A r t ic le

A R a n d o m iz e d C o n tro lle d Tria l C o m p a rin g F o ste r C a re

a n d In stitu tio n a l C a re fo r C h ild re n
W ith S ig n s o f R e a c tiv e A tta c h m e n t D iso rd e r

Anna T. Smyke, Ph.D. O b je c tiv e : The authors exam ined signs
of em otionally w ithdraw n (inhibited type)
and indiscrim inately social (disinhibited
Charles H. Zeanah, M.D.
type) reactive attachm ent disorder in Ro-
m anian children enrolled in a random -
Mary Margaret Gleason, M.D. ized trial of foster care com pared w ith
institutional care and in a com parison
Stacy S. Drury, M.D., Ph.D. group of never-institutionalized children.
M e th o d : At baseline and w hen children
Nathan A. Fox, Ph.D. w ere ages 30, 42, and 54 m onths and 8
years, care givers w ere interview ed w ith
Charles A. Nelson, Ph.D. the D isturbances of Attachm ent Inter-
view to assess changes in signs of reac-
Donald Guthrie, Ph.D. tive attachm ent disorder in three groups
of children: those receiving care as usual
(including continued institutional care)
(N=68); those placed in foster care after
institutional care (N=68); and those w ho
w ere never institutionalized (N=72). The
im pact of gender, ethnicity, and baseline
cognitive ability w as also exam ined.
R e s u lts : O n the D isturbances of Attach-
m ent Interview, signs of the inhibited
type of reactive attachm ent disorder de-
creased after placem ent in foster care,
and scores w ere indistinguishable from
those of never-institutionalized children
after 30 m onths. Signs of the disinhibited
type w ere highest in the usual care group,
low er in the foster care group, and low est
in the never-institutionalized group. Early
placem ent in foster care (before age 24
m onths) w as associated w ith few er signs
of the disinhibited type. Low er baseline
cognitive ability w as associated w ith m ore
signs of the inhibited type in the usual
care group and m ore signs of the disin-
hibited type in both groups.
C o n c lu s io n s : Signs of the inhibited type
of reactive attachm ent disorder respond-
ed quickly to placem ent in foster care;
signs of the disinhibited type show ed
less robust resolution w ith foster place-
m ent. Low er baseline cognitive ability
w as linked to signs of reactive attachm ent
disorder.

(A m J P sy c h ia try 2 0 1 2 ; 1 6 9 :5 0 8 5 1 4 )

T he association of institutional deprivation and reac-

tive attachment disorder has been noted in the literature
since the mid-20th century (14). Both types of the dis-
orderthe emotionally withdrawn (inhibited) and the
indiscriminately social (disinhibited) typeshave been
described in young children who have been maltreated or
were raised in conditions of deprivation (24). Interest in
the effects of institutional care persists to the present day
because many children throughout the world are raised in
institutions as a result of abuse or neglect, abandonment,
or parental incapacity or death (57). Often, these insti-
tutions are large group settings with multiple caregivers
whose rotating schedules do not support the development
of a focused attachment relationship between a child and
a given caregiver (8, 9). Significant numbers of children
living in institutions show signs of attachment disorders
(10). For children adopted from institutions, rates of at-
tachment disorders are elevated but are lower than those
for children living in institutions (11).
To our knowledge, there have been no previous planned
intervention studies of attachment disorders, although
some natural experiments have provided valuable data.
Tizard and colleagues (12, 13) first systematically observed
the development of what are now known as attachment
disorders in groups of institutionally reared children.
These children were placed in institutions, mostly at birth,
and remained there at least until age 2. Between ages 2
and 4, some were adopted, some were returned to their
parents, and some remained in institutions. At the initial
follow-up assessment when the children were 4 years old,
the majority of those who had remained in institutions
exhibited signs of reactive attachment disorder, either the
inhibited or the disinhibited type. Of those who had been
returned to their parents or been adopted, none exhibited
signs of the inhibited type, and a minority continued to
exhibit signs of the disinhibited type (13).
These findings were replicated in two longitudinal stud-
ies of young children adopted out of institutions in Roma-
nia. In a study of children adopted into Canada, signs of
indiscriminate behavior persisted in a minority of chil-
dren for several years after they had been adopted (3, 11).
Similarly, Rutter and colleagues (4, 1416) found no signs

