Validity of Evidence-Derived Criteria for Reactive Attachment Disorder: Indiscriminately Social/Disinhibited and Emotionally Withdrawn/Inhibited Types

Department of Psychiatry and Behavioral Sciences, Tulane University School of Medicine, 1440 Canal Street, New Orleans, LA 70112, USA.
Journal of the American Academy of Child and Adolescent Psychiatry (Impact Factor: 7.26). 03/2011; 50(3):216-231.e3. DOI: 10.1016/j.jaac.2010.12.012
Source: PubMed
ABSTRACT
This study examined the validity of criteria for indiscriminately social/disinhibited and emotionally withdrawn/inhibited reactive attachment disorder (RAD).
As part of a longitudinal intervention trial of previously institutionalized children, caregiver interviews and direct observational measurements provided continuous and categorical data used to examine the internal consistency, criterion validity, construct validity, convergent and discriminant validity, association with functional impairment, and stability of these disorders over time.
As in other studies, the findings showed distinctions between the two types of RAD. Evidence-derived criteria for both types of RAD showed acceptable internal consistency and criterion validity. In this study, rates of indiscriminately social/disinhibited RAD at baseline and at 30, 42, and 54 months were 41/129 (31.8%), 22/122 (17.9%), 22/122 (18.0%), and 22/125 (17.6%), respectively. Signs of indiscriminately social/disinhibited RAD showed little association with caregiving quality. Nearly half of children with indiscriminately social/disinhibited RAD had organized attachment classifications. Signs of indiscriminately social/disinhibited RAD were associated with signs of activity/impulsivity and of attention-deficit/hyperactivity disorder and modestly with inhibitory control but were distinct from the diagnosis of attention-deficit/hyperactivity disorder. At baseline, 30, 42, and 54 months, 6/130 (4.6%), 4/123 (3.3%), 2/125 (1.6%), and 5/122 (4.1%) of children met criteria for emotionally withdrawn/inhibited RAD. Emotionally withdrawn/inhibited RAD was moderately associated with caregiving at the first three time points and strongly associated with attachment security. Signs of this type of RAD were associated with depressive symptoms, although two of the five children with this type of RAD at 54 months did not meet criteria for major depressive disorder. Signs of both types of RAD contributed independently to functional impairment and were stable over time.
Evidence-derived criteria for indiscriminately social/disinhibited and emotionally withdrawn/inhibited RAD define two statistically and clinically cohesive syndromes that are distinct from each other, shows stability over 2 years, have predictable associations with risk factors and attachment, can be distinguished from other psychiatric disorders, and cause functional impairment.

Full-text

Available from: Charles H Zeanah
NEW RESEARCH
Validity of Evidence-Derived Criteria for
Reactive Attachment Disorder:
Indiscriminately Social/Disinhibited and
Emotionally Withdrawn/Inhibited Types
Mary Margaret Gleason, M.D., Nathan A. Fox, Ph.D., Stacy Drury, M.D., Ph.D.,
Anna Smyke, Ph.D., Helen L. Egger, M.D., Charles A. Nelson III, Ph.D.,
Matthew C. Gregas, Ph.D., Charles H. Zeanah, M.D.
Objective: This study examined the validity of criteria for indiscriminately social/disinhibited
and emotionally withdrawn/inhibited reactive attachment disorder (RAD). Method: As part of
a longitudinal intervention trial of previously institutionalized children, caregiver interviews and
direct observational measurements provided continuous and categorical data used to examine the
internal consistency, criterion validity, construct validity, convergent and discriminant validity,
association with functional impairment, and stability of these disorders over time. Results: As
in other studies, the findings showed distinctions between the two types of RAD. Evidence-
derived criteria for both types of RAD showed acceptable internal consistency and criterion
validity. In this study, rates of indiscriminately social/disinhibited RAD at baseline and at 30, 42,
and 54 months were 41/129 (31.8%), 22/122 (17.9%), 22/122 (18.0%), and 22/125 (17.6%),
respectively. Signs of indiscriminately social/disinhibited RAD showed little association with
caregiving quality. Nearly half of children with indiscriminately social/disinhibited RAD had
organized attachment classifications. Signs of indiscriminately social/disinhibited RAD were
associated with signs of activity/impulsivity and of attention-deficit/hyperactivity disorder and
modestly with inhibitory control but were distinct from the diagnosis of attention-deficit/
hyperactivity disorder. At baseline, 30, 42, and 54 months, 6/130 (4.6%), 4/123 (3.3%), 2/125 (1.6%),
and 5/122 (4.1%) of children met criteria for emotionally withdrawn/inhibited RAD. Emotionally
withdrawn/inhibited RAD was moderately associated with caregiving at the first three time
points and strongly associated with attachment security. Signs of this type of RAD were associated
with depressive symptoms, although two of the five children with this type of RAD at 54 months
did not meet criteria for major depressive disorder. Signs of both types of RAD contributed
independently to functional impairment and were stable over time. Conclusions: Evidence-
derived criteria for indiscriminately social/disinhibited and emotionally withdrawn/inhibited
RAD define two statistically and clinically cohesive syndromes that are distinct from each
other, shows stability over 2 years, have predictable associations with risk factors and
attachment, can be distinguished from other psychiatric disorders, and cause functional
impairment. J. Am. Acad. Child Adolesc. Psychiatry, 2011;50(3):216–231. Clinical trial regis-
tration information—The Bucharest Early Intervention Project, URL: http://www.clinicaltrials.gov,
unique identifier: NCT00747396. Key Words: Reactive attachment disorder, early childhood
D
escriptions of clinical syndromes in very
young children exposed to social depriva-
tion appeared as early as the mid-20th
century.
1
These syndromes comprised a range of
impairing clinical problems that included so-
cial interactions, affect, growth, and immune-
mediated responses in young children in institu-
tions and those who had experienced maltreat-
ment.
2-4
In the first major, systematic, longitudinal
study, Tizard and Rees
5
described the two major
types of “affectional” disorders in very young
institutionalized children who experienced social
deprivation despite adequate attention to nutri-
tion and basic needs. The first was a socially
This article is the subject of an editorial by Dr. Anne L. Glowinski
on page 210.
Supplemental material cited in this article is available online.
An interview with the author is available by podcast at
www.jaacap.org.
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indiscriminant type, in which children exhibited
social boundary violations and were nonselective
in their use of adult caregivers for comfort-
seeking and overly engaging with relative
strangers. The second was an emotionally with-
drawn type, in which children showed limited
social responsiveness, little positive affect and
emotion dysregulation, and a failure to seek
comfort when distressed. The two behavioral
phenotypes were later defined as reactive attach-
ment disorder (RAD), with a requirement that
the signs result from pathogenic care.
