Attachment Disorders in Early Childhood: Julianna Finelli Charles H. Zeanah, Jr. Anna T. Smyke

CHAPTER 27
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Attachment Disorders in Early Childhood
Julianna Finelli
Charles H. Zeanah, Jr.
Anna T. Smyke
“A ttachment” describes the human infant’s

tendency to seek comfort, support, nurturance,
century that “essential for mental health is that
an infant and young child should experience
and protection selectively from a small number a warm, intimate and continuous relationship
of caregivers. Based on experiences of regular with his mother (or mother substitute . . . ) in
interactions with adult caregivers, infants learn which both find satisfaction and enjoyment.”
gradually to seek comfort and protection not The propensity for human infants to form se-
from just anyone but selectively, from caregiv- lective attachments is believed to be so strong
ers on whom they have learned they can rely. that only in highly unusual and maladaptive
According to attachment theory, infants’ behav- caregiving environments do attachments fail to
iors with these caregivers are guided by their develop. For young children raised in species-
“internal working models” of relationships, a atypical rearing conditions, however, seriously
heuristic term describing a set of tendencies to disturbed and developmentally inappropri-
experience and behave in intimate relationships ate ways of relating may evolve. Examples of
in particular ways; that is, as early as the first atypical environments include institutions (i.e.,
year of life, infants begin to construct expec- orphanages), frequent changes of caregivers (as
tations about how they and others with whom sometimes happens in foster care), neglectful
they interact will feel and behave. The internal or abusive caregiving, or being raised by insen-
working model is more than a set of expecta- sitive or unresponsive caregivers. In these ex-
tions, however, as it includes selective attention treme situations, young children may develop
to incoming social information and salient so- clinical disorders of attachment.
Copyright @ 2019. The Guilford Press.
cial cues, feelings elicited during intimate inter- In this chapter, we review the construct of
actions with others, memories of similar feel- attachment disorders, with an emphasis on re-
ings in previous interactions and relationships, active attachment disorder and disinhibited
and the infant’s own behavioral responses to social engagement disorder. Although derived
others. Attachment is considered a vital compo- from descriptive studies dating back at least to
nent of social and emotional development in the the 1940s, these disorders have been subjected
early years, and individual differences in the to systematic study only in the past decade or
quality of attachment relationships are believed so, and are still often misunderstood (Chaffin
to be important early indicators of infant mental et al., 2006). Therefore, we review developmen-
health. John Bowlby (1952, p. 11), who elaborat- tal perspectives on attachment, as well as the
ed attachment theory, declared in the mid-20th phenomenology, correlates, epidemiology, and
452
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27. Attachment Disorders in Early Childhood 453
course of reactive attachment disorder and dis- those to whom they are attached. Bowlby (1969)
inhibited social engagement disorder. Finally, emphasized that play partners are not necessar-
we consider assessment and treatment of reac- ily attachment figures. We may think of a con-
tive attachment disorder and disinhibited social tinuum of infants’ behavior with caregivers, be-
engagement disorder. ginning with recognition/familiarity, followed
by familiarity/comfort, then comfort/pleasure,

