptoms and behaviors.
Reactive attachment disorder first made its appearance in standard nosologies of psychological disorders in DSM-III, 1980, following an accumulation of evidence on institutionalized children. The criteria included a requirement of onset before the age of 8 months and was equated with failure to thrive. Both these features were dropped in DSM-III-R, 1987. Instead, onset was changed to being within the first 5 years of life and the disorder itself was divided into two subcategories, inhibited and disinhibited. These changes resulted from further research on maltreated and institutionalized children and remain in the current version, DSM-IV, 1994, and its 2000 text revision, DSM-IV-TR, as well as in ICD-10, 1992. Both nosologies focus on young children who are not merely at increased risk for subsequent disorders but are already exhibiting clinical disturbance.
The broad theoretical framework for current versions of RAD is attachment theory, based on work conducted from the 1940s to the 1980s by John Bowlby, Mary Ainsworth and René Spitz. Attachment theory is a framework that employs psychological, ethological and evolutionary concepts to explain social behaviors typical of young children. Attachment theory focuses on the tendency of infants or children to seek proximity to a particular attachment figure (familiar caregiver), in situations of alarm or distress, behavior which appears to have survival value. This is known as a discriminatory or selective attachment. Subsequently, the child begins to use the caregiver as a base of security from which to explore the environment, returning periodically to the familiar person. Attachment is not the same as love and/or affection although they are often associated. Attachment and attachment behaviors tend to develop between the ages of six months and three years. Infants become attached to adults who are sensitive and responsive in social interactions with the infant, and who remain as consistent caregivers for some time. Caregiver responses lead to the development of patterns of attachment, that in turn lead to internal working models which will guide the individual's feelings, thoughts, and expectations in later relationships. For a diagnosis of reactive attachment disorder, the child's history and atypical social behavior must suggest the absence of formation of a discriminatory or selective attachment.
The pathological absence of a discriminatory or selective attachment needs to be differentiated from the existence of attachments with either typical or somewhat atypical behavior patterns, known as styles or patterns. There are four attachment styles ascertained and used within developmental attachment research. These are known as secure, anxious-ambivalent, anxious-avoidant, (all organized) and disorganized. The latter three are characterised as insecure. These are assessed using the Strange Situation Procedure, designed to assess the quality of attachments rather than whether an attachment exists at all.
A securely attached toddler will explore freely while the caregiver is present, engage with strangers, be visibly upset when the caregiver departs, and happy to see the caregiver return. The anxious-ambivalent toddler is anxious of exploration, extremely distressed when the caregiver departs but ambivalent when the caregiver returns. The anxious-avoidant toddler will not explore much, avoid or ignore the parent—showing little emotion when the parent departs or returns—and treat strangers much the same as caregivers with little emotional range shown. The disorganized/disoriented toddler shows a lack of a coherent style or pattern for coping. Evidence suggests this occurs when the caregiving figure is also an object of fear, thus putting the child in an irresolvable situation regarding approach and avoidance. On reunion with the caregiver, these children can look dazed or frightened, freezing in place, backing toward the caregiver or approaching with head sharply averted, or showing other behaviors implying fear of the person who is being sought. It is thought to represent a breakdown of an inchoate attachment strategy and it appears to affect the capacity to regulate emotions.
Although there are a wide range of attachment difficulties within the styles which may result in emotional disturbance and increase the risk of later psychopathologies, particularly the disorganized style, none of the styles constitute a disorder in themselves and none equate to criteria for RAD as such. A disorder in the clinical sense is a condition requiring treatment, as opposed to risk factors for subsequent disorders. Reactive attachment disorder denotes a lack of typical attachment behaviors rather than an attachment style, however problematic that style may be, in that there is an unusual lack of discrimination between familiar and unfamiliar people in both forms of the disorder. Such discrimination does exist as a feature of the social behavior of children with atypical attachment styles. Both DSM-IV and ICD-10 depict the disorder in terms of socially aberrant behavior in general rather than focusing more specifically on attachment behaviors as such. DSM-IV emphasizes a failure to initiate or respond to social interactions across a range of relationships and ICD-10 similarly focuses on contradictory or ambivalent social responses that extend across social situations. The relationship between patterns of attachment in the Strange Situation and RAD is not yet clear.