6,7
Despite
appearing in DSM since 1980 and in the DSM-IV
8
and the ICD-10, there was little formal study of
the disorders until the past 10 to 12 years. Re-
cently, there has been a growing literature exam-
ining indiscriminant social behaviors in children
exposed to caregiving adversity (reviewed else-
where
9,10
), but the validation of the two disorders
is incomplete. Questions remain about the con-
ditions necessary for the two disorders to de-
velop. Other questions include the degree to
which these syndromes represent distinct disor-
ders that impair functioning, how they relate to
the developmental construct of selective attach-
ment relationships, and the validity of the diag-
nostic criteria. The criteria have been criticized
for being insufficiently informed by the substan-
tial developmental literature on selective attach-
ments, and there are questions about the relation
between RAD and selective attachments.
11,12
To address disordered attachment, it is impor-
tant to understand the construct of attachment.
By 7 to 9 months of age, a young child begins to
direct attachment behaviors selectively toward a
parent figure in times of distress. This process
occurs cross-culturally, and a large literature
describes variations and perturbations in attach-
ment under species-typical rearing conditions.
13
When securely attached, a young child ap-
proaches the parent for comfort and is effectively
calmed by physical proximity to the parent and
the parents’ soothing.
14,15
Secure attachment is
more likely to develop with higher-quality care-
giving. A securely attached child is more likely
to have normal physiologic status and more
positive psychological outcomes.
16-18
Conver-
sely, disorganized attachment patterns describe the
most disturbed classifications of selective attach-
ments, although they are not in and of themselves
evidence of psychopathology and occur in roughly
15% of low-risk dyads.
19
This classification de-
scribes behaviors that demonstrate that the child
lacks a coherent strategy for eliciting comfort from
a caregiver. Disorganized attachment is associated
with a substantially increased risk for subsequent
psychopathology.
19-21
In contrast to these normal
variants of formed attachments, extreme violations
of the expectable environment, such as institutional
rearing, which limit opportunities for a young child
to form selective attachments, create conditions in
which disorders of attachment may develop.
Unlike classifications of attachment security,
which are specific to the relationship between a
child and caregiver, the diagnostic criteria for the
two types of RAD describe cross-situational,
within-the-child disorders. The DSM-IV-TR
8
in-
discriminately social/disinhibited type of RAD
includes criteria describing attachment behaviors
(“lack of selectivity in choice of attachment fig-
ures”) and generalized social behaviors of the
child with strangers (“excessive familiarity with
relative strangers”). The emotionally withdrawn
type of RAD is defined by problems in “most
social interactions.”
Research Diagnostic Criteria for RAD
In 2003, a task force of early childhood mental
health researchers proposed empirically derived
research diagnostic criteria (RDC) modified from
the DSM-IV-TR.
22
The modified diagnostic crite-
ria for RAD maintain the requirement for patho-
genic caregiving for both diagnoses, but the
criteria more closely adhere to focused attach-
ment behaviors than the DSM-IV-TR or ICD-10.
In the RDC, the indiscriminately social/disinhib-
ited type is defined by the child’s lack of selective
approaching of caregivers in situations that
should activate attachment behaviors and by the
presence of nonselective attachment behaviors
toward strangers, such as proximity-seeking.
22,23
The inhibited type of RAD is defined by a per-
vasive lack of active attachment behaviors, with
the child failing to seek proximity, obtain com-
fort, or share positive affect with adult caregiv-
ers. These two distinct patterns of RAD have
been identified in institutionalized and mal-
treated children.
7,10,24,25
Establishing the Validity of a Psychiatric Disorder
This study examined the validity of the RDC for
the two types of RAD in a young children with a
history of institutional care, using an approach
derived from Robins and Guze’s criteria
26
for de-
fining a psychiatric disorder. A clinical disorder
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must demonstrate internal consistency, that is, the
clinical signs cluster together, and criterion validity,
that is, the clinical signs predict a specific measur-
able outcome or gold standard. The clinical presen-
tation, including associations with putative etio-
logic factors, should be part of the characterization
of a psychiatric disorder. A disorder also must
show discriminant validity, that is, the clinical signs
reflect a disorder that can be differentiated from
other known disorders. This is particularly impor-
tant when a disorder has some apparent overlap
with more established disorders. In addition, a
disorder must show some stability over time. Al-
though not required by Robins and Guze, the
criteria must define a clinical entity associated with
functional impairment. Although the two types of
RAD are linked in the DSM nomenclature, they are
defined as two distinct disorders in ICD-10,
27
and
extant research suggests that the research describ-
ing aspects of the disorders’ validity ought to be
examined independently.
One Disorder or Two Disorders
Several studies have examined the two types
of RAD concurrently and provided some evid-
ence that they represent separate clinical enti-
ties due to distinctive symptoms, divergent
relation with quality of caregiving, and differ-
ing courses.
24,28,29
In a study of signs of RAD in
institutionalized young children (mean age, 39
months), four clusters of disordered attachment
patterns were identified. Although the vast ma-
jority of the group demonstrated no signs of
attachment disorder, the remainder were nearly
equally divided among three groups: children
demonstrating the signs of emotionally with-
drawn/inhibited RAD, children with signs of
indiscriminately social/disinhibited RAD, and
children who demonstrated signs of both types
of RAD.
29
Other studies of previously institution-
alized children have suggested that the two types
of RAD have significantly different courses. The
emotionally withdrawn/inhibited type is virtu-
ally nonexistent in large follow-up studies of
children placed in adoptive homes, whereas the
persistence of RAD indiscriminately social/disin-
hibited is much higher.
24,30
There is growing agree-
ment within the field that these two syndromes
should be considered distinct disorders.
6,31
Indiscriminately Social/Disinhibited RAD. Previous
research has demonstrated a link between his-
tory of caregiving adversity, including institu-
tional care, and indiscriminately social/disinhib-
ited RAD.
9,10,32,33
Although the specific nature or
threshold of caregiving adversity required is only
vaguely defined in diagnostic criteria, it is a
critical requirement for the diagnosis because it
distinguishes these children from those with
indiscriminant sociability related to abnormal-
ities of chromosome 7 (i.e., Williams syn-
drome). Conversely, internal consistency and
criterion validity have not been established,
and there are substantial inconsistencies in
reports of associated clinical findings, espe-
cially regarding attachment security and exter-
nalizing behaviors.
10-12,34-37
Stability of the
signs over time beginning after removal from
adverse caregiving has been demonstrated in
postadoption studies, but the trajectory from
the time of institutional care and the influence
of potential selection bias in adopted children
remain unaddressed.