then pleasure/reliance and finally reliance/pref-
Developmental Perspectives on Attachment erence (see Figure 27.1). Only at the level of reli-
ance/preference may we say infants have fully
The capacity to form an attachment is not pres- formed attachments to caregivers.
ent at birth but develops gradually over the first Though older children can sustain attach-
year of life. For the first 2 months after birth, in- ment relationships over time and space, in the
fants are not well developed socially, spending first 3 years or so of life, the young child needs
most of their time sleeping, eating, and crying. actual interaction with caregivers in order to
At around 2 months of age, they become dra- become attached to them. This has important
matically more social, exhibiting a responsive implications both for custody and visitation and
“social” smile, as well as cooing responsively for infants in foster care.
and making more sustained eye-to-eye contact.
They seem more interested in social interaction
Classifications of Attachment
and are willing to interact readily with adults.
Although infants in the first 6 months are able Attachment is most often assessed in the early
to distinguish among different interactive part- years of life with a procedure known as the
ners, they do not express an obvious preference Strange Situation Procedure (SSP). This obser-
for one caregiver over another. vational paradigm involves a series of interac-
This lack of obvious preference changes at tions between a young child, an attachment fig-
around 7–9 months of age. At that point, in- ure, and a stranger (Ainsworth, Blehar, Waters
fants begin to exhibit stranger wariness and & Wall, 1978). The procedure was designed to
separation protest, two behaviors that herald examine the young child’s balance between at-
the onset of “focused” or “selective” attach- tachment and exploratory behaviors, primarily
ment. “Stranger wariness” varies from mild through comparing the child’s behavior with the
reticence to outright distress, but it contrasts attachment figure and with the unfamiliar adult.
with the infant’s selective seeking of comfort, Because separation from the attachment figure
support, nurturance, and protection. “Separa- activates the young child’s need for closeness
tion protest” describes the infant’s reaction to and comfort, the SSP includes two brief separa-
actual or anticipated separation from an attach- tions and reunions that allow direct observation
ment figure. Once infants have developed the of the child making use of the caregiver to regu-
cognitive capacity to exhibit separation protest late his or her emotions during this moderately
and stranger wariness, they may form new at- stressful experience.
tachments with any caregivers with whom they Based on the organization of child’s attach-
have significant and sustained interactive expe- ment behaviors and the balance between the
riences. child’s tendency to seek proximity to the at-
It is important to emphasize that infants are tachment figure and to move away from the
likely to recognize and may even be comfort- attachment figure and explore, it is possible to
able with a larger number of caregivers than derive an overall classification of attachment
Recogni�on/ Familiarity/ Comfort/ Pleasure/ Reliance/
familiarity comfort pleasure reliance preference
FIGURE 27.1. Continuum of behaviors relevant to development of attachment relationships.
454 I V . P sychopathology
between the child and caregiver. Ainsworth and mary caregivers (Deklyen & Greenberg, 2016;
colleagues (1978) described three major pat- Lyons-Ruth & Jacobvitz, 2016). Thus, SSP clas-
terns of attachment. Children who expressed sifications of secure, avoidant, resistant, and
distress directly, sought comfort unhesitatingly, disorganized are risk and protective factors for
and responded to comfort readily were classi- disorders rather than diagnostic entities them-
fied as “securely” attached to their caregivers. selves. Secure attachment appears to be espe-
Children who showed little distress on sepa- cially important as a protective factor in high-
ration and little need for closeness or comfort risk samples (e.g., Tharner et al., 2012). Still,
on reunion were classified as “avoidantly” at- it seems increasingly clear that taken alone,
tached to their caregivers. Finally, children classifications of attachment have more limited
who showed intense distress but could not be long-term predictive power, whereas when con-
comforted on reunion were classified as “resis- sidered with other variables, they appear to be
tantly” (sometimes referred to as “ambivalent- important, if not vital, considerations (Sroufe,
ly”) attached to their caregivers. Essentially, 2005).
these patterns represent balanced (“secure”), Given the ubiquity of attachment for human
diminished (“avoidant”) and excessive (“resis- infants, an important clinical challenge is to
tant”) activation of the child’s need for comfort distinguish between typically appearing vari-
when stressed. A fourth classification was later ants of attachment and actual clinical disorders
added by Main and colleagues (Main & Hesse, of attachment. For this, we turn to a consider-
1990; Main & Solomon, 1990). They described ation of the clinical perspective on attachment
“disorganized” attachment, a heterogeneous set disorders.
of behaviors that involves various aberrant be-
haviors and/or mixed strategies comprising in-
coherent combinations of secure, avoidant, and Clinical Presentation of Attachment Disorders
resistant attachment behaviors. Disorganized
attachment is the classification that is most pre- Attachment disorders were first described for-