This article is discussed in an E d ito ria l by D r. Schecter (p. 452)

508 a jp.p sych ia tryo n lin e.o rg A m J Psych ia try 1 6 9 :5 , M ay 2 0 1 2


of the inhibited type of reactive attachment disorder in
children adopted before age 4, but a minority of children
showed signs of indiscriminate behavior. Furthermore,
the authors observed a linear relationship between dura-
tion of deprivation and signs of disinhibited reactive at-
tachment disorder through age 6.
Since studies of children currently living in institu-
tions have demonstrated that both types of the disorder
are readily identifiable (9, 13), the absence of the inhib-
ited type and the persistence of the disinhibited type in
children after they are placed in more favorable caregiving
environments are notable. These findings suggest that the
inhibited type may be more responsive to enhanced care-
giving than the disinhibited type.
These adoption studies have inherent limitations, how-
ever. First, the studies did not include assessments of the
children prior to adoption. Second, because children ad-
opted out of institutions are not selected at random, the
results of these naturalistic studies may not be represen-
tative. For example, one study (12) found that redhead-
ed children and children of mothers with mental health
problems typically were not released for adoption. Third,
the comparison groups for two recent studies (11, 15) were
Canadian and British children, respectively, rather than
ethnically matched children, introducing the possibility
that cultural differences may affect outcomes.
The Bucharest Early Intervention Project, which was
designed as a randomized controlled trial of foster care
as an alternative to care as usual among institutionalized
young children, addressed many of the limitations of pre-
vious studies (17). Despite 60 years of research compar-
ing young children in foster care and those in institutional
care, no randomized trial had been conducted until the
Bucharest Early Intervention Project was initiated in 2001.
Children in the study had been abandoned at or soon af-
ter birth and placed in institutional care in the custody of
the government. They were assessed comprehensively at
baseline and then randomly assigned to care as usual (in-
cluding continued institutional care) or to placement in
foster care, which was created as part of the project.
By including assessments of reactive attachment disor-
der prior to removal from institutions and by using well-
validated measures administered longitudinally, this ran-
domized controlled trial reduces selection bias and directly
addresses questions about the responsiveness of children
with reactive attachment disorder to enhanced caregiving.
Elsewhere, we have demonstrated the positive impact of
this intervention on brain functioning (18), language de-
velopment (19), cognitive abilities (20), attachment secu-
rity (21), physical growth (22), and psychiatric disorders
(23). No previous studies have examined the impact of the
intervention on attachment disorders. In this study, we ad-
dressed the following questions. First, did removing young
children from institutions and placing them in foster care
reduce signs of both the inhibited and the disinhibited
types of reactive attachment disorder? Second, was the
A m J Psych ia try 1 6 9 :5 , M ay 2 0 1 2 a jp.p sych ia tryo n lin e.o rg 509
S myk e , Z e anah , G l e ason , e t a l .
timing of the intervention (age at placement in foster care)
related to signs of attachment disorder? And finally, did
demographic factors (gender, ethnicity) or cognitive abil-
ity at baseline have an impact on the effect of placement
on change in signs of reactive attachment disorder?
M e th o d
S a m p le
Study subjects were three groups of young Romanian children
enrolled in the Bucharest Early Intervention Project and repeat-
edly assessed over time; assessments were conducted at baseline
(ages 630 months) and at ages 30, 42, and 54 months and 8 years
(17, 20).
All children under age 31 months (N=187) at study initiation
(April 2001) who were cared for in the six study institutions in
Bucharest were assessed for participation in the study. Children
were screened for signs of exclusion criteria, which included ge-
netic syndromes, fetal alcohol syndrome, and head circumfer-
ence more than two standard deviations from normal. Fifty-one
children met exclusion criteria, resulting in an initial study popu-
lation of 136 children. Baseline comprehensive evaluations (20,
24), which included assessments for signs of reactive attachment
disorder, were conducted (10). The children were then randomly