11,18,20
Emotionally Withdrawn/Inhibited RAD. Compared
with the literature focused on the indiscrimi-
nately social/disinhibited type of RAD, the liter-
ature focused on emotionally withdrawn/inhib-
ited RAD is quite small. Cross-sectional studies
in the United States, Great Britain, and Romania
have demonstrated acceptable statistical internal
consistency of the criteria,
25,29
an association with
caregiving adversity including institutional rear-
ing,
25,29,32,34
and an association between emotion-
ally withdrawn/inhibited RAD and completely
developed attachment.
28
Beyond these scattered
findings, there has been limited study of emo-
tionally withdrawn/inhibited RAD.
Goals of This Study
To address these inconsistent findings and examine
the validity of each of the two types of RAD, the
clinical signs and trajectory of RAD signs in chil-
dren enrolled in the Bucharest Early Intervention
Project (BEIP) were examined. In this study, the
clinical presentation was examined by assessing the
internal consistency of the signs and criterion va-
lidity of the two types of RAD, comparing adult-
reported signs of RAD with the diagnosis as deter-
mined by a diagnostic interview and, for
indiscriminately social/disinhibited RAD, with ob-
served behaviors. The construct validity was as-
sessed by examining the predicted associations
between caregiving quality, a putative risk factor
for each type of RAD, and attachment security,
which is inconsistently linked to indiscriminately
social/disinhibited RAD and more consistently
linked with emotionally withdrawn/inhibited
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RAD in the existing literature. Next, convergent
and discriminant validity were examined. Specifi-
cally, indiscriminately social/disinhibited RAD
was hypothesized to have some overlap with
signs of attention-deficit/hyperactivity disorder
(ADHD) but diverge from an ADHD diagnosis and
emotionally withdrawn/inhibited RAD was hy-
pothesized to be be distinct from major depressive
disorder, although some shared clinical character-
istics were hypothesized. In sum, the two RAD
disorders were hypothesized as separate from
more established disorders in young children. The
signs of each type of RAD were predicted to show
moderate stability and over time and be associated
with functional impairment, as would be expected
for a clinically relevant disorder.
METHOD
Participants
This study presents data from the BEIP, which has
been described in detail elsewhere.
38-42
BEIP is the first
randomized, controlled trial of foster care as an alter-
native to institutional care. Children were followed
from baseline (mean age, 21 months) to 54 months.
Initially, 187 children younger than 31 months (range,
6–30 months) living in six institutions for young
children in Bucharest, Romania, were screened for
participation in the study. Figure 1 presents the flow
diagram for the study. Children in the study spent a
mean of 86% of their lives in institutional care. For
most, specific details of their early experiences were
unavailable. Children were excluded from BEIP if they
had genetic syndromes, dysmorphic features of fetal
alcohol syndrome, or microcephaly. Eligible children
were assessed comprehensively and then randomly
assigned to care as usual (continued institutional care)
or placement in foster care. The foster care network
was created and supported by the research team
because of limited foster care availability in Bucharest
at the time of the study. Foster parents were trained by
a Romanian nongovernmental organization and re-
ceived ongoing support from social workers with the
project, with consultation from U.S. consultants with
expertise in foster care, a process described in detail
FIGURE 1 Participant flow diagram.
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elsewhere.
38
For children in the study, all placement
decisions after randomization were made by the Ro-
manian National Authority for Child Protection in
accordance with Romanian law. The only difference
from the usual practice was a negotiated commitment
that any child placed in foster care by the study would
never return to an institution.
43
Children in the care-as-usual group and foster-care
group were at risk of developing RAD by virtue of their
experience in institutional caregiving and are the focus of
this article. Table 1 lists the demographic characteristics
of the participants, and Figure 1 presents the gender and
placement of children at baseline and 54 months.
Measurements
All measurements used in this study were originally
developed in English and were translated into Roma-
nian and back-translated to confirm accuracy by bilin-
gual Romanian research team members. For children
living in a family, the foster mother reported on
caregiver report measurements. If a child in an insti-
tution had a favorite caregiver, that caregiver com-
pleted the measurements. For children who had no
known favorite caregiver, a caregiver who knew the
child well and worked with the child regularly com-
pleted the measurements.
Disturbances of Attachment Interview. The Distur-
bances of Attachment Interview (DAI)
29
is a semistruc-
tured examiner-based interview of a caregiver who
reports on signs of RAD in very young children. The
complete DAI items are included as supplemental
online material (Supplement 1, available online). Re-
sponses to each item are coded on a three-point scale,
where 0 is “clearly demonstrates” a behavior, 1 is
“sometimes or somewhat” demonstrates a behavior,
and 2 is “rarely or minimally” demonstrates a behav-
ior. The DAI includes three items focused on signs
of indiscriminately social/disinhibited RAD and five
items focused on signs of emotionally/withdrawn
inhibited signs of RAD.
The indiscriminately social/disinhibited items exam-
ine how the child uses the caregiver in unfamiliar set-
tings, whether the child exhibits reticence with unfamil-
iar adults, and whether the child is likely to leave with a
stranger. This total score on this scale can range from 0 to
6, with higher scores indicating more signs of indiscrim-
inately social/disinhibited RAD. The emotionally with-
drawn/inhibited items focus on how well the child
differentiates among adults and includes whether the
child shows a clear preference for a particular caregiver,
seeks comfort from a preferred caregiver, and responds
to comforting when offered and the degree to which the
child responds reciprocally in social interactions and
whether the child shows developmentally appropriate
levels of emotional regulation. The emotionally with-
drawn/inhibited scale produces scores of 0 to 10, with
higher scores representing increasing signs of emotion-
ally withdrawn/inhibited RAD.
The DAI scales have demonstrated strong internal
validity in previous research for both types of RAD
(Cronbach
0.83 and 0.80, respectively).
29
Inter-
rater reliability for the DAI was demonstrated to be
excellent (
0.88).
29
Both scales of the DAI distin-
guish between institutionalized and never-institution-
alized children and vary as predicted in children
experiencing differing levels of caregivers.
28,29
The
indiscriminately social/disinhibited scale of the DAI
has been shown to converge with other measurements
of this construct.
37
The emotionally withdrawn/inhib-
ited scale was moderately associated with the degree
to which attachment had formed in very young chil-
dren (mean age, 22 months).
28
The RDC for RAD were applied to the DAI items to
create categorical variables for each type of RAD. For
indiscriminately social/disinhibited RAD, two or
more DAI items must be endorsed, and for emotion-
ally withdrawn/inhibited RAD, at least three items
must be endorsed.