dictive of concurrent and subsequent psychopa- mally in the psychological literature in 1980
thology (Lyons-Ruth & Jacobvitz, 2016). with the publication of the third edition of the
Important work by Sroufe and colleagues (see Diagnostic and Statistical Manual of Mental
Sroufe, 2005; Weinfield, Sroufe, Egeland, & Disorders (DSM-III; American Psychiatric As-
Carlson, 2008) established the construct valid- sociation, 1980). Since then, the criteria have
ity of the SSP for the assessment of the quality been revised in more recent nosologies [the
of parent–child attachment in young children. fifth edition of the Diagnostic and Statistical
The disorganized classification, in particu- Manual of Mental Disorders (DSM-5; Ameri-
lar, extended the value of observing the young can Psychiatric Association, 2013); the Inter-
child’s behavior in the SSP to clinical popula- national Classification of Diseases (ICD-10;
tions of young children. Indeed, the SSP is now World Health Organization, 1992); Research
considered quite useful in attachment-based in- Diagnostic Criteria-Preschool Age (American
terventions such as the Circle of Security (Doz- Academy of Child and Adolescent Psychiatry
ier & Bernard, Chapter 31, this volume), but the [AACAP] Task Force on Research Diagnostic
emphasis is on specific behaviors rather than Criteria: Infant Preschool, 2003); and the Di-
overall classification. The SSP has been used agnostic Classification of Mental Health and
in hundreds of studies of attachment around the Developmental Disorders of Infancy and Early
world and still is widely considered the “gold Childhood (DC:0–5; Zero to Three, 2016)].
standard” for assessing quality of attachment Nevertheless, only in the past two decades have
in the early years. Nevertheless, it is important there appeared studies focused explicitly on the
that these classifications not be confused with diagnostic criteria.
diagnoses nor that the SSP be confused with a The phenomenology of attachment disorders
clinical assessment. was derived from descriptive studies of young
A number of studies have demonstrated children raised in extreme caregiving environ-
increased risk for anxiety disorders, disrup- ments, such as children who have been mal-
tive behavior disorders, dissociative disorders, treated or those who have been reared in institu-
substance use, delinquency, and personality tional settings (Goldfarb, 1945; Main & George,
disorders among children with insecure and es- 1979; Spitz, 1945; Wolkind, 1974). Drawing on
pecially disorganized attachments to their pri- these studies, Tizard and Rees (1975) reported
that at age 4 years, a majority of young chil- tachment framework in understanding DSED,
dren (18/26) who had been raised in residential given research that implicates disturbed devel-
nurseries in the United Kingdom since birth ex- opment of selective attachment relationships.
hibited aberrant attachment behaviors. A group Similarities and differences in the two disorders
of eight children was described as emotionally are summarized in Table 27.1.
withdrawn and unresponsive, and another group Further keeping in line with the literature,
of 10 children was described as indiscriminate, DSM-5 focuses the criteria for RAD on dis-
attention seeking, and socially superficial. turbed or absent attachment behaviors, rather
These two phenotypes became subtypes of than on general social behaviors (as in DSM-IV
one attachment disorder, reactive attachment and ICD-10), and focuses the criteria for DSED
disorder, though ICD-10 defined reactive at- on aberrant social behaviors. This change is
tachment disorder as comprising emotionally consistent with studies that have identified lack
withdrawn/inhibited behavior and defined dis- of attachment behaviors as the core deficit in
inhibited attachment disorder as indiscriminate RAD (Boris et al., 2004; Gleason et al., 2011;
social behavior associated with social boundary Zeanah, Smyke, Koga, Carlson, & the BEIP
violations. DSM-5 followed the lead of ICD-10, Core Group, 2005), and indiscriminate social
separating the two disorders and naming them behaviors as the core deficit in DSED (Lawler,
reactive attachment disorder (RAD) and dis- Hostinar, Mliner, & Gunnar, 2014; Soares et al.,
inhibited social engagement disorder (DSED). 2014; Tizard & Hodges, 1978; Zeanah, Smyke,
Two distinct disorders are in line with recent & Dumitrescu, 2002).
research, which suggests that although both dis- In addition to the disturbed attachment and
orders arise in conditions of social neglect, they social behaviors that form the core of contem-
differ significantly in their phenotypic charac- porary descriptions of attachment disorders,
teristics, course, associated comorbidities, and DSM-5 specifies that the etiology of attachment
response to treatment interventions (Zeanah & disorders is extremes of insufficient caregiv-
Gleason, 2010, 2015). Studies using confirma- ing. Indeed, RAD has been reported only in
tory factor analyses have supported the valid- children with histories of either maltreatment
ity of the two-factor model (Lehman, Breivik, or institutional rearing, though this may be be-
Heiervang, Havik, & Havik, 2016; Oosterman cause the insufficient care criterion is required.
& Schuengel, 2007; Vervoort, DeSchipper, A direct assessment of individual differences in
Bosmans, & Verschueren, 2013). However, the quality of the caregiving environment and indi-
classification of RAD and DSED as two distinct vidual differences of RAD found moderate as-
disorders remains a point of contention. Lyons- sociations between caregiving quality and signs
Ruth (2015) argues for the importance of the at- of RAD, but no association between caregiv-
TABLE 27.1. Similarities and Contrasts between RAD and DSED