assigned either to continued institutional care (the usual care
group; N=68) or to placement in newly created foster care (the
foster care group; N=68). One child in the foster care group was
subsequently found to meet exclusion criteria and was excluded
from further analyses.
A third group of never-institutionalized children, raised in
families, was recruited from pediatric clinics in Bucharest (N=72).
These children, who were born at the same maternity hospitals
and whose families were from the same sectors as the children in
the two study groups, served as a typically developing Romanian
comparison group.
Over the course of the study, there was some movement of chil-
dren from their original group assignment. All decisions regarding
placement of institutionalized children were made by Romanian
child protection officials with no interference from study person-
nel. We did, however, ensure that no child, once placed in foster
care through the Bucharest Early Intervention Project, would
be returned to an institutional setting, either during or after the
study. A CONSORT diagram is available in the data supplement
that accompanies the online edition of this article. We followed
an intent-to-treat approach in all analyses so that original group
assignment was maintained.
F o ste r C a re In te rv e n tio n
A foster care network consisting of 56 foster homes was created
for the Bucharest Early Intervention Project, designed to amelio-
rate the effects of early institutionalization on young children,
including reducing signs of attachment disorders. A description
of this child-centered foster care intervention has been published
elsewhere (25). Project social workers supported foster parents
in establishing warm, nurturing relationships with their foster
children and assisted them in managing difficult child behavior.
Foster parents were encouraged to view their foster children as
members of the family and to become committed psychological
parents (25).
M e a su re s
R e a c tiv e a t ta c h m e n t d is o rd e r. Signs of reactive attachment
disorder were assessed with the Disturbances of Attachment In-
terview (A.T. Smyke and C.H. Zeanah, unpublished instrument),
a semistructured interview that has been used to assess children
T r ia l C ompa r ing F ost e r C a r e and Inst itut iona l C a r e
raised in institutions (9, 25, 26), young foster children (27, 28), and
young children exposed to domestic violence (29). The instrument
has shown strong convergent (9, 30) and discriminant (29) validity.
The first five items of the interview assess signs of inhibited reac-
tive attachment disorder, asking about whether the child has de-
veloped a preference for a specific caregiver, approaches the care-
giver for comfort, responds to comfort when offered, engages in
reciprocal social interaction, and regulates emotions well. Scores
on these five items are rated 0 (often/clearly demonstrates the be-
havior), 1 (sometimes/somewhat demonstrates the behavior), or 2
(rarely/minimally demonstrates the behavior) (score range, 010).
Three items assess signs of the disinhibited type, using the same
ratings for questions about whether the child checks back with
the caregiver when exploring, shows age-appropriate reticence
around strangers, and demonstrates willingness to go off with a
stranger (score range, 06). For children residing in foster or biolog-
ical families, the foster or biological mother was interviewed. For
institutionalized children, interviews were conducted with either
the favorite caregiver (as determined by staff) or, if the child did
not have a favorite caregiver, a caregiver who knew the child well
and cared for the child on a regular basis. Two Romanian-speaking
research assistants who were trained to reliability on the interview
(10) coded each interview. Discrepancies were resolved by confer-
encing, and a consensus code was recorded for each item.
C o g n itiv e a b ilitie s . Childrens cognitive abilities at baseline
were examined using the Bayley Scales of Infant DevelopmentII
(31). A developmental quotient was derived because some chil-
dren had scores below the basal score for the Bayley Scales and
could be included in analyses only if a developmental quotient
was computed. The developmental quotient at baseline for the
children in the two study groups was dichotomized (median split
at 77) for the analyses (24).
P ro c e d u re
After baseline assessments, children were randomly assigned to
care as usual or to foster care. Each child was given a number (sib-
lings were placed together), and numbers were drawn from a hat
and alternately assigned to the two groups. Subsequently, all de-