The DAI was administered at baseline (mean, 22
months) and at 30, 42, and 54 months of age by
interviewers trained to reliability (
0.80). In this
study, the respective DAI scales for indiscriminately
social/disinhibited RAD and emotionally withdrawn/
inhibited RAD were used to examine continuous rat-
ings of the signs of RAD at each time point. Scores on
this measurement are presented in Table 1.
TABLE 1 Demographic Characteristics of Participants,
Caregiving Conditions, and Disturbances of Attachment
Scores
Ethnicity, n (%)
Romanian 75 (53.9)
Roma 39 (28.9)
Other 21 (15.6)
Gender, n (%)
Girl 68 (50.4)
Boy 67 (49.6)
Age at randomization, mean (SD) 20.7 (7.2)
Percentage of life in institution at baseline,
mean (SD)
86.5 (20.6)
Disturbances of attachment
Indiscriminately social/disinhibited, range 0–6
Baseline, mean (SD) 2.6 (1.8)
30 mo, mean (SD) 1.9 (1.8)
42 mo, mean (SD) 1.6 (1.9)
54 mo, mean (SD) 1.8 (2.1)
Emotionally withdrawn/inhibited, range 0–10
Baseline, mean (SD) 2.6 (2.5)
30 mo, mean (SD) 1.5 (2.0)
42 mo, mean (SD) 1.2 (1.9)
54 mo, mean (SD) 1.1 (2.2)
Note: SD standard deviation.
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Measurements of Criterion Validity. Preschool Age
Psychiatric Assessment. The Preschool Age Psychiatric
Assessment (PAPA) is a comprehensive parent-report
psychiatric diagnostic interview for preschool chil-
dren.
44,45
Based on responses to the PAPA, an algo-
rithm generates diagnoses, scale scores, and scores
reflecting the number of domains in which the child is
impaired. For this study, DSM-IV criteria were applied
for all diagnoses except RAD, for which the RDC for
preschool age criteria were used. The test-retest reli-
ability of the PAPA is similar to the reliability of
structured psychiatric interviews focused on older
children and adults.
45
The interview was administered
when children were 54 months of age. For this study,
each RAD diagnosis, categorical and symptom count
measurements of ADHD, disruptive behavior disor-
der, major depressive disorder, and continuous scores
of functional impairment were examined.
Stranger at the Door. This procedure was developed
specifically for this study as an observational measure-
ment of indiscriminate behavior at 54 months. Care-
givers were instructed ahead of time to be at the door
with the child when a research assistant who was
unknown to the child (stranger) arrived. When the
parent/caregiver opened the door, this stranger
looked at the child and said, “Come with me. I have
something to show you.” The parent/caregiver was
instructed to look at the child but not to signal any
directions. The child’s behavior was coded as 0
(“stayed with parent”) or 1 (“left with the stranger”). If
the child left with the research assistant, they walked
around the corner, where they found a familiar re-
search assistant who said, “Hello, I am here to play
with you again,” and then resumed the visit. Raters
coded written descriptions of the child’s behavior that
were composed by the research assistant at the time of
the procedure. The
value was 1.0 on the coding of
stayed versus left using two coders blinded to the
child’s placement.
Measurements of Construct Validity. Observational
Record of the Caregiving Environment. The Observational
Record of the Caregiving Environment,
46
with adap-
tations for institutional use, was used to assess the
quality of the caregiving environment at baseline and
at 30 and 42 months. Children were videotaped during
naturalistic interactions in their caregiving setting with
their preferred caregiver for hours. The caregiving
quality score was calculated by averaging the score on
each of five factors (sensitivity, stimulation of devel-
opment, positive regard for child, flat affect [reversed],
detachment [reversed]), which were rated from 1 (not
at all characteristic) to 4 (highly characteristic) and
averaged. The training process, which included an
overview of the Observational Record of the Care-
giving Environment items used in the BEIP and
coding and discussion of practice tapes, led to
excellent internal and inter-rater reliability (Cron-
bach
0.86 and 0.88 0.99, respectively) and has
been described elsewhere.
47
Strange Situation Procedure. Strange situations were
administered at 42 months and coded using the
MacArthur Preschool Attachment Classification Sys-
tem,
48
as described elsewhere,
49
with the categories of
secure, avoidant, ambivalent, disorganized, control-
ling, and insecure-other. Coding is based on the same
principles as the Ainsworth Infant Strange Situation
coding but involves developmental modifications. For
example, secure attachment behaviors in preschoolers
include positive engagement and attention to verbal
and nonverbal interactions. Physical proximity-
seeking is less commonly seen than in infants. The
Preschool Attachment Classification System has
been validated in studies that have demonstrated
predicted associations between attachment classifi-
cations and observed parent–child interaction quali-
ties, parental internal representations and well-
being,
50
and a child’s narrative qualities.
51
Stability of
these classifications is moderate to high (44%–78%)
over 2.5 years, and stability from infant classifications
to preschool classifications is variable but associated
with exposure to stressful life events.
52
Native Roma-
nian coders were blind to a child’s group status. In
addition, 75% of the procedures were double coded to
assess inter-rater reliability, which was more than
acceptable (for every classification,
0.87).
28,49
A continuous rating of the child’s security of attach-
ment to the caregiver was also coded (1 “no security
evident” and 9 “most secure”).
48
Inter-rater reliabil-
ity for this scale was excellent (r 0.87).
53
In this study, the continuous rating of security and
classifications of attachment were examined.
Measurements of Convergent and Discriminant
Validity.
Wechsler Preschool Primary Scale of Intelligence.
The Wechsler Preschool Primary Scale of Intelligence
54
was used to measure cognitive development at 54
months. The 14 subtests of the Wechsler Preschool
Primary Scale of Intelligence assess intellectual func-
tioning in verbal and performance domains. In this
study, a measurement of a child’s general intellectual
ability (full-scale IQ) was included as a potential factor
that contributed to functional impairment.
Infant Toddler Social Emotional Assessment. The Infant
Toddler Social Emotional Assessment (ITSEA) uses care-
giver reports to assess social and emotional well-being
and behavior problems. The ITSEA includes 166 items
rated on a three-point scale. U.S. normative scores can be
converted to T scores for children 12 to 48 months of
age.
55,56
The ITSEA’s psychometric properties are well-
established, with strong test-retest reliability, conver-
gence with the Child Behavior Checklist, and observed
parent–child interactions.
57,58
The ITSEA was adminis-
tered at baseline and at 30 and 42 months.
In this study, the ITSEA scales of activity/impul-
sivity and aggression/defiance were examined as pre-
dicted correlates of indiscriminately social/disinhib-
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ited RAD and depressive signs were included because
of the shared clinical presentation with emotionally
withdrawn/inhibited RAD. The competency scale was
used as a measurement of functional adaptation in
children with signs of both types of RAD.