Attachment disorder RAD DSED
Etiology Linked etiologically to social deprivation/ Linked etiologically to social
neglect deprivation/neglect
Maltreatment Identified in neglected children Identified in neglected children
Institutional care Identified in children raised in Identified in children raised in

institutions institutions
Children adopted from Not identified Not identified

institutions
SSP classifications/behavior Related to attachment behavior in SSP Not related to attachment behavior
(not attachment classifications) or classifications in the SSP
Intervention Very responsive to enhanced Less responsive to enhanced

caregiving caregiving
Sensitive period No evidence Suggestive evidence
ing and signs of DSED (Zeanah et al., 2005), At least three different interviews with care-
though this was within the relatively deprived givers have operationalized indiscriminate
context of an institution. Other studies have behavior in young children (Chisholm, 1998;
found an association between indiscriminate O’Connor & Rutter, 2000; Smyke, Dumitrescu,
behavior and caregiving quality (Love, Minnis, & Zeanah, 2002). Despite some differences in
& O’Connor, 2015). definition, these three different approaches ac-

tually showed substantial convergence (inter-
correlations ranging from 0.64 to 0.97) when
Reactive Attachment Disorder
used to assess a group of young children living
RAD is characterized by minimal or no dis- in institutions (Zeanah et al., 2002). There also
criminated attachment behavior, even at times have been naturalistic (Gleason et al., 2014),
when the child’s attachment behaviors should clinic (Boris et al., 2004), and laboratory obser-
be activated. Phenomenologically, it is charac- vational measures of indiscriminate behavior
terized by the absence of organized attachment (Lawler et al., 2014; Lyons-Ruth, Bureau, Riley,
behaviors, reduced social engagement and reci- & Atlas-Corbett, 2009). There is some evidence
procity, and emotion regulation difficulties (i.e., that observational measures also converge with
low levels of positive affect, outbursts of irri- caregiver report measures (Gleason et al., 2011;
tability, unexplained fear and hypervigilance). O’Connor, Marvin, Rutter, Olrick, & Britner,
Children with this pattern seek comfort either 2003).
inconsistently or not at all, even when dis- Recent studies have attempted to elucidate
tressed, and are not easily soothed when they the nature of the social deficits in DSED. Miel-
do become distressed. let, Caldara, Gillberg, Raju, and Minnis (2014)
The criteria for RAD in formal nosologies found altered facial processing in children with
have changed somewhat over time. In recent DSED. Specifically, children with indiscrimi-
nosologies (i.e., DSM-5 and DC:0–5), criteria nate friendliness had lower interparticipant
for RAD have focused more specifically on agreement on evaluations of face attractiveness
disturbed or absent attachment behaviors as and trustworthiness, and did not show the ex-
the core behavioral disturbance rather than dis- pected correlation between trustworthiness and
turbed social behaviors more generally. attractiveness judgments.
There have been some attempts to assess con-
vergent validity of caregiver reports of RAD
using behavioral observations. For example, Epidemiology
young children living in institutions who had
signs of RAD also were rated by observers to Attachment disorders are rare in young chil-
have almost nonexistent attachments based on dren. In a sample of more than 300 two- to
the children’s behavior in the SSP (Zeanah et 5-year-old children drawn from pediatric clin-
al., 2005). ics in North Carolina, there were no cases of
RAD or DSED (Egger et al., 2006). Even in
disadvantaged samples of young children, the
Disinhibited Social Engagement Disorder
disorder seems to be rare. For example, Boris
The essence of DSED is the failure to exhibit and colleagues (2004) reported that there were
developmentally expectable reticence around no cases of RAD (or what is now called DSED)
unfamiliar adults. This is manifested by the among impoverished young children attending
child’s lack of reticence about engaging socially a Head Start program, and only two of 25 home-
with them, failure of the child to check back less young children met ICD-10 criteria for dis-
with the caregiver in unfamiliar settings and inhibited attachment disorder.
instead tending to wander off, and the child’s Among samples of maltreated children, the
willingness to approach, interact with, and “go disorder seems to be more common. In one
off” with a stranger. Developmentally, stranger retrospective study, clinicians who were ad-
wariness appears early in the second half of the ministered a structured interview reported that
first year of life. Though individual differences 35% of young children coming into foster care
are evident, some degree of stranger wariness is had met criteria for RAD (Zeanah et al., 2004).
evident in all typically developing children. In Oosterman and Schuengel (2007) showed that
DSED, wariness around strangers is absent or signs of both emotionally withdrawn and in-
substantially diminished. discriminate social types of RAD were evident
in preschool children in foster care. In a study ments, RAD cannot. Furthermore, there is no
of 6- to 8-year-old children from a deprived reason to expect selective deficits in imagina-
population in the United Kingdom, Minnis and tive play, deficits in the initiation or response
colleagues (2013) found a prevalence of RAD to joint attention, or deviant language develop-
(based on DSM-IV criteria, and including both ment (e.g., echolalia) in RAD, whereas these
inhibited and disinhibited subtypes) of 1.40%; are common, if not pathognomonic, in ASD.
all but one of the subjects with a definite diag- In addition, persistently restricted, repetitive,
nosis of RAD had histories of maltreatment, as and stereotyped patterns of behaviors, interests,
did all but two of the subjects with a borderline and activities ought to be more characteristic of
diagnosis of RAD. The authors noted that it was ASD than of RAD. Despite these distinctions,
impossible to determine maltreatment histories Davidson and colleagues (2015) found that 62%
for the other three subjects. of their sample of 64 children with ASD met
Signs of RAD and DSED have been readily criteria for “likely RAD” on a semistructured
identified among young children living in insti- parent interview based on DSM-IV criteria (and
tutions. Smyke and colleagues (2002) reported included both “inhibited” and “disinhibited”
some signs of both RAD and DSED in almost subtypes). However, for all but one of those
three-fourths of young children being raised in children, structured observational assessments
a large institution in Bucharest, Romania. In were able to identify clear features that were
another sample of institutionalized young chil- more indicative of ASD. In another study, Sadiq
dren, most had incompletely developed attach- and colleagues (2012) focused on social com-
ments and clinically significant signs of both munication difficulties in children with RAD
types of attachment disorders (Zeanah et al., compared to children with ASD and typically
2005). developing children. They found that the pro-
file of social impairments differed between
the groups, but the RAD group showed even
Differential Diagnosis greater difficulties with rapport, social relation-
ships, and use of context than the ASD group.
Though some of the signs and symptoms of The authors highlighted the importance of mul-
RAD and DSED are similar to those of other tidisciplinary and observational assessment in
disorders, the diagnosis is usually clear because correctly discriminating between the disorders.
of the distinctive clinical features and the his- Anxiety disorders also may include substantial
tory of social neglect. Nevertheless, in clinical inhibition, but positive affect is apparent with
settings, it may be challenging to know histori- caregivers, and selective attachment behaviors
cal details about a particular child, which means ought to be present.
that careful assessments are necessary to dis-
tinguish RAD and DSED from other disorders.
Other clinical problems associated with severe
neglect, such as language and cognitive delays, The insufficient care criterion is particularly
may co-occur and sometimes complicate the important in distinguishing indiscriminate/
clinical picture. disinhibited RAD from conditions such as Wil-
liams syndrome and fetal alcohol syndrome,
both of which have been reported to be asso-
ciated with indiscriminate social behavior (Ja-
The mostly likely clinical entity that can be cobson & Jacobson, 2003; Jones et al., 2000). In
challenging to distinguish from RAD is autism addition, some children with attention-deficit/
spectrum disorders (ASD). DSM-5 (American hyperactivity disorder (ADHD) may be so-
Psychiatric Association, 2013) precludes a diag- cially impulsive. If the child has clear signs of
nosis of RAD in the presence of ASD. Though ADHD including general impulsivity and also
the disorders share impairments in social re- shows indiscriminate behavior with unfamiliar
sponsiveness and evidence of deprivation (e.g., adults, both ADHD and DSED may be present.
stereotypies), there are also important differ- In a study of international adoptees using adop-
ences. Although deprived caregiving condi- tive parents’ reports, Elovainio, Raaska, Sink-
tions characterize RAD, the deprivation in ASD konen, Mäkipää, and Lapinleimu (2015) found
is likely disorder induced. Thus, whereas ASD that both DSED and RAD were associated with
usually occurs in adequate caregiving environ- ADHD; DSED also was associated with higher
externalizing and total problem scores on the cluded some children who had experienced
Child Behavior Checklist (CBCL), while RAD more prolonged institutional rearing, emphasiz-
was associated with higher internalizing, exter- ing that not all children who experience serious
nalizing, and total problem scores. deprivation develop RAD.