cisions regarding childrens placements were made by Romanian
child protection officials. Thus, for example, children were some-
times returned to their biological families or placed in government-
sponsored foster care that did not exist at the time the study began.
Interviews and assessments were conducted in the study labo-
ratory.
C o n se n t
After institutional review board approval was obtained from
the universities of each of the principal investigators, approval
was obtained from the local child protection commissions in Bu-
charest. The commissioner for child protection in each sector in
which a child resided signed consent for individual children. The
study was conducted in collaboration with the Institute of Ma-
ternal and Child Health and the Romanian Ministry of Health.
In addition, assent for each procedure was obtained from each
caregiver or parent who accompanied a child to a visit. The ethi-
cal considerations for study of this vulnerable group have been
discussed in detail elsewhere (3234).
S ta tistic a l A n a ly sis
The effects of foster care intervention and of usual care on
signs of reactive attachment disorder were measured across time
(at baseline and at ages 30, 42, and 54 months and 8 years) and
analyzed using repeated-measures analysis of variance (ANOVA;
likelihood model, data missing at random, SAS PROC MIXED, two
groups and five assessments), with post hoc comparisons based
on least squares means. Age at placement in foster care was di-
chotomized at 24 months (median split) to examine the timing ef-
510 a jp.p sych ia tryo n lin e.o rg A m J Psych ia try 1 6 9 :5 , M ay 2 0 1 2
fects of the intervention. Gender, ethnicity (Romanian compared
with Roma or other), and cognitive ability at baseline (higher
compared with lower developmental quotient) were entered
separately as between-subject factors to examine their impact on
change in signs of reactive attachment disorder. All p values were
based on two-tailed tests.
R e su lts
Table 1 presents basic demographic information (gen-
der and ethnicity) and lists the mean total scores for signs
of inhibited and disinhibited reactive attachment disorder
for the two study groups and the never-institutionalized
comparison group. There were fewer Roma children in the
never-institutionalized group. On average, children in the
never-institutionalized group were younger at the base-
line assessment than children in the study groups (data
not shown). Preliminary analyses revealed no significant
effect of gender or ethnicity, and these variables were ex-
cluded from further analyses.
S ig n s o f In h ib ite d R e a c tiv e A tta c h m e n t D iso rd e r
The repeated-measures analysis showed a significant
group-by-time interaction (F=2.51, df=4, 475, p<0.05), in-
dicating that scores decreased differentially for the usual
care and foster care groups (Figure 1). Post hoc com-
parisons at ages 30 months (t=4.51, df=475, p<0.001), 42
months (t=4.58, df=475, p<0.001), 54 months (t=4.07,
df=475, p<0.001), and 8 years (t=2.70, df=475, p<0.01) all
indicated fewer signs of inhibited reactive attachment dis-
order for children in the foster care group compared with
those in the usual care group. Differences between the fos-
ter care group and the never-institutionalized group were
evident at baseline and at ages 30 months and 8 years.
S ig n s o f D isin h ib ite d R e a c tiv e A tta c h m e n t D iso rd e r
The repeated-measures analysis showed significant
main effects for change over time (F=12.72, df=4, 475,
p<0.001) and for group (F=15.42, df=1, 133, p<0.001), but
not for the group-by-time interaction, suggesting that
scores did not decrease differentially for the usual care
and foster care groups (Figure 1). While respecting protec-
tion for multiple comparisons, we nevertheless decided
that analyses of specific time points would be informa-
tive. Thus, we conducted post hoc comparisons and ob-
served that at ages 42 months (t=2.61, df=475, p<0.01),
54 months (t=2.34, df=475, p<0.05), and 8 years (t=2.44,
df=475, p<0.05), children in the foster care group had sig-
nificantly fewer signs of disinhibited reactive attachment
disorder relative to children in the usual care group. These
findings may be attributed to the significant group main
effect. There were significantly more signs in the foster
care group than in the never-institutionalized group at
each age measured after baseline.
T im in g o f In te rv e n tio n
As shown in Figure 2, children placed in foster care be-
fore age 24 months did not differ significantly from chil-
 S myk e , Z e anah , G l e ason , e t a l .