There is a lack of consensus about the precise meaning of the term "attachment disorder". The term is frequently used both as an alternative to reactive attachment disorder and in discussions about different proposed classifications for disorders of attachment beyond the limitations of the ICD and DSM classifications. It is also used within the field of attachment therapy, as is the term reactive attachment disorder, to describe a range of problematic behaviors not within the ICD or DSM criteria or not related directly to attachment styles or difficulties at all.
Research from the late 1990s indicated there were disorders of attachment not captured by DSM or ICD and showed that RAD could be diagnosed reliably without evidence of pathogenic care, thus illustrating some of the conceptual difficulties with the rigid structure of the current definition of RAD. Research published in 2004 showed that the disinhibited form can endure alongside structured attachment behavior (of any style) towards the child's permanent caregivers.
Some authors have proposed a broader continuum of definitions of attachment disorders ranging from RAD through various attachment difficulties to the more problematic attachment styles. There is as yet no consensus, on this issue but a new set of practice parameters containing three categories of attachment disorder has been proposed by C.H. Zeanah and N. Boris. The first of these is disorder of attachment, in which a young child has no preferred adult caregiver. The proposed category of disordered attachment is parallel to RAD in its inhibited and disinhibited forms, as defined in DSM and ICD. The second category is secure base distortion, where the child has a preferred familiar caregiver, but the relationship is such that the child cannot use the adult for safety while gradually exploring the environment. Such children may endanger themselves, cling to the adult, be excessively compliant, or show role reversals in which they care for or punish the adult. The third type is disrupted attachment. Disrupted attachment is not covered under ICD-10 and DSM criteria, and results from an abrupt separation or loss of a familiar caregiver to whom attachment has developed. This form of categorisation may demonstrate more clinical accuracy overall than the current DSM-IV-TR classification, but further research is required. The practice parameters would also provide the framework for a diagnostic protocol. Most recently, Daniel Schechter and Erica Willheim have shown a relationship between some maternal violence-related posttraumatic stress disorder and secure base distortion (see above) which is characterized by child recklessness, separation anxiety, hypervigilance, and role-reversal.
Some research indicates there may be a significant overlap between behaviors of the inhibited form of RAD or DAD and aspects of disorganized attachment where there is an identified attachment figure.
An ongoing question is whether RAD should be thought of as a disorder of the child's personality or a distortion of the relationship between the child and a specific other person. It has been noted that as attachment disorders are by their very nature relational disorders, they do not fit comfortably into noslogies that characterize the disorder as centered on the person. Work by C.H. Zeanah indicates that atypical attachment-related behaviors may occur with one caregiver but not with another. This is similar to the situation reported for attachment styles, in which a particular parent's frightened expression has been considered as possibly responsible for disorganized/disoriented reunion behavior during the Strange Situation Procedure.
The draft of the proposed DSM-V suggests dividing RAD into two disorders, Reactive Attachment Disorder for the current inhibited form of RAD, and Disinhibited Social Engagement Disorder for what is currently the disinhibited form of RAD, with some alterations in the proposed DSM definition.
- DSM-IV-TR (2000) American Psychiatric Association p. 129.
- Schechter DS, Willheim E (July 2009). "Disturbances of attachment and parental psychopathology in early childhood". Child and Adolescent Psychiatric Clinics of North America 18 (3): 665–86. doi:10.1016/j.chc.2009.03.001. PMC 2690512. PMID 19486844.
- World Health Organisation (1992) International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10). Geneva: World health Organization.
- American Psychiatric Association (2000). "Diagnostic criteria for 313.89 Reactive attachment disorder of infancy or early childhood". Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision (DSM-IV-TR) ed.). United States: AMERICAN PSYCHIATRIC PRESS INC (DC). ISBN 0-89042-025-4.
- Prior & Glaser (2006), pp. 218–219.
- Boris NW, Zeanah CH, Work Group on Quality Issues (2005). "Practice parameter for the assessment and treatment of children and adolescents with reactive attachment disorder of infancy and early childhood" (PDF). J Am Acad Child Adolesc Psychiatry 44 (11): 1206–19. doi:10.1097/01.chi.0000177056.41655.ce. PMID 16239871. Retrieved 25 January 2008.
- Prior & Glaser (2006), p. 228.
- O'Connor TG, Zeanah CH (2003). "Attachment disorders: assessment strategies and treatment approaches". Attach Hum Dev 5 (3): 223–44. doi:10.1080/14616730310001593974. PMID 12944216.
- Prior & Glaser (2006), p. 231.