Clinical Course
DSED seems to be more persistent than RAD
One of the important considerations for disor- following deprivation. Tizard and Rees (1975)
ders in early childhood is their predictive va- first described indiscriminate behavior in
lidity, but longitudinal studies of signs of at- 4-year-old children with a history of institu-
tachment disorders are uncommon. Evidence tional rearing. These signs persisted when the
regarding the predictive validity of attachment children were 8 years of age (Hodges & Tiz-
disorders comes from the study of Tizard and ard, 1978). At age 16 years, adolescents in this
colleagues of young children in British residen- sample who had demonstrated indiscriminate
tial nurseries (Hodges & Tizard, 1989; Tizard behavior with caregivers at ages 4 and 8 years
& Hodges, 1978; Tizard & Rees, 1975), from were more indiscriminate with peers at 16 years
studies of children adopted out of institutions (Hodges & Tizard, 1989). In addition, signs of
and from the Bucharest Early Intervention indiscriminate behavior have been noted to be
Project (BEIP), and a randomized controlled quite persistent in longitudinal studies of chil-
trial of foster care versus care as usual, for dren adopted out of institutions (Chisholm,
children who experienced early institutional 1998; O’Connor et al., 2003) and in one study
rearing (Zeanah, Humphreys, Fox, & Nelson, of foster children exposed to pathogenic care
2017). (Jonkman et al., 2014). Rutter and colleagues
(2007) reported moderate stability in signs of
indiscriminate behavior in children adopted out
of Romanian institutions into the United King-
The emotionally withdrawn/inhibited type of dom between ages 6 and 11 years. They also
RAD has not been evident in follow-up stud- identified children who showed persistent signs
ies of children adopted out of institutions (see of DSED from early childhood through mid-
Chisholm, 1998; O’Connor et al., 2003). In the adolescence and noted that virtually all were
BEIP, however, there was continuity of signs adopted after 6 months of age. In the BEIP,
of this type of RAD during the first 8 years of children with a history of institutional rearing
life (Gleason et al., 2011), especially for chil- continued to show signs of the indiscriminate
dren who remained in institutions. When chil- type of RAD through 8 years of age, even if
dren with RAD are placed in more favorable they had been placed in foster care (Smyke et
environments, however, signs of the disorder al., 2012).
seemed to dissipate, since they are not report- Similar to RAD, a person centered longitu-
ed in postadoption samples (Chisholm, 1998; dinal analysis of DSED in children followed in
O’Connor et al., 2003; Rutter et al., 2007). BEIP yielded patterns of elevated, persistently
A more recent person-centered longitudinal low, early decreasing, and minimal (Guyon
analysis of the BEIP showed four patterns of Harris et al., 2018). As with RAD, even some
RAD in children from early childhood to early children who experienced severe and prolonged
adolescence: a persistently elevated, a rapidly institutional rearing showed no signs of DSED,
decreasing, a persistently low, and an absent highlighting that a small subset of severely de-
cluster (Guyon-Harris et al., in press). Not sur- prived children did not develop signs of DSED.
prisingly, most children in the rapidly decreas- The elevated pattern mostly comprised children
ing pattern were from the group randomized to with more prolonged institutional exposure, and
foster care. Also, most children in the persis- the early decreasing pattern occurred primarily
tently elevated group were from the group of in children who were removed from depriving
children who had more prolonged institutional institutions and placed before 2 years of age
rearing. Later age of placement into families into foster care. The persistently low profile
and greater percent time in institutional care also was a mixture of children with more and
were each associated with prolonged, elevated less institutional exposure. Elevated and stable
signs of RAD. The absent group, however, in- low patterns were associated with having expe-
rienced more placement disruptions, later age of Asking the caregiver to elicit attachment be-
placement into families, and more time in insti- haviors and separate from the child by leaving
tutional care compared to courses of decreasing the room often provides useful data. Observing
and minimal signs of DSED. the child’s approach to and interaction with the
Taken together, these results suggest that clinician permits an in vivo examination of the
both RAD and DSED show moderate stability child’s behavior with strangers. Comparing the
over time. The difference seems to be that RAD child’s behavior with familiar and unfamiliar
continues to be evident only if adverse care- adults is necessary for diagnosis. One observa-
giving environments continue, whereas DSED tional procedure specifically designed for as-
persists in some children even after caregiving sessing signs of RAD and DSED was proposed
environments improve. by Boris and colleagues (2004) and is included
in the AACAP Practice Parameters (Zeanah et
al., 2016). Other observational laboratory para-
Assessment digms for recording signs of DSED also have
been studied (Bruce, Tarullo, & Gunnar, 2009;
In order to diagnose RAD or DSED, the AACAP Lawler et al., 2014).
Practice Parameters recommend a minimum Ideally, a complete assessment involves more
of careful interviewing of the child’s primary than one observation of the child, with inter-
caregiver about signs of RAD or DSED and ob- views helping to determine how typical the
servations of the child’s interactions with that observed behavior is. Videotaping both obser-
caregiver and with an unfamiliar adult (Zeanah, vational procedures and interviews allows the
Chesher, Boris, & AACAP Committee on Qual- clinician to review relevant data with parents.
ity Issues, 2016). Structured and unstructured Although the SSP has significant constraints
methods of both inquiry and observation of a on its use diagnostically, as part of a compre-
child’s attachment and exploratory behaviors hensive assessment it may have value (Zeanah
are available (Zeanah, Berlin, & Boris, 2011). et al., 2011). In fact, indiscriminate behavior
Inquiring about the child’s attachment be- during the SSP has been coded formally (Ly-
haviors is most important. Establishing that the ons-Ruth et al., 2009). As part of a clinical as-
child has preferred adult caregivers to whom he sessment, however, it is best used to inform an
or she turns for comfort, support, nurturance, understanding of how the child’s attachment
and protection is important. Inquiring about behaviors are organized toward the parent or
the child’s pattern of seeking and responding caregiver rather than to derive a classification
to comfort, protesting separation, being reti- of attachment.
cent with unfamiliar adults, and checking back
in unfamiliar settings are all important. The
clinician should gather a detailed history, for Intervention
example, about the child’s pattern of comfort
seeking, beginning with the onset of stranger To date, the only intervention studies regarding
wariness and progressing through to the time RAD or DSED per se have been in samples of
of assessment. In addition to comfort seeking, children with histories of institutional rearing.
the clinician should inquire about separation These interventions were designed to change
protest, which peaks at around 18 months of age caregiving practices within institutional set-
but typically continues into the preschool years. tings or to remove children from institutions
Data about the child’s behavior in child care set- and place them in families.
tings or schools may be useful as an indication