TA B LE 1 . D e m o g ra p h ic a n d C lin ic a l C h a ra c te ristic s o f th e S a m p le in a R a n d o m iz e d C o n tro lle d Tria l C o m p a rin g F o ste r C a re

a n d In stitu tio n a l C a re fo r C h ild re n W ith S ig n s o f R e a c tiv e A tta c h m e n t D iso rd e r a
Randomized Groups
Comparison Group (Never
Characteristic Usual Care Group (N=68) Foster Care Group (N=68) Institutionalized) (N=72)
N % N % N %
Female 35 51 34 50 41 57
Ethnicity
Romanian 34 50 42 62 66 92
Roma or other 34 50 26 38 6 8
Mean SD Mean SD Mean SD
Score for signs of reactive attachment
disorder, by type and assessment age
Inhibited type
Baseline 2.71 2.67 2.39 2.29 0.45 0.77
30 months 2.34 2.46 0.69 0.88 0.35 0.59
42 months 2.08 2.36 0.42 0.83 0.38 0.63
54 months 1.92 2.77 0.42 0.99 0.42 0.99
8 years 1.52 2.37 0.50 1.35 0.05 0.22
Disinhibited type
Baseline 2.56 1.83 2.61 1.89 1.60 1.32
30 months 2.09 1.90 1.61 1.65 0.42 0.80
42 months 2.00 1.85 1.16 1.77 0.25 0.86
54 months 2.22 2.07 1.45 2.09 0.24 1.07
8 years 1.38 1.71 0.55 1.21 0.10 0.45
a The
usual care and foster care groups were randomly assigned; the never-institutionalized comparison group was recruited nonrandomly
from local pediatric clinics. Baseline age was 630 months.

dren placed after age 24 months across the course of the
study through age 8 in signs of inhibited reactive attach-
ment disorder.
With regard to signs of disinhibited reactive attachment
disorder, repeated-measures analysis showed a significant
interaction of age at placement by time (F=3.39, df=4, 239,
p<0.05), indicating that scores decreased differentially for
the children placed in foster care before age 24 months
compared with those placed after that age. Post hoc analy-
ses indicated that children placed in foster care before age
24 months had fewer signs of disinhibited reactive attach-
ment disorder at ages 30 months (t=3.11, df=239, p<0.01)
and 54 months (t=2.62, df=239, p<0.01) than did those
placed after age 24 months. Differences were not evident
at ages 42 months or 8 years.
F a c to rs R e la te d to C h a n g e in S ig n s o f R e a c tiv e
A tta c h m e n t D iso rd e r
Results of repeated-measures ANOVA revealed a base-
line cognitive ability-by-group interaction (F=5.89, df=1,
127, p<0.05), indicating a differential effect of baseline
cognitive ability on signs of inhibited reactive attachment
disorder. Post hoc comparisons revealed more signs of
this type of reactive attachment disorder among children
in the usual care group with lower baseline cognitive abili-
ties, across the entire intervention period, compared with
children in this group with higher baseline cognitive abil-
ity (t=4.24, df=127, p<0.001). This difference was not ob-
served for the children in the foster care group.
With regard to signs of disinhibited reactive attachment
disorder, repeated-measures ANOVA revealed a main ef-
fect for baseline cognitive ability (F=18.14, df=1, 127,
p<0.001), suggesting that children with better cognitive
abilities at baseline had fewer signs of this type of reactive
attachment disorder across the entire intervention period.
There was no significant effect of baseline cognitive ability
on change over time in scores for reactive attachment dis-
order of either the inhibited or the disinhibited type.
D isc u ssio n
We report results of a randomized controlled trial of the
effects of foster care as an interventionto our knowl-
edge, the first such trialto address directly the effects of
institutionalization, focusing on signs of reactive attach-
ment disorder and its treatment. Our findings have impor-
tant implications for children living in conditions of social
deprivation and other forms of neglect.
The most important finding was that placement of
young institutionalized children in quality foster care re-
sulted in a marked reduction of signs of inhibited reactive
attachment disorder and compellingly demonstrated res-
olution of the disorder, since signs were indistinguishable
between children in the foster care group and those in the
never-institutionalized group after age 30 months. The
children had been with families an average of 8 months at
the 30-month assessment, which may explain why adop-
tion studies with follow-up periods of 1 year or more after
adoption have not detected signs of this disorder (3, 35).
Responsiveness of disinhibited reactive attachment dis-
order to intervention was less straightforward. Children
in the foster care intervention arm had lower scores than

