Chapter 27: Attachment Disorders in Early Childhood

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CHAPTER 27

Attachment Disorders in Early Childhood

Julianna Finelli Charles H. Zeanah, Jr. Anna T. Smyke

“Attachment” describes the human infant’s century that “essential for mental health is that tendency to seek comfort, support, nurturance, 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. 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

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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 reliance/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. Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.

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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 behaviors 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

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- Reactive Attachment Disorder correlations ranging from 0.64 to 0.97) when 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 convergent 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 Disinhibited Social Engagement Disorder disadvantaged samples of young children, the 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-

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 profile of social impairments differed between the groups, but the RAD group showed even Differential Diagnosis greater difficulties with rapport, social relationships, 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 distinguish RAD and DSED from other disorders. Disinhibited Social Engagement Disorder 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, Reactive Attachment Disorder both of which have been reported to be associated 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

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 Disinhibited Social Engagement Disorder 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 Reactive Attachment Disorder 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

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

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 Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.

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 The Bucharest Early Intervention Project experienced varying amounts of institutional 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- Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.

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- Implications for Clinicians ing environments (Chisholm, 1998; O’Connor & 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) reported 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-

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 social 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 raised in institutions, higher ratings of quality REFERENCES of care are related to increased probability of children having more fully developed attach- AACAP Task Force on Research Diagnostic Criteria: ments, as well as reduced likelihood of having Infancy and Preschool. (2003). Research diagnostic RAD. There is more limited evidence, however, criteria for infants and preschool children: The pro- cess and empirical support. Journal of the American that individual differences in signs of DSED Academy of Child and Adolescent Psychiatry, 42, are related to individual differences in quality 1504–1512. of care, though, clearly, severe deprivation does Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, seem to be associated with the ontogenesis of S. (1978). Patterns of attachment. Hillsdale, NJ: Erl- indiscriminate behavior. baum. Placement of institutionalized young children American Psychiatric Association. (1980). Diagnostic in families seems to reduce signs of RAD and and statistical manual of mental disorders (3rd ed.). DSED, with perhaps more consistent effects Washington, DC: Author. on reducing signs of RAD. Studies of children American Psychiatric Association. (2013). Diagnostic adopted out of institutions, for example, have and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. found virtually no children with significant Boris, N. W., Hinshaw-Fuselier, S. S., Smyke, A. signs of RAD. Findings to date have suggested T., Scheeringa, M., Heller, S. S., & Zeanah, C. H. that RAD and DSED are remediable if children (2004). Comparing criteria for attachment disorders: are placed in more appropriate caregiving en- Establishing reliability and validity in high-risk vironments, although additional interventions samples. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 568–577.

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