of the child’s typical behavior in the absence of
Interventions within Institutions
the parent/caregiver. Teacher reports of extreme
withdrawal or indiscriminate behavior could McCall and colleagues (St. Petersburg–USA
raise suspicion about RAD or DSED. Struc- Orphanage Research Team, 2008) conducted
tured interviews to assess RAD (Smyke et al., an ambitious intervention to change the qual-
2002) and DSED (Chisholm 1998; O’Connor et ity of caregiving within institutions for young
al., 2003; Smyke et al., 2002) provide more sys- children in Russia. Using a quasi-experimental
tematic inquiry. design, this group provided training to pro-
Observational data are especially valuable mote more sensitive/responsive caregiving, and
in making the diagnosis of RAD and DSED. structural changes to support positive relation-
ships between children and caregivers, predom- of such references on the standard caregiving
inantly by decreasing the number of caregivers unit.
per child. In one institution for young children,
both of these changes were implemented; in a
International Adoption Studies
second, only training was provided; and in a
third, no intervention was implemented. Two longitudinal studies of children adopted

Although the study included no direct assess- out of Romanian institutions have reported
ments of attachment disorders, the investigators findings regarding RAD. Chisholm (1998) re-
found that nondisabled children in an institution ported on two groups of children adopted from
who received training plus structural changes Romania into Canada. Children in the first
displayed more positive emotions, a greater group (N = 46) were adopted after eight or more
number of emotions, and more activity during months of institutional care. Those in the sec-
free play and reunions following brief separa- ond group (N = 30) were adopted after less than
tion, and they showed more negative emotions 4 months of institutional care. These groups
when their caregiver left and returned. They were compared to another group of 46 typically
also found that children in institutions who developing Canadian children with no history
received training and structural changes dis- of adoption. The groups were assessed initially
played substantially more proximity-seeking at a median of 11 months and later at a median
and contact-maintaining attachment behavior of 39 months following adoption. Attachment
and less avoidant attachment behavior with was assessed by parental report.
their caregivers than did children in the other O’Connor and Rutter (2000) assessed 165
groups. children adopted from Romania into the United
Smyke and colleagues (2002) studied young Kingdom. Of these, 111 were adopted prior to
children in a large institution in Romania. age 6 months, and 54 were adopted between
They examined signs of RAD and DSED in ages 24 and 42 months. They were compared
children on a standard care unit and in chil- to 52 children without histories of maltreatment
dren on a “pilot” unit. These children then who had been adopted within the United King-
were compared to children living with their dom prior to age 6 months.
parents but attending community child care Despite design differences, there was a con-
settings. Whereas children on the standard vergence of findings in these two studies. First,
care unit had many different caregivers in a there were no reports of children with signs of
week, children on the pilot unit had caregiv- RAD, but a substantial minority of children in
ers drawn from a pool of four women on the both samples had signs of DSED. In fact, signs
day and evening shifts; that is, without chang- of indiscriminate behavior are among the most
ing the ratio of caregivers to children (roughly commonly reported social abnormalities in
1:12), the investigators were able to evaluate young children with histories of institutional
the specific effect of reducing the number of rearing. These findings suggest that signs of
caregivers for each child. DSED persist even after the environment im-
Smyke and colleagues (2002) reported that, proves. Both studies also suggested that risk for
not surprisingly, institutionalized children indiscriminate behavior increased with increas-
had significantly more signs of both RAD and ing length of time in institutional rearing. For
DSED than children living with parents. Of example, O’Connor and Rutter (2000) found
note, they also found that children on the stan- that children who exhibited indiscriminate be-
dard unit had more signs of RAD and DSED havior at age 6 years had experienced depriva-
than children on the pilot unit. Anecdotally, tion twice as long (22 months) as children ex-
the investigators noted that caregivers on the hibiting no signs of indiscriminate behavior (11
pilot unit seemed to be more psychologically months).
invested in the children compared to caregiv- Despite these important findings, the limi-
ers on the standard care unit. For example, each tations of adoption studies are that they do not
of the groups of children on the pilot unit had include assessments of individual differences
a name (e.g., “puppies,” “kittens,” “cubs,” or in the preadoptive caregiving environments,
“bunnies”), and the caregivers often referred nor are they able to determine anything about
to “my child” during structured interviews. the children’s possible attachments within the
This was in striking contrast to the absence institutions. In addition, they are somewhat less
representative of institutionally reared children, nally in the foster care group still showed sig-
since those adopted are likely to be selected nificantly fewer signs of RAD than those ran-
based on nonrandom factors. domized to care as usual.
Longitudinal analysis of children who had
experienced varying amounts of institutional
The Bucharest Early Intervention Project