A m J Psych ia try 1 6 9 :5 , M ay 2 0 1 2 a jp.p sych ia tryo n lin e.o rg 511

T r ia l C ompa r ing F ost e r C a r e and Inst itut iona l C a r e

F IG U RE 1 . M e a n S c o re s fo r S ig n s o f In h ib ite d a n d D isin h ib - F IG U RE 2 . M e a n S c o re s fo r S ig n s o f In h ib ite d a n d D isin h ib -

ite d R e a c tiv e A tta c h m e n t D iso rd e r o n th e D istu rb a n c e s o f ite d R e a c tiv e A tta c h m e n t D iso rd e r o n th e D istu rb a n c e s o f
A tta c h m e n t In te rv ie w, b y G ro u p a A tta c h m e n t In te rv ie w, b y T im in g o f P la c e m e n t in F o ste r
Signs of Inhibited Type C a re a
Signs of Inhibited Type
Usual care 3.5
3.0 Placement age <24 months
Foster care
3.0
Never institutionalized Placement age >24 months
2.5
2.5
Total Score

2.0

Total Score
2.0
1.5
1.5
1.0
1.0
0.5
0.5
0.0
Baseline 30 42 54 8
months months months years 0.0
Baseline 30 42 54 8
Assessment Age months months months years
Assessment Age
Signs of Disinhibited Type
Usual care Signs of Disinhibited Type
3.0 3.5
Foster care
Placement age <24 months
2.5 Never institutionalized 3.0 Placement age >24 months
Total Score

2.0 2.5
Total Score

1.5 2.0

1.0 1.5

0.5 1.0

0.0
Baseline 30 42 54
months months months
Assessment Age
a The
usual care and foster care groups were randomly assigned; the
never-institutionalized comparison group was recruited nonran-
domly from local pediatric clinics. Baseline age was 630 months.
those in the usual care arm at some test ages but higher
scores than children who had never been institutional-
ized. Factors beyond an adequate family caregiving envi-
ronment seem relevant to understanding how to reduce
signs of disinhibited reactive attachment disorder (36).
The timing of placement in foster care has been shown
to have an impact on cognitive recovery for children who
experienced institutional care (20) and has some bear-
ing on the question of whether there are sensitive peri-
ods during which children are more likely to recover from
early deprivation. In the present study, we observed no
effects of timing of placement in foster care on signs of in-
hibited reactive attachment disorder. The lack of a timing
effect suggests that children raised in institutional settings
retain a capacity for forming attachments, with no obvi-
ous sensitive period. When placed with families, children
form new attachments (21) and signs of inhibited reactive
attachment disorder disappear. Results for disinhibited
0.5
8
years
0.0
Baseline 30 42 54 8
months months months years
Assessment Age
a The
usual care and foster care groups were randomly assigned; the
never-institutionalized comparison group was recruited nonran-
domly from local pediatric clinics. Baseline age was 630 months.
reactive attachment disorder with regard to age at place-
ment in foster care were mixed. Scores decreased differen-
tially for children placed before age 24 months, with scores
noted to be lower at ages 30 and 54 months for this group.
These findings indicate that placement in families
clearly eliminates signs of the inhibited type of reactive
attachment disorder, as measured by the Disturbances
of Attachment Interview, among young children raised
in institutions, but it has a more attenuated effect on the
disinhibited type. This raises the question of what addi-
tional components should be included in interventions
for indiscriminate behavior, which can be a risk factor for
subsequent psychiatric impairment and interpersonal
difficulties. For example, training in reading and respond-
ing to social cues might lead to reductions in disinhibited
social behavior. Such training would be enhanced by bet-