- O'Connor TG, Nilsen WJ (2005) "Models versus Metaphors in Translating Attachment Theory to the Clinic and Community". In Berlin LJ, Ziv Y, Amaya-Jackson L and Greenberg MT (Eds) Enhancing Early Attachments: Theory, research, intervention, and policy. pp. 313–26. The Guilford Press. Duke series in Child Development and Public Policy. (2005) ISBN 1-59385-470-6.
- Sadock, BJ; Sadock VA (2004). Kaplan & Sadock's Concise Textbook of Clinical Psychiatry. Philadelphia: Lippincott Williams and Wilkins. pp. 570–72. ISBN 0-7817-5033-4.
- Chaffin et al. (2006), p. 80. The APSAC Taskforce Report
- Rutter M (2002). "Nature, nurture, and development: from evangelism through science toward policy and practice". Child Dev 73 (1): 1–21. doi:10.1111/1467-8624.00388. PMID 14717240.
- Ainsworth MD, Blehar M, Waters E, Wall S (1979). Patterns of Attachment: A Psychological Study of the Strange Situation. Lawrence Erlbaum Associates. ISBN 0-89859-461-8
- Main M, Solomon J (1986). "Discovery of an insecure disorganized/disoriented attachment pattern: procedures, findings and implications for the classification of behavior". In Brazelton TB and Yogman M (Eds.) Affective development in infancy, pp. 95–124. Norwood, NJ: Ablex ISBN 0-89391-345-6
- Main M, Solomon J (1990). "Procedures for identifying infants as disorganized/disoriented during the Ainsworth Strange Situation". In Greenberg M, Cicchetti D and Cummings E (Eds.) Attachment in the preschool years: Theory, research and intervention, pp. 121–60. Chicago: University of Chicago Press. ISBN 0-226-30630-5.
- Crittenden PM (1992). "Quality of attachment in the preschool years". Development and Psychopathology 4 (02): 209–41. doi:10.1017/S0954579400000110. Retrieved 6 January 2008.
- National Institute of Child Health and Human Development, D (1996). "Characteristics of infant child care: Factors contributing to positive caregiving". Early Childhood Research Quarterly 11 (3): 269–306(38). doi:10.1016/S0885-2006(96)90009-5.
- Waters E, Deane K (1985). "Defining and assessing individual differences in attachment relationships: Q-methodology and the organization of behavior in infancy and early childhood". In Bretherton I and Waters E (Eds.) Growing pains of attachment theory and research: Monographs of the Society for Research in Child Development 50, Serial No. 209 (1–2), pp. 41–65.
- Zeanah CH, Benoit D (1995). "Clinical applications of a parent perception interview in infant mental health". Child and Adolescent Psychiatric Clinics of North America 43: 539–554.
- Smyke A, Zeanah CH (1999). "Disturbances of Attachment Interview". Available on the Journal of the American Academy of Child and Adolescent Psychiatry website at www.jaacap.com via Article plus. Retrieved on 3 March 2008.
- Mercer (2006), pp. 104–05.
- Prior & Glaser (2006), p. 218.
- Marshall PJ, Fox NA (2005). "Relationship between behavioral reactivity at 4 months and attachment classification at 14 months in a selected sample". Infant Behavior and Development 28 (4): 492–502. doi:10.1016/j.infbeh.2005.06.002.
- Prior & Glaser (2006), p. 219.
- Zeanah CH, Fox NA (2004). "Temperament and attachment disorders". J Clin Child Adolesc Psychol 33 (1): 32–41. doi:10.1207/S15374424JCCP3301_4. PMID 15028539.
- Heller SS, Boris NW, Fuselier SH, Page T, Koren-Karie N, Miron D (2006). "Reactive attachment disorder in maltreated twins follow-up: from 18 months to 8 years". Attach Hum Dev 8 (1): 63–86. doi:10.1080/14616730600585177. PMID 16581624.
- Reactive Attachment Disorder. American Academy of Child & Adolescent Psychiatry, Facts for Families, No. 85; Updated December 2002. Retrieved on 13 February 2008.
- For examples see Reactive Attachment Disorder, DCFS, State of Illinois and DBHS Practice Protocol: Disturbances and Disorders of Attachment (PDF), Arizona Department of Health Services, 2 October 2006. Retrieved on 2008-02-23.