rearing and never-institutionalized children
The most intentional intervention study of RAD revealed four patterns of signs of RAD: persis-
and DSED conducted to date is the BEIP (Zea- tent elevated, persistent low, early decreasing,
nah et al., 2003). This randomized controlled and absent (Guyon-Harris et al., in press). Age
trial (RCT) of foster care as an alternative to in- at which a child was first placed into a fam-
stitutional care was conducted with young chil- ily—foster, adoptive, or biological—proved
dren living in Romanian institutions. Children predictive of profiles. Children in the “early
ranged from 6–30 months of age at the time of decreasing” profile were placed at younger
recruitment. They were assessed comprehen- ages compared to children in the “persistent
sively, then randomly assigned to care as usual elevated” and “persistent low” profiles. There-
or foster care. The RCT continued until the fore, stable, even mildly elevated RAD signs
children were 54 months of age. At that point, over time are associated with longer periods
the foster care network was turned over to local in institutional care before being placed into
government authorities. The children were fol- families.
lowed up at ages 8 and 12 years. Related to this metric, differences between
The goal of the BEIP intervention was to profiles were also found for percentage of time
test a model of foster care that was effective, in institutional care through age 54 months.
affordable, replicable, and culturally sensitive. Spending a greater percentage of time in insti-
Furthermore, the foster care was designed to be tutional care early in life was associated with
informed by the latest clinical and research find- stable moderate to high courses of RAD signs
ings (see Nelson, Fox, & Zeanah, 2014; Smyke, across development, whereas spending less
Zeanah, Fox, & Nelson, 2009). Three project time in care was associated with either no signs
social workers were recruited and trained to of RAD over time or a dramatic drop in symp-
provide a variety of services to foster parents toms followed by sustained absence of signs
and the children for whom they cared. In addi- (Guyon Harris et al., in press).
tion to initial training, the social workers also In contrast, signs of DSED responded to
received regular weekly consultation/supervi- placement somewhat more modestly (Smyke et
sion from experienced clinicians in the United al., 2012), though there were still significantly
States who worked with young, maltreated chil- fewer signs of DSED in children randomized to
dren. The goal was to have the social workers foster care 8 years after the RCT concluded. In-
orchestrate foster care around the needs of the terestingly, elevated and stable low to moderate
children for stable, consistent, and emotionally courses were associated with greater placement
available caregivers. The aim was to have the disruptions, even those that occurred between
foster parent become emotionally invested in 54 months and 12 years of age. Persistence of
the child and advocate on the child’s behalf as signs also was associated with a child’s later age
if he or she were the foster parent’s own child. of placement into a family, and more time in in-
The social workers supported, monitored, and stitutional care compared to courses of decreas-
intervened with foster parents as needed. ing and minimal signs of DSED.
Results of the BEIP indicated that at the Smyke and colleagues (2012) found that
trial’s completion, signs of RAD were reduced children removed from institutions and placed
substantially by placement in foster care, and into foster homes prior to age 24 months had
the response to placement was both early and reductions in signs of DSED compared to those
sustained (Humphreys, Nelson, Fox, & Zeanah, placed after 24 months. In addition, in the Eng-
2017; Smyke et al., 2012). In fact, signs of RAD lish and Romanian Adoptees Study found that
in the foster care group were indistinguishable children with persistent signs of DSED were ad-
from those in the community group at each as- opted after rather than before 6 months of age.
sessment point during the trial and at follow-up. This evidence is compatible with the notion of a
Eight years after the completion of the trial, sensitive period for DSED, suggesting that sig-
when children were 12 years old, children origi- nificantly more benefit will derive from envi-
ronmental enhancement if it is provided earlier adverse caregiving environments (Zeanah et al.,