512 a jp.p sych ia tryo n lin e.o rg A m J Psych ia try 1 6 9 :5 , M ay 2 0 1 2


P a tie n t P e r s p e c tiv e
R o xa n a w a s a b a n d o n e d b y h e r m o th e r a t th e m a -
te rn ity h o sp ita l w h e re sh e w a s b o rn a n d w a s tra n sfe rre d
to a la rg e in stitu tio n in B u c h a re st sh o rtly a fte r b irth . Sh e
h a d live d o n th re e d iffe re n t u n its d u rin g h e r sta y th e re ,
a n d a t 2 0 m o n th s sh e h a d p o o r e m o tio n re g u la tio n w ith
irrita b ility a n d little p o sitive a ffe ct. Sh e w a s n o t a tta ch e d
to a n y ca re g ive rs, a n d h e r d e ve lo p m e n ta l q u o tie n t w a s
5 2 . Sh e w a s o b se rve d to cry a n d ro c k b a ck a n d fo rth fre -
q u e n tly. W h e n h e ld b y a ca re g ive r id e n tifie d a s h e r fa vo r-
ite , sh e a rch e d h e r b a ck a n d co u ld n o t b e co n so le d . Sh e
w a s p la ce d w ith a fo ste r fa m ily a n d b e g a n to th rive . B y 3 0
m o n th s, sh e co u ld tu m b le if e n co u ra g e d b y h e r d o tin g fo s-
te r p a re n ts b u t h a d little re co g n iza b le la n g u a g e , a n d h e r
d e ve lo p m e n ta l q u o tie n t w a s 7 3 . B y 4 2 m o n th s, sh e w a s
e m o tio n a lly w e ll re g u la te d , h a d a d e ve lo p m e n ta l q u o tie n t
o f 8 4 , a n d w a s o b se rve d te llin g a n in trica te sto ry a b o u t a
b e a r w h o w e n t to p re sch o o l in h is slip p e rs. Sig n s o f in h ib -
ite d re a ctive a tta ch m e n t d iso rd e r d ro p p e d m a rke d ly so o n
a fte r h e r p la ce m e n t in fo ste r ca re a n d re m a in e d lo w fo r
th e re m a in d e r o f th e stu d y. A t 8 ye a rs, in th e p e e r in te ra c -
tio n a sse ssm e n t, R o xa n a s in te ra ctio n s w e re ch a ra cte rize d
b y so m e b o ssin e ss b u t o ve ra ll se e m e d sa tisfy in g to b o th
R o xa n a a n d h e r sa m e -a g e co m m u n ity p e e r.
Iu lia n w a s b o rn in a m a te rn ity h o sp ita l a n d re m a in e d
in th e h o sp ita ls tra n sitio n u n it, o fte n tig h tly sw a d d le d a n d
ter characterization of the social cognitive abnormalities
that presumably underlie indiscriminate behavior.
Regarding factors influencing intervention effects, gen-
der and ethnicity appear to be unrelated to the recovery of
young children from reactive attachment disorders. Among
children in the usual care group, those with lower cognitive
ability at baseline had more signs of the inhibited type over
the course of the study than did children with higher cog-
nitive ability. This effect was not evident among children
in the foster care group, suggesting that the intervention
of foster care was beneficial to children regardless of their
cognitive abilities. Lower cognitive ability at baseline was
also related to higher scores for signs of disinhibited reac-
tive attachment disorder for both groups. Taken together,
these findings highlight the increased risk for children with
lower cognitive ability exposed to early adversity.
One limitation of the study may be that because of its
longitudinal nature and the detailed questioning of care-
givers during the interview, interviewers were not always
blind to group status. Another limitation may be the use
of caregiver report, a method often used in studies of early
childhood psychopathology. Nevertheless, our confidence
in the caregiver reports for this sample is high because
they converge with observer ratings (29).
Results from this study have implications not only for
young children raised in institutions but also for those
who have experienced maltreatment (29, 37, 38) and oth-
A m J Psych ia try 1 6 9 :5 , M ay 2 0 1 2 a jp.p sych ia tryo n lin e.o rg 513
S myk e , Z e anah , G l e ason , e t a l .
re ce iv in g p e rfu n cto ry in stru m e n ta l ca re , fo r 6 m o n th s. H e