- Attachment Disorders, their Assessment and Intervention/Treatment (PDF). British Association for Adoption and Fostering, Position Statement 4, 2006. Retrieved on 23 February 2008
- Mercer (2006), p. 116.
- Diagnostic and Statistical Manual of Mental Disorders: Text Revision. American Psychiatric Association. 2000. p. 943. ISBN 978-0-89042-025-6.
- Prior & Glaser (2006), pp. 220–21.
- Zeanah CH, Scheeringa M, Boris N, Heller S, Smyke A, Trapani J (August 2004). "Reactive Attachment Disorder in Maltreated Toddlers". Child Abuse & Neglect: the International Journal 28 (8): 877–88. doi:10.1016/j.chiabu.2004.01.010. PMID 15350771.
- Zilberstein, K. (2006). Clarifying core characteristics of attachment disorders. American Journal of Orthopsychiatry, 76, 55-64.
- Proposed Revision Reactive Attachment Disorder, American Psychiatric Association (2012). Retrieved from http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=120
- Hanson RF, Spratt EG (2000). "Reactive Attachment Disorder: what we know about the disorder and implications for treatment". Child Maltreat 5 (2): 137–45. doi:10.1177/1077559500005002005. PMID 11232086.
- Wilson SL (2001). "Attachment disorders: review and current status". J Psychol 135 (1): 37–51. doi:10.1080/00223980109603678. PMID 11235838.
- Chaffin et al. (2006), p. 81. The APSAC Taskforce Report
- Chaffin et al. (2006), pp. 82–83. The APSAC Taskforce Report
- Guttmann-Steinmetz S, Crowell JA (2006). "Attachment and externalizing disorders: a developmental psychopathology perspective". J Am Acad Child Adolesc Psychiatry 45 (4): 440–51. doi:10.1097/01.chi.0000196422.42599.63. PMID 16601649.
- Randolph, Elizabeth Marie. (1996). Randolph Attachment Disorder Questionnaire. Institute for Attachment, Evergreen CO.
- Mercer J (2005). "Coercive restraint therapies: a dangerous alternative mental health intervention". MedGenMed 7 (3): 6. PMC 1681667. PMID 16369232.
- Cappelletty G, Brown M, Shumate S (2005). "Correlates of the Randolph Attachment Disorder Questionnaire (RADQ) in a Sample of Children in Foster Placement". Child and Adolescent Social Work Journal 22 (1): 71–84. doi:10.1007/s10560-005-2556-2.
The findings showed that children in foster care have reported symptoms within the range typical of children not involved in foster care. The conclusion is that the RADQ has limited usefulness due to its lack of specificity with implications for treatment of children in foster care
- Prior & Glaser (2006), p. 231.
- Bakermans-Kranenburg M, van IJzendoorn M, Juffer F (2003). "Less Is More: Meta-Analyses of Sensitivity and Attachment Interventions in Early Childhood" (PDF). Psychological Bulletin 129 (2): 195–215. doi:10.1037/0033-2909.129.2.195. PMID 12696839. Retrieved 2 February 2008.
- Stovall KC, Dozier M (2000). "The development of attachment in new relationships: single subject analyses for 10 foster infants". Dev. Psychopathol. 12 (2): 133–56. doi:10.1017/S0954579400002029. PMID 10847621.
- Cohen N, Muir E, Lojkasek M, Muir R, Parker C, Barwick M, Brown M (1999). "Watch, wait and wonder: testing the effectiveness of a new approach to mother-infant psychotherapy". Infant Mental health Journal 20 (4): 429–51. doi:10.1002/(SICI)1097-0355(199924)20:4<429::AID-IMHJ5>3.0.CO;2-Q.
- van den Boom D (1994). "The influence of temperament and mothering on attachment and exploration: an experimental manipulation of sensitive responsiveness among lower-class mothers with irritable infants". Child Development (Blackwell Publishing) 65 (5): 1457–77. doi:10.2307/1131277. JSTOR 1131277. PMID 7982362.
- van den Boom D (1995). "Do first-year intervention effects endure? Follow-up during toddlerhood of a sample of Dutch irritable infants". Child Dev (Blackwell Publishing) 66 (6): 1798–816. doi:10.2307/1131911. JSTOR 1131911. PMID 8556900.
- Benoit D, Madigan S, Lecce S, Shea B, Goldberg S (2002). "Atypical maternal behaviour toward feeding disordered infants before and after intervention". Infant Mental Health Journal 22 (6): 611–26. doi:10.1002/imhj.1022.