rather than later. 2004, 2005) and not in children who have been
removed and placed in more optimal caregiv-
ing environments (Chisholm, 1998; O’Connor
Implications for Clinicians
& Rutter, 2000). It is so crucial for children
Based on results to date, it is clear that the first to form and sustain attachments to caregiving
priority of treatment is to establish a safe and adults that they seem to retain the capacity to do
stable caregiving environment with a warm and so once environments improve.
consistent caregiver. Treatment of RAD begins For DSED, the evidence is somewhat differ-
by carefully assessing the relationship between ent. Measures of indiscriminate behavior clear-
the primary caregiver and child. The first ques- ly diverge from other measures of attachment
tion is whether the child has an attachment fig- quality, and in fact, indiscriminate behavior
ure. If not, then treatment means helping the has been identified in children who lack attach-
child to establish an attachment relationship. ments, those with insecure and disorganized
Secure attachments are fostered by caregivers attachments, and even in some children with
who are emotionally available, sensitive, and secure attachments (Chisholm, 1998; O’Connor
responsive, valuing the child as a unique indi- et al., 2003; Zeanah et al., 2005). DSED is less
vidual and placing the needs of the child ahead responsive than RAD to enhanced caregiving
of their own needs. These features are impor- (Smyke et al., 2012).
tant for all children but especially for those who
lack an attachment relationship and must begin
to create one (Zeanah et al., 2011). Relational Disorders of Attachment
Stovall-McClough and Dozier (2004) report-
ed that attachment behaviors of young children The preceding discussion of attachment dis-
in foster care begin to organize around their orders focuses on RAD and DSED, which
new primary caregiver within days to weeks of by definition are within-the-child disorders.
placement, based on diary ratings kept by foster Clinically impairing relationship-specific dis-
parents. If young children have a strong propen- turbances of attachment also have been de-
sity to form attachments, then in species-typical scribed (Lieberman & Pawl, 1988; Lieberman
rearing conditions (i.e., in families), such at- & Zeanah, 1995; Zeanah & Boris, 2000; Zea-
tachments should form readily. This premise is nah, Mammen, & Lieberman, 1993). The basic
supported by all studies conducted to date, in- premise underlying these forms of attachment
cluding studies of children being raised within disorders is that the child has an attachment
institutions, internationally adopted children, relationship with a discriminate caregiver, but
and young children in foster care. Even chil- that the attachment relationship is seriously
dren who have experienced significant neglect disturbed. Lieberman and Pawl (1988) deemed
appear to be capable of forming secure attach- these disturbances “secure base distortions.”
ments, especially if their caregivers are secure- Later, several disturbed relationship patterns
ly attached (Dozier, Stovall, Albus, & Bates, were described, including “self-endangering,”
2001). Adjunctive treatment may be necessary “vigilant/hypercompliant,” and “role-reversed”
in some cases, with a focus on the relationship (Zeanah & Boris, 2000). These descriptions de-
between the child and primary caregiving adult. fined disorders that existed between rather than
The chief goal of the treatment is helping the within individuals.
child to learn through repeated interactions There is considerable evidence that a child’s
with the adult caregiver that the caregiver can pattern of attachment to one caregiver may
be relied upon to provide comfort, support, nur- be different from the pattern of attachment to
turance and protection. Associated problems, another caregiver. van IJzendoorn and Wolff
such as cognitive and language delays, aggres- (1997) conducted a meta-analysis of such stud-
sion, or posttraumatic symptoms, should also ies involving mother–infant and father–infant
be addressed with appropriate therapeutic in- attachment in 950 families. They found a very
terventions. modest but significant concordance (phi = 0.17,
Increasing evidence indicates that RAD is p < .05), indicating that attachment to mother
analogous to absent or nearly absent preferred and attachment to father are largely indepen-
attachments. This may explain why it has been dent. Some have advocated for inclusion of at-
described only in young children in extremely tachment relationship disorders as disorders be-
tween individuals rather than within individuals case report, for example, described adaptation
(Zeanah, 1996; Zeanah & Boris, 2000; Zeanah of parent–child interaction therapy to a young
et al., 1993). Nevertheless, the previously de- child with DSED (Dickmann & Allen, 2017).
scribed secure base distortions have not been Based on available evidence, it appears that
examined systematically, and validity data sup- it is never too late for a child to form an attach-
porting them are lacking. ment. Nevertheless, we do not yet know about
Still, the recently defined relationship-specif- potential long-term impairments in the qual-
ic disorder of infancy and early childhood (Zero ity of attachments that young children who
to Three, 2016) does provide a means by which have had RAD or DSED in early childhood
severely disturbed attachment relationships subsequently develop. Certainly, results from
may be identified. Relationship-specific disor- O’Connor and colleagues (2003) and Marco-
der requires only functionally impairing symp- vitch and colleagues (1997) have suggested
tomatology in the young child that is evident in that these children are at increased risk for un-
the context of one caregiving relationship but healthy and atypical attachments in early child-
not others. Thus, if the disturbed attachment be- hood, even after they are placed in enhanced
havior is specific to one particular relationship, caregiving environments.
then each of the disturbed attachment relation- Other challenges remain for the field. For
ships described earlier—self-endangering, vigi- example, we have little understanding of the
lant/hypercompliant, and role-reversed—would reasons that similar conditions of risk give rise
meet criteria for relationship-specific disorder to the very different clinical pictures of RAD
of infancy and early childhood. This disorder is and DSED. In addition, which aspects of care-
derived from clinical observations and decades giving are most crucial in remediating signs
of attachment research on relationship specific- of disturbance remain to be determined. Also,
ity (Zeanah & Lieberman, 2016), but as a new little is understood about the neural substrate
disorder, it has not yet been subjected to assess- underlying attachment processes. A clearer un-
ments of reliability and validity. derstanding might help to resolve some of the
current dilemmas.
Progress in these and related areas will en-
Summary and Future Directions hance our understanding of the family and so-
cial context of attachment disorders and con-
Insufficient care such as that in social neglect tinue to fill in details of Bowlby’s illuminating
and institutional care increases the risk for insights.
disorders of attachment in young children.
Furthermore, within groups of young children
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Attachment Disorders in Early Childhood: Julianna Finelli Charles H. Zeanah, Jr. Anna T. Smyke

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Attachment Disorders in Early Childhood: Julianna Finelli Charles H. Zeanah, Jr. Anna T. Smyke

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CHAPTER 27

Attachment Disorders in Early Childhood

“A ttachment” describes the human infant’s

by familiarity/comfort, then comfort/pleasure,

Recogni�on/ Familiarity/ Comfort/ Pleasure/ Reliance/

familiarity comfort pleasure reliance preference

FIGURE 27.1. Continuum of behaviors relevant to development of attachment relationships.

TABLE 27.1. Similarities and Contrasts between RAD and DSED

Maltreatment Identified in neglected children Identified in neglected children

Institutional care Identified in children raised in Identified in children raised in

Children adopted from Not identified Not identified

Intervention Very responsive to enhanced Less responsive to enhanced

Sensitive period No evidence Suggestive evidence

& O’Connor, 2015). definition, these three different approaches ac-

Disinhibited Social Engagement Disorder

tings or schools may be useful as an indication

third, no intervention was implemented. Two longitudinal studies of children adopted

The Bucharest Early Intervention Project

ronmental enhancement if it is provided earlier adverse caregiving environments (Zeanah et al.,

Placement of institutionalized young children American Psychiatric Association. (1980). Diagnostic

opted children. Development and Psychopathology, and Human Development.

nis, H. (2014). Disinhibited reactive attachment dis- 349–367.

try (AACAP) Committee on Quality Issues (CQI). thor.

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