w a s tra n sfe rre d to th e b a b y u n it a t a n e a rb y in stitu tio n a n d
th e n tra n sfe rre d to a n o th e r u n it in th a t in stitu tio n a t 1 3
m o n th s o f a g e . V isito rs to th e u n it n o te d h is h a p p y sm ile
a n d h is e n g a g in g n a tu re a s h e a p p ro a ch e d th e m a n d p u t
h is a rm s u p fo r a h u g . T h e y n o tice d a s w e ll th a t so m e tim e s
h e w o u ld h a n g o n th e ir ca m e ra b a g s. O n ce w h e n a v isito r
le a n e d d o w n to ta lk w ith h im , Iu lia n g ra b b e d th e v isito rs
g la sse s a n d b e n t th e m . Iu lia n re ce ive d in stitu tio n a l ca re fo r
th e d u ra tio n o f th e stu d y. D u rin g h is p e e r in te ra ctio n a s-
se ssm e n t a t a g e 8 , h e p lie d h is sa m e -a g e co m m u n ity p e e r
w ith a v a rie ty o f q u e stio n s, ta lke d fre q u e n tly w ith o u t b e -
in g co n ve rsa tio n a l, a n d h a d d ifficu lty ta kin g tu rn s a s th e y
p la ye d a ca rd g a m e . H e le a n e d a g a in st th e p e e r re p e a t-
e d ly, e ve n w h e n th e p e e r g a ve c le a r sig n a ls th a t th e p hy si-
ca l co n ta ct w a s n o t w e lco m e .
V la d w a s b o rn in to a co m m u n ity fa m ily o f m o d e st
m e a n s. H is fa th e r w a s a la b o re r, a n d h is m o th e r sta ye d
h o m e w ith h im fo r th e u su a l 2 ye a rs a n d th e n re tu rn e d
to h e r jo b in a b a ke ry. H e re sid e d w ith h is fa m ily th ro u g h -
o u t th e stu d y a n d e n te re d kin d e rg a rte n a t a g e 5 . H e co n -
siste n tly sco re d in th e 1 0 0 1 0 5 ra n g e fo r co g n itive te stin g
a n d sh o w e d n o sig n s o f e ith e r ty p e o f re a ctive a tta ch m e n t
d iso rd e r a t a n y tim e . H is p e e r in te ra ctio n s a t a g e 8 w e re
co o p e ra tive a n d co m p le x.
er forms of neglect. Changing childrens experiences by
placement in child-centered foster care demonstrably re-
duced signs of an impairing disorder. This is the strongest
evidence to date on what interventions are needed to treat
attachment disorders in young children. Future studies
should examine the long-term effects of such interven-
tions, more carefully identify which components are criti-
cal to successful adaptation, and provide a greater under-
standing of the nature of both types of reactive attachment
disorder as children mature.
R e ce ive d M a y 1 7 , 2 0 1 1 ; re v isio n s re ce ive d O ct. 7 a n d D e c . 4 , 2 0 1 1 ;
a cce p te d D e c . 1 8 , 2 0 1 1 (d o i: 1 0 .1 1 7 6 /a p p i.a jp.2 0 1 1 .1 1 0 5 0 7 4 8 ).
Fro m th e D e p a rtm e n t o f P sych ia try a n d B e h a v io ra l Scie n ce s, Tu la n e
U n ive rsity Sch o o l o f M e d icin e , N e w O rle a n s; D e p a rtm e n t o f H u m a n
D e ve lo p m e n t, U n ive rsity o f M a ry la n d , C o lle g e P a rk; D e p a rtm e n t o f
Pe d ia trics, H a rv a rd M e d ica l Sc h o o l, B o sto n ; D e p a rtm e n t o f D e ve l-
o p m e n ta l M e d icin e , C h ild re n s H o sp ita l B o sto n ; a n d th e D iv isio n o f
C h ild P sych ia try, U C L A Sch o o l o f M e d icin e , Lo s A n g e le s. A d d re ss co r-
re sp o n d e n ce to D r. Sm y ke (a sm y ke @tu la n e .e d u ).
D r. G u th rie h a s se rve d o n d a ta m o n ito rin g co m m itte e s fo r M e d tro n -
ic a n d th e D e p a rtm e n t o f Ve te ra n s A ffa irs a n d o n se ve ra l a ca d e m ic
d a ta a n d sa fe ty m o n ito rin g b o a rd s; h e se rve s a s a sta tistica l co n su l-
ta n t to se ve ra l a ca d e m ic in stitu tio n s; a n d h e o w n s sh a re s o f Jo h n so n
& Jo h n so n sto ck. T h e o th e r a u th o rs re p o rt n o fin a n cia l re la tio n sh ip s
w ith co m m e rcia l in te re sts.
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