- Schechter DS, Myers MM, Brunelli SA, et al. (September 2006). "Traumatized mothers can change their minds about their toddlers: Understanding how a novel use of videofeedback supports positive change of maternal attributions". Infant Mental Health Journal 27 (5): 429–447. doi:10.1002/imhj.20101. PMC 2078524. PMID 18007960.
- Toth, S; Maughan A; Manly J; Spagnola M; Cicchetti D (2002). "The relative efficacy of two in altering maltreated preschool children's representational models: implications for attachment theory". Development and Psychopathology 14 (4): 877–908. doi:10.1017/S095457940200411X. PMID 12549708.
- Marvin R, Cooper G, Hoffman K, Powell B (April 2002). "The Circle of Security project: Attachment-based intervention with caregiver – pre-school child dyads" (PDF). Attachment & Human Development 4 (1): 107–24. doi:10.1080/14616730252982491. PMID 12065033. Retrieved 2 February 2008.
- Cooper G, Hoffman K, Powell B and Marvin R (2005). "The Circle of Security Intervention; differential diagnosis and differential treatment". In Berlin LJ, Ziv Y, Amaya-Jackson L and Greenberg MT (Eds.) Enhancing Early Attachments: Theory, research, intervention, and policy. pp. 127–51. The Guilford Press. Duke series in Child Development and Public Policy. (2005) ISBN 1-59385-470-6.
- Dozier M, Lindheim O and Ackerman JP (2005) "Attachment and Biobehavioral Catch-Up: An intervention targeting empirically identified needs of foster infants". In Berlin LJ, Ziv Y, Amaya-Jackson L and Greenberg MT (Eds.) Enhancing Early Attachments: Theory, research, intervention, and policy pp. 178–94. Guilford Press. Duke series in Child Development and Public Policy. (2005) ISBN 1-59385-470-6 (pbk)
- Zeanah CH, Larrieu JA (1998). "Intensive intervention for maltreated infants and toddlers in foster care". Child Adolesc Psychiatr Clin N Am 7 (2): 357–71. PMID 9894069.
- Larrieu JA, Zeanah CH (2004). "Treating infant-parent relationships in the context of maltreatment: An integrated, systems approach". In Saner A, McDonagh S and Roesenblaum K (Eds.) Treating parent-infant relationship problems pp. 243–64. New York. Guilford Press. ISBN 1-59385-245-2
- Zeanah CH, Smyke AT (2005) "Building Attachment Relationships Following Maltreatment and Severe Deprivation". In Berlin LJ, Ziv Y, Amaya-Jackson L and Greenberg MT (Eds) Enhancing Early Attachments: Theory, research, intervention, and policy The Guilford Press. Duke series in Child Development and Public Policy. (2005) pp. 195–216. ISBN 1-59385-470-6 (pbk)
- Lieberman AF, Silverman R, Pawl JH (2000). "Infant-parent psychotherapy". In Zeanah CH (Ed.) Handbook of infant mental health (2nd ed.) p. 432. New York: Guilford Press. ISBN 1-59385-171-5
- "Dir/floortime model". Interdisciplinary Council on Developmental & Learning Disorders. 2007. Retrieved 2 February 2008.
- Newman L, Mares S (2007). "Recent advances in the theories of and interventions with attachment disorders". Current Opinion in Psychiatry 20 (4): 343–8. doi:10.1097/YCO.0b013e3281bc0d08. PMID 17551348.
- Chaffin et al. (2006), pp. 79–80. The APSAC Taskforce Report.
- Chaffin et al. (2006), p. 85. The APSAC Taskforce Report
- Chaffin et al. (2006), p. 78–83. The APSAC Taskforce Report.
- Speltz ML (2002). "Description, History and Critique of Corrective Attachment Therapy" (PDF). The APSAC Advisor 14 (3): 4–8. Retrieved 3 March 2008.
- Prior & Glaser (2006), p. 267.
- Chaffin et al. (2006), p.79. The APSAC Taskforce Report.
- "Treatments and drugs". Mayo Clinic Staff.
- O'Connor TG, Rutter M (2000). "Attachment disorder behavior following early severe deprivation: extension and longitudinal follow-up. English and Romanian Adoptees Study Team". J Am Acad Child Adolesc Psychiatry 39 (6): 703–12. doi:10.1097/00004583-200006000-00008. PMID 10846304.