Bear-Dragon. Bear-Dragon is a test of inhibitory
control.
59
In this task, the experimenter uses two hand
puppets, a bear and a dragon, that each provides
directions to the child. The child was instructed to
follow the bear’s instructions and to not follow the
dragon’s directions. Each puppet gave five directions
and children were coded on a four-point scale that
reflected the degree to which the child responded to
the command. The Bear-Dragon task has demon-
strated high inter-rater reliability and strong consis-
tency with other measurements of inhibition and, as a
composite, is associated with maternal report of inhib-
itory control.
59,60
Typically developing children show
substantial developmental changes in performance on
the task in the preschool years.
61
For this study, a
composite score of bear minus dragon was calculated
as a measurement of inhibitory control. Bear-Dragon
was examined as a correlate of the clinical presentation
of indiscriminately social/disinhibited RAD.
Informed Consent
The institutional review boards of Tulane University
School of Medicine, University of Maryland, and Uni-
versity of Minnesota (institutions of the three principal
investigators) and the commissions on child protection
in each sector (city district) of Bucharest and by the
Romanian Institute of Maternal Child Health reviewed
and approved the study. In 2002, the Romanian Min-
istry of Health established an ad hoc ethics committee
that reviewed and approved the project.
Informed consent was obtained from each child’s
legal guardian. For children in institutions or foster
care, the local child protection commission for the
sector in which the child lived, who was the child’s
legal guardian, gave consent. In addition, institutional
caregivers and foster parents provided assent at the
time of each procedure.
Data Analyses
Because of preliminary research suggesting that the
two types of RAD have different patterns of associa-
tion with attachment, with concurrent caregiving qual-
ity, and vastly different responses to adoption, the
syndromes were predited to show different patterns of
associations. Thus, although the overall analytic ap-
proach was similar with each type of the disorder,
different hypothesis-driven analyses were done when
examining associations between the RAD signs and
other clinical signs.
For most analyses, the sum of scores on the indis-
criminately social/disinhibited scale of the DAI pro-
vided the continuous measurement of indiscriminately
social/disinhibited RAD and the sum of the emotion-
ally withdrawn/inhibited items on the DAI provided
the continuous measurement of emotionally with-
drawn/inhibited RAD. The categorical DAI variable
for each type of RAD derived from the RDC were used
for categorical analyses at baseline and at 30 and 42
months. The PAPA RAD diagnoses were used in
analyses at 54 months because this measurement is a
more extensive interview than the DAI and could be
considered closer to a “gold standard.” For continuous
variables (DAI sum scores, ITSEA scores, sums of
PAPA symptoms, and incapacity scores), two-tailed
Pearson moment correlations were applied. Associa-
tions among categorical variables were assessed using
2
analyses. Fisher exact test was applied when cells
had fewer than five subjects.
For baseline analyses, children 10 months of age
and older were included because focused attachment
behaviors would not be expected in younger children,
making measurements of attachment disorders inap-
propriate.
For analyses that involved longitudinal analyses
(predictive validity), only children randomized to the
care-as-usual group were included to avoid potential
confound of the experimentally induced changes in
caregiving. Repeated measurement analysis, using a
mixed model approach, was used to examine predic-
tive validity, a longitudinal measurement. For each
type of RAD, the DAI score at each time point was
entered, with time as a fixed effect and within-subjects
effect. For these analyses, a random intercept was
used. Model covariance structure for each type of RAD
was selected based on model fit as demonstrated by
2 restricted log likelihood after testing autoregressive
and unstructured models. For indiscriminately social/
disinhibited RAD, an unstructured model demon-
strated the best fit (2 restricted log likelihood
994.0.0) and an autoregressive covariance model
showed the best fit for emotionally withdrawn/inhib-
ited RAD (2 restricted log likelihood 1114.7).
RESULTS
Rates of RAD
Mean scores for both types of RAD on the DAI are
presented in Table 1. As presented in Tables 2 and
3, at baseline and at 30, 42, and 54 months, 41 of 129
(31.8%), 22 of 122 (17.9%), 22 of 122 (18.0%), and 22
of 125 children (17.6%) met criteria for indiscrimi-
nately social/disinhibited RAD. At the same ages, 6
of 130 (4.6%), 4 of 123 (3.3%), 2 of 125 (1.6%), and 5
of 122 children (4.1%) met criteria for emotionally
withdrawn/inhibited RAD.
Internal Consistency
At baseline and at 30, 42, and 54 months, the
internal consistencies of the indiscriminately so-
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cial/disinhibited RAD criteria analyzed using
Cronbach
were 0.68, 0.68, 0.72, and 0.75, respec-
tively. The same analyses for emotionally with-
drawn/inhibited type of RAD revealed Cron-
bach
values of 0.69, 0.70, 0.70, and 0.84.
Association Between Two Types of RAD
Signs of indiscriminately social/disinhibited RAD
and emotionally withdrawn/inhibited RAD were
moderately and significantly correlated at baseline
and at 30, 42, and 54 months (r 0.40, 0.34, 0.41,
and 0.43, respectively; p .001). However, as
would be anticipated by extant research on the
two types of RAD, there was no association
between the two categorical diagnoses at baseline
or 30, 42, or 54 months using Fisher exact test
analyses.
Criterion Validity
The criterion validity of each type of RAD was
examined by comparing the DAI results with the
concurrent PAPA diagnoses, thereby using two
different approaches to measurement the same
outcome. For indiscriminately social/disinhib-
ited RAD, the diagnosis was als compared by
observed social indiscriminance.
Using categorical diagnoses, the diagnosis of
indiscriminately social/disinhibited RAD on the
DAI at 54 months and indiscriminately social/
disinhibited RAD on the PAPA showed concor-
dance in 85.8% of cases (103/120; Fisher exact
test, p .001). Of the children who completed the
stranger-at-the-door procedure, 85.0% (51/60)
behaved as predicted by indiscriminately social/
disinhibited RAD status on the DAI (Fisher exact
test, p .001). That is, 13 children met criteria for
RAD and left with the stranger and 38 children
neither met diagnostic criteria nor left. Of the 15
children who met diagnostic criteria for RAD on
the DAI, 86.7% (13/15) left with the stranger and
13.3% (2/15) did not.
As presented in Table 3, the diagnosis of
emotionally withdrawn/inhibited RAD on the
DAI at 54 months showed 98.3% concordance
with the corresponding PAPA RAD diagnosis
(118/120; Fisher exact test, p .001)).
Construct Validity: Caregiving Quality
All children in the study experienced institu-
tional care, thus meeting the pathogenic care
criteria of RAD. There was, however, no associ-
ation between duration of exposure to institu-
tional care, measured as percentage of life in the
institution, and signs of either type of RAD at
baseline.
The association between signs of the two types
of RAD and concurrent caregiving quality is
presented in Table 4. There was no significant
association between concurrent caregiving qual-
ity and indiscriminately social/disinhibited RAD
at baseline or at 30 months. At 42 months, there
was a small association between caregiving qual-
ity and signs of indiscriminately social/disinhib-
ited RAD. For the emotionally withdrawn/inhib-
ited type of RAD, signs of RAD were associated
with concurrent caregiving at baseline and 30
months.
TABLE 2 Criterion Validity: Rates of Children Meeting
Criteria for Indiscriminately Social/Disinhibited Reactive
Attachment Disorder (RAD) by Disturbances of
Attachment Interview (DAI) and Preschool Age
Psychiatric Assessment (PAPA) at 54 Months
RAD Indiscriminately
Social/Disinhibited
(DAI)
No Yes Total
RAD indiscriminately social/
disinhibited (PAPA)
No 90 14 104
Yes 3 13 16
Total 93 27 120
Note: Concordance 103/120 85.8%, associations significant by
Fisher exact test at p .001.
TABLE 3 Criterion Validity: Rates of Children Meeting
Criteria for Emotionally Withdrawn/Inhibited Reactive
Attachment Disorder (RAD) by Disturbances of
Attachment Interview (DAI) and Preschool Age
Psychiatric Assessment (PAPA) at 54 Months
RAD Emotionally
Withdrawn/Inhibited
(DAI)
No Yes Total
RAD emotionally withdrawn/
inhibited (PAPA)
No 114 1 115
Yes 1 4 5
Total 115 5 120
Note: Concordance 118/120 98.3, associations significant by
Fisher exact test at p .001.
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Construct Validity: Selective Attachment Patterns
Signs of indiscriminately social/disinhibited
RAD were moderately and inversely associated
with security of attachment at 42 months, as
presented in Table 4. Of the 22 children who met
the RDC for indiscriminately social/disinhibited
RAD at 42 months, two (9%) were classified as
secure, four (18.2%) as avoidant, one (4.5%) as
ambivalent, three (13.6%) as disorganized/con-
trolling, and 12 (54.6%) as insecure-other. Over-
all, 7 of 15 (46.7%) who met criteria for indiscrim-
inately social/disinhibited RAD showed an
organized attachment pattern.
In comparison, 39 of the 101 (39%) who did
not meet the RAD criteria were classified as
secure and an additional 22 were avoidant (22%),
11 were ambivalent (11%), seven were disorga-
nized/controlling (7%), and 22 were insecure-
other (22%). When attachment classification was
dichotomized into organized and disorganized,
children who met criteria for indiscriminately
social/disinhibited RAD were less likely to be
classified as having an organized attachment
pattern (
2
2
12.3; p .001), but one third of
them were classified as having an organized
attachment pattern.
Signs of emotionally withdrawn/inhibited
RAD were negatively correlated with concurrent
level of observed attachment security at 42
months. The two children who met the RDC for
emotionally withdrawn/inhibited RAD at 42
months were classified as insecure-other on the
Macarthur Preschool Attachment Classification,
although there was no statistical difference in
distributions (Fisher exact test, p .1).
Convergent and Discriminant Validity:
ADHD Patterns and Inhibitory Control
Signs of indiscriminately social/disinhibited
RAD showed no association with activity level or
aggression on the ITSEA at the first three assess-
ment points but showed a substantial relation
with signs of ADHD on the PAPA at 54 months.
There was a modest association between concur-
rent signs of indiscriminately social/disinhibited
RAD with low levels of inhibitory control as
assessed by the Bear-Dragon task at 54 months
(Table 5).
To assess discriminant validity, diagnoses of
RAD indiscriminately social/disinhibited were
compared with ADHD. Only four of the 16
children who met RDC for indiscriminate/disin-
hibited RAD on the PAPA also met criteria for
ADHD, and there was no statistical association
between the two.
Discriminant Validity: Depression
As predicted and reported in Table 6, signs of
emotionally withdrawn/inhibited RAD were as-
TABLE 4 Construct Validity: Correlations between Signs
of Reactive Attachment Disorder (RAD) and Caregiving
Quality and Security of Attachment
Caregiving
Quality
Security of
Attachment
Indiscriminately social/
disinhibited RAD
Baseline 0.11
30 mo 0.11
42 mo 0.21* 0.39***
Emotionally withdrawn/
inhibited RAD
Baseline 0.33***
30 mo 0.38***
42 mo 0.29** 0.51***
Note: *p .05; **p .01; ***p .001.
TABLE 5 Convergent Validity: Associations Between Signs of Indiscriminately Social/Disinhibited Reactive Attachment
Disorder and Externalizing Signs
ITSEA Activity/
Impulsivity
ITSEA Aggression/
Defiance
Bear-Dragon
Procedure
PAPA ADHD
Signs
PAPA ODD,
CD Signs
Baseline (n 130) 0.01 0.07
30 mo (n 126) 0.12 0.07
42 mo (n 123) 0.19* 0.14
54 mo (n 123) 0.28* 0.45*** 0.30**
Note: ADHD attention-deficit/hyperactivity disorder; CD compulsive disorder; ITSEA Infant Toddler Social Emotional Assessment; ODD
oppositional defiant disorder; PAPA Preschool Age Psychiatric Assessment.
*p .05; **p .01; ***p .001.
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sociated with higher levels of depressive symp-
toms at all time points. However, despite the
association between emotionally withdrawn/in-
hibited RAD and depressive signs, two of the five
children who met PAPA RDC for emotionally
withdrawn/inhibited RAD did not met criteria
for major depressive disorder, demonstrating
discriminant validity for the diagnosis, although
there was a statistical association (Fisher exact
test, p .001).