- O'Connor TG, Marvin RS, Rutter M, Olrick JT, Britner PA (2003). "Child-parent attachment following early institutional deprivation". Dev. Psychopathol. 15 (1): 19–38. doi:10.1017/S0954579403000026. PMID 12848433.
- O’Connor TG, Bredenkamp D, Rutter M, & The English and Romanian Adoptees (ERA) Study Team (1999). "Attachment disturbances and disorders in children exposed to early severe deprivation". Infant Mental Health Journal 20: 10–29. doi:10.1002/(SICI)1097-0355(199921)20:1<10::AID-IMHJ2>3.0.CO;2-S.
- Hodges J, Tizard B (1989). "Social and family relationships of ex-institutional adolescents". J Child Psychol Psychiatry 30 (1): 77–97. doi:10.1111/j.1469-7610.1989.tb00770.x. PMID 2925822.
- Roy P, Rutter M, Pickles A (2004). "Institutional care: Associations between overactivity and lack of selectivity in social relationships". Journal of Child Psychology and Psychiatry 45 (4): 866–73. doi:10.1111/j.1469-7610.2004.00278.x. PMID 15056316.
- Hinshaw-Fuselier, Sarah; Boris, Neil W.; Zeanah, Charles H. (1999). "Reactive attachment disorder in maltreated twins". Infant Mental Health Journal 20 (1): 42–59. doi:10.1002/(SICI)1097-0355(199921)20:1<42::AID-IMHJ4>3.0.CO;2-B.
- Hall SE, Geher G (2003). "Behavioral and personality characteristics of children with reactive attachment disorder". J Psychol 137 (2): 145–62. doi:10.1080/00223980309600605. PMID 12735525.
- Skovgaard AM, Houmann T, Christiansen E et al. (2007). "The prevalence of mental health problems in children 1½ years of age – the Copenhagen Child Cohort 2000". J Child Psychol Psychiatry 48 (1): 62–70. doi:10.1111/j.1469-7610.2006.01659.x. PMID 17244271.
- Prior & Glaser (2006), pp. 218–19.
- Chisholm, K; Carter, M; Ames, E; Morison, S (1995). "Attachment Security and indiscriminately friendly behavior in children adopted from Romanian orphanages". Development and Psychopathology 7 (02): 283–94. doi:10.1017/S0954579400006507.
- Smyke AT, Dumitrescu A, Zeanah CH (2002). "Attachment disturbances in young children. I: The continuum of caretaking casualty". J Am Acad Child Adolesc Psychiatry 41 (8): 972–82. doi:10.1097/00004583-200208000-00016. PMID 12162633.
- Zeanah CH, Smyke AT, Koga SF, Carlson E (2005). "Attachment in institutionalized and community children in Romania". Child Dev 76 (5): 1015–28. doi:10.1111/j.1467-8624.2005.00894.x. PMID 16149999.
- Chisholm K (1998). "A three year follow-up of attachment and indiscriminate friendliness in children adopted from Romanian orphanages". Child Dev (Blackwell Publishing) 69 (4): 1092–106. doi:10.2307/1132364. JSTOR 1132364. PMID 9768488.
- Boris NW, Hinshaw-Fuselier SS, Smyke AT, Scheeringa MS, Heller SS, Zeanah CH (2004). "Comparing criteria for attachment disorders: establishing reliability and validity in high-risk samples". J Am Acad Child Adolesc Psychiatry 43 (5): 568–77. doi:10.1097/00004583-200405000-00010. PMID 15100563.
- Prior & Glaser (2006), p. 215.
- DSM-IV American Psychiatric Association 1994, as discussed in Chaffin et al. (2006), p. 81.
- Bonanno GA (2004). "Loss, trauma, and human resilience: Have we underestimated the human capacity to thrive after extremely aversive events?" (PDF). American Psychologist 59 (1): 20–28. doi:10.1037/0003-066X.59.1.20. PMID 14736317. Retrieved 26 January 2008.
- Zeanah CH (1996). "Beyond insecurity: a reconceptualization of attachment disorders of infancy". J Consult Clin Psychol 64 (1): 42–52. doi:10.1037/0022-006X.64.1.42. PMID 8907083.
- Bowlby  (1997 edition) pp. 224–27.
- Bowlby  (1997 edition) pp. 313–17.
- Bretherton I, Munholland KA (1999). "Internal Working Models in Attachment Relationships: A Construct Revisited". In Cassidy J and Shaver PR (Eds.) Handbook of Attachment: Theory, Research and Clinical Applications. pp. 89–111. Guilford Press ISBN 1-57230-087-6.
- Bowlby  (1997 edition) p. 354.
- Van Ijzendoorn M, Bakermans-Kranenburg M (September 2003). "Attachment disorders and disorganized attachment: Similar and different". Attachment & Human Development 5 (3): 313–20(8). doi:10.1080/14616730310001593938. PMID 12944229.
- Thompson RA (2000). "The legacy of early attachments". Child Dev 71 (1): 145–52. doi:10.1111/1467-8624.00128. PMID 10836568.
- O’Connor TG (2002), "Attachment disorders in infancy and childhood". In Rutter M, Taylor E, (Eds.) Child and Adolescent Psychiatry: Modern Approaches (4th ed.) Blackwell Scientific publications. pp. 776-792. ISBN 0-632-01229-3
- Chaffin et al. (2006), p. 77. The APSAC Taskforce Report
- Chaffin et al. (2006), p. 82–83. The APSAC Taskforce Report
- Boris NW, Zeanah CH, Larrieu JA, Scheeringa MS, Heller SS (1 February 1998). "Attachment disorders in infancy and early childhood: a preliminary investigation of diagnostic criteria". Am J Psychiatry 155 (2): 295–97. PMID 9464217. Retrieved 31 January 2008.
- Boris NW, Zeanah CH (1999). "Disturbance and disorders of attachment in infancy: An overview". Infant Mental Health Journal 20: 1–9. doi:10.1002/(SICI)1097-0355(199921)20:1<1::AID-IMHJ1>3.0.CO;2-V.
- Zeanah CH (2000). "Disturbances and disorders of attachment in early childhood". In Zeanah CH (Ed.) Handbook of infant mental health (2nd ed.) pp. 358–62. New York: Guilford Press. ISBN 1-59385-171-5
- Schechter DS, Willheim E (2009). Disturbances of attachment and parental psychopathology in early childhood. Infant and Early Childhood Mental Health Issue. Child and Adolescent Psychiatry Clinics of North America, 18(3), 665-687.
- Greenberg MT (1999). Attachment and Psychopathology in Childhood. In Cassidy J and Shaver PR (Eds.) Handbook of Attachment: Theory, Research and Clinical Applications. pp. 469–96. Guilford Press ISBN 1-57230-087-6
- Main M, Hesse E (1990) "Parents' unresolved traumatic experiences are related to infants' insecure-disorganized/disoriented attachment status: Is frightened or frightening behavior the linking mechanism?" In Greenberg M, Cicchetti D and Cummings E (Eds.) Attachment in the preschool years: Theory, research and intervention, pp. 161–182 Chicago: University of Chicago Press. ISBN 0-226-30630-5.
- DSM-V Proposed Draft. Reactive attachment disorder. American Psychiatric Association. Charles H. Zeanah.
- American Psychiatric Association (1994). DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders. 4th edition. Text Revision Washington, DC: American Psychiatric Association. ISBN 0-89042-025-4
- Bowlby J  (1997). Attachment and Loss: Attachment Vol 1 (Attachment and Loss). Pimlico; New Ed edition ISBN 0-7126-7471-3
- Bowlby J (1973). Attachment and Loss: Separation — Anxiety and Anger v. 2 (International Psycho-Analysis Library). London: Hogarth Press. ISBN 0-7012-0301-3
- Bowlby J (1980). Attachment and Loss: Loss — Sadness and Depression v. 3 (International Psycho-Analysis Library). London: Hogarth Press. ISBN 0-7012-0350-1
- Chaffin M, Hanson R, Saunders BE, et al. (2006). "Report of the APSAC task force on attachment therapy, reactive attachment disorder, and attachment problems". Child Maltreat 11 (1): 76–89. doi:10.1177/1077559505283699. PMID 16382093.
- Mercer J (2006). Understanding Attachment: Parenting, child care and emotional development. Westport, CT: Praeger. ISBN 0-275-98217-3
- Prior V, Glaser D (2006). Understanding Attachment and Attachment Disorders. Theory, Evidence and Practice. Child and Adolescent Mental Health series, RCPRTU, Jessica Kingsley Publishers. ISBN 978-1-84310-245-8 (pbk)