Stability of Indiscriminately Social/
Disinhibited RAD Over Time
Next, the stability of RAD over time was exam-
ined. Because of a substantial but experimentally
imposed change in caregiving experiences (from
institutional care to family care), only the chil-
dren randomized to the care-as-usual group
were examined for this analysis. Linear mixed
modeling demonstrated that there was a de-
crease in signs of RAD from baseline to 54
months over the four time points (F
4, 22,505
4.0;
p .01). However, at every time point, the
estimated marginal means showed overlapping
95% confidence intervals, a finding that is equiv-
alent to p .05 or no significant difference (Table
7 and Figure 2). Examination of the pairwise
comparisons demonstrated that there were no
significant differences between signs of indis-
criminately social/disinhibited RAD at any time
points (p .1). Post hoc analysis examining the
effect of remaining in the institution throughout
the study period approached significance (F
1,88
3.4; p .06). Signs of emotionally withdrawn/
inhibited RAD also showed a decrease in time
over the course of the study in the care-as-usual
group (F
4,122
25.4; p .001). As seen in the
indiscriminately social/disinhibited type of RAD,
95% confidence intervals for the estimated mar-
ginal means were overlapping at every time
point, indicating that no difference in the inter-
vals between time points. Similarly, pairwise
comparisons revealed no significant difference
between any consecutive time points (e.g., be-
tween baseline and 30 months and between 30
and 42 months). The only significant difference
was between baseline and 54 months (mean
difference, 0.9; p .04; Figure 3 and Table 7).
Functional Impairment
Both types of RAD were predicted to be associ-
ated with functional impairment. Using the
FIGURE 2
Signs of indiscriminately social/disinhibited
reactive attachment disorder (RAD) across time points by
placement status at 54 months in CAU group. Note:
DAI Disturbances of Attachment Interview; NS not
significant.
TABLE 6 Convergent Validity: Correlation between
Emotionally Withdrawn/Inhibited Reactive Attachment
Disorder and Depressive Signs
ITSEA Depression PAPA Depression
Baseline (n 121) 0.44***
30 mo (n 123) 0.35***
42 mo (n 126) 0.72***
54 mo 0.62*
Note: ITSEA Infant Toddler Social Emotional Assessment; PAPA
Preschool Age Psychiatric Assessment.
*p 05; ***p .001.
TABLE 7 Predictive Validity: Estimated Marginal Mean (EMM) Scores of Reactive Attachment Disorder (RAD) Across
Four Time Points in Care-as-Usual Group
EMM Score (95% CI)
Baseline 30 mo 42 mo 54 mo
Signs of indiscriminately social/disinhibited RAD 2.5 (0.4–4.7) 2.1 (0–2.3) 2.1 (0–4.2) 2.2 (0.01–4.3)
Signs of emotionally withdrawn/inhibited RAD 2.8 (2.1–3.4) 2.4 (1.8–3.0) 2.0 (1.4–2.7) 1.9 (1.2–2.5)
Note: CI confidence interval.
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ITSEA social competence at the first three time
points and the PAPA incapacity scale at 54
months, there was a statistically significant asso-
ciation between indiscriminately social/disinhib-
ited RAD and impairment at all ages except
baseline, with a large association at age 54
months. At 30 and 54 months, these associations
remained significant in a linear regression, after
controlling for two other potentially impairing
factors—signs of ADHD and IQ—as presented in
Table 8.
As predicted, having more signs of emotion-
ally withdrawn/inhibited RAD was moderately
associated with measurements of social emo-
tional competence and functional impairment in
the predicted directions at all time points. Con-
trolling for IQ and clinical signs of depression,
signs of emotionally withdrawn/inhibited RAD
independently contributed to the variance in
competence on the ITSEA at baseline and 30 and
42 months, but not at 54 months (Table 9).
Signs of emotionally withdrawn/inhibited RAD
at each age were hypothesized to predict functional
impairment at age 54 months in children random-
ized to care as usual, and this prediction was
confirmed. The magnitude of the association be-
tween impairment at 54 months and signs of emo-
tionally/withdrawn/inhibited RAD was moderate
at baseline and 42 and 54 months. The association
remained significant in a stepwise regression that
included independent contributions by IQ and
signs of depression at baseline (adjusted R
2
0.15;
F
1
9.6;
0.4; t
1
3.7; p .003).
DISCUSSION
These findings represent the most complete as-
sessment of the reliability and validity of two
types of RAD in young children published in a
single study to date. First, previous suggestive
findings that the indiscriminately social/disinhib-
ited and the emotionally withdrawn/inhibited
types appear to be distinct clinical disorders were
replicated. Statistically, although the continuous
variable of signs of RAD showed moderate inter-
correlations between the two disorders, the cate-
gorical diagnoses were not associated at any time
point. These findings extend the literature demon-
strating that these two constructs likely represent
clinically distinct disorders that should be consid-
ered separately.
With regard to indiscriminately social/disin-
hibited RAD, previous findings of high levels of
internal consistency of the signs of indiscrimi-
nately social/disinhibited RAD over multiple
time points were replicated.
28
The mean internal
consistency of 0.71 indicates statistical cohe-
sion,
62
similar to that found in other studies of
validated preschool and school age criteria.
63,64
Second, criterion validity was demonstrated by
the convergence of diagnoses by different mea-
surements, including a psychiatric diagnostic in-
terview, an observational measurement, and a
FIGURE 3 Signs of emotionally withdrawn/inhibited
reactive attachment disorder (RAD) across time points by
placement status at 54 months in CAU group. Note:
DAI Disturbances of Attachment Interview; NS not
significant.
TABLE 8 Functional Impairment: Indiscriminately
Social/Disinhibited Reactive Attachment Disorder (RAD)
and Concurrent and Predictive
Concurrent Associations
(N 135)
Social
Competence
(ITSEA)
Total
Impairment
(PAPA)
Indiscriminately social/
disinhibited RAD
Baseline (n 130) 0.13
30 mo (n 126) 0.28**
42 mo (n 123) 0.21*
54 mo 0.49***
Emotionally withdrawn/
inhibited RAD
Baseline (n 130) 0.64***
30 mo (n 126) 0.25**
42 mo (n 123) 0.60***
54 mo (n 123) 0.41**
Note: ITSEA Infant Toddler Social Emotional Assessment; PAPA
Preschool Age Psychiatric Assessment.
*p .05; **p .01; ***p .001.
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structured interview assessing indiscriminate be-
havior. Convergence with an observational mea-
surement extends previously reported findings
that different interviews showed convergence
with one another.
11
The association of indiscriminately social/dis-
inhibited RAD with caregiving quality and at-
tachment was examined. Caregiving quality is
asserted to be an etiologic contributor to indiscrim-
inately social/disinhibited RAD.
8
However, in the
present study, concurrent caregiving quality was
associated with signs of indiscriminately social/
disinhibited RAD only at 42 months and then only
modestly. In other studies, indiscriminate behavior
has been associated with maternal psychopathol-
ogy and history of maltreatment,
25,50
disrupted
affective communication and duration of institu-
tional care,
9,10,12
but only one of these studies
included direct assessments of caregiving behavior.
It is possible that low-quality caregiving in institu-
tions is necessary to potentiate the development of
indiscriminately social/disinhibited RAD, at least
in some children, but that once indiscriminate be-
havior develops, the importance of caregiving
quality diminishes. This could explain why postin-
stitutional caregiving environments in other popu-
lations do not eliminate signs of indiscriminately
social/disinhibited RAD even when they are of
high quality.
10,30
At this time, the relation be-
tween specific characteristics of caregiving and
indiscriminately social/disinhibited RAD ap-
pears to be less than straightforward and war-
rants further investigation.
Regarding the relation between indiscrimi-
nately social/disinhibited RAD and selective at-
tachment patterns, the present findings were
mixed. A continuous rating of secure attachment
was moderately and inversely related to signs of
indiscriminately social/disinhibited RAD at 42
months. In contrast, several studies, including the
present one, have demonstrated that organized
classifications in the Strange Situation Procedure
does not preclude high levels of indiscriminate
behavior.
12,30
In fact, in the present study, nearly
half of children who met criteria for indiscrimi-
nately social/disinhibited RAD showed organized
attachment classifications. Others have reported
similar findings,
10,12,30
including Lyons-Ruth et
al.
50
who showed that indiscriminate behavior car-
ried additional risks for adverse mental health
outcomes over and above disorganized attach-
ment. The present results support a growing em-
pirical base that indicates that, although the signs of
indiscriminately social/disinhibited RAD are mod-
erately associated with the construct of attachment,
indiscriminately social/disinhibited RAD reflects a
separate construct that often can occur independent
of the quality of the child’s selective attachment
TABLE 9 Contribution of Reactive Attachment Disorder (RAD) in Logistic Regression Predicting Functional Impairment
When Controlling for Psychiatric Signs and IQ
Standard
Coefficient T Statistical Significance (p)
Signs of indiscriminately social/disinhibited RAD
Baseline 0.11 1.7 NS
Model R
2
0.14, F
3
6.8
30 mo 0.24 2.7 .01
Model R
2
0.16, F
3
8.3
42 mo
Model R
2
0.24, F
3
14.2 0.05 0.54 NS
54 mo 0.19 2.3 .03
Model R
2
0.43, F
3
27.6
Signs of emotionally withdrawn/inhibited RAD
Baseline 0.47 6.2 .001
Model R
2
0.43, F
3
36.6
30 mo 0.20 2.1 .04
Model R
2
0.2, F
3
12.0
42 mo 0.24 2.4 .02
Model R
2
0.46, F
3
34.5
54 mo 0.01 0.1 NS
Model R
2
0.27, F
3
14.4
Note: Baseline, 30, 42 months models predict social competence on ITSEA, 54 month model predict functional impairment on PAPA. NS not significant.
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relationships and concurrently with organized at-
tachment patterns. These and similar findings have
led some to question whether indiscriminately so-
cial/disinhibited RAD is best considered some-
thing other than an attachment disorder.
7,19
Other researchers have suggested that indis-
criminately social/disinhibited RAD represents
an adaptive process for children vying for atten-
tion in institutions
65
or a failure to develop
committed social relationships.
7
The present
findings allow us to comment on these hypothe-
ses. In the present study, this type of RAD was
not adaptive because signs of this type of RAD
were associated with functional impairment. In
this study, some children with indiscriminately
social/disinhibited RAD showed organized at-
tachment patterns, thus not supporting the hy-
pothesis that the core deficit in this type of RAD
is a failure of committed social relationships. The
finding that signs of RAD were only modestly
associated with cognitive measurements of inhibi-
tory control on the Bear-Dragon task is intriguing
and suggests that socially indiscriminant behavior
in these children is a separate construct from cog-
nitive disinhibition. Further research examining the
core deficit in children with indiscriminately so-
cial/disinhibited RAD is warranted.
The present study also allowed an investiga-
tion of other constructs that can be differentiated
from indiscriminately social/disinhibited RAD.
Previous studies have provided mixed findings
about the association between this type of RAD and
externalizing signs. In the present study, signs of
indiscriminately social/disinhibited RAD before 54
months were minimally associated with externaliz-
ing behavior problems, thereby providing support
for discriminant validity. Few previous studies
have explored this association in children this
young. The present study confirmed the previ-
ously reported association between indiscrimi-
nately social/disinhibited RAD and clinical signs
of ADHD at 54 months, but also showed that
these disorders most often occur independently
of each other. Taken together, these findings and
the modest association between indiscriminately
social/disinhibited RAD and lower observed lev-
els of inhibitory control suggest that indiscrimi-
nately social/disinhibited RAD is driven by a
process that may be related to problems with
social inhibitory control but is distinct from the
processes involved with ADHD. The more mod-
est association between activity and impulsivity
and RAD at the first three time points than with
ADHD at 54 months may reflect a developmental
process in which problematic indiscriminately
social behaviors are the first clinical presentation
of an inhibitory control problem that progresses
and generalizes over time or facilitates the devel-
opment of other forms of disinhibition. Alterna-
tively, it is possible that the differences reflect
differences in measurements between a parent-
report questionnaire and a structured psychiatric
interview format or increased specificity of these
measurements with age.
Indiscriminately social/disinhibited RAD in
the care-as-usual group showed significant sta-
bility at all intervals in the study, although over-
all there was a decline in levels of RAD over the
course of the study. The decrease in signs of RAD
in the group randomized to care as usual could
be related to caregiving changes because some of
the care-as-usual children moved out of the in-
stitutions, a hypothesis that was not supported
but warrants further examination particularly
because the subgroup of children who remained
in the institutions by 54 months was relatively
small. The caregiving experiences of the children
in the care-as-usual groups were determined by
nonrandom factors including a range of family
and nonfamily experiences, which may contrib-
ute to the overall decrease of signs of RAD. The
overall finding of stability in the intervals mea-
sured is consistent with other studies that have
demonstrated persistence of signs of indiscrimi-
nately social/disinhibited RAD after removal
from institutional care and extends the findings
by demonstrating stability of symptoms begin-
ning with institutional care.
10,24
Overall, these
findings reflect the presence of a nontransient
pattern of a clinical syndrome.
In addition, indiscriminately social/disinhib-
ited RAD signs were demonstrated to be associ-
ated with functional impairment, which is neces-
sary to distinguish the disorder from children
who are adaptably sociable. The magnitude of
the association between signs of RAD and im-
pairment was strongest at 54 months. At 54 and
30 months, signs of indiscriminately social/dis-
inhibited RAD contributed to impairment even
when controlling for IQ and signs of ADHD,
adding to the evidence that, at least at those ages,
this type of RAD is impairing to children above
and beyond other impairing clinical factors. It
should be noted that the measurement of impair-
ment used for the first three time points only
measures social competence, and that PAPA
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Page 13
measures impairment in a broader range of
domains, including family, peer, school, and pub-
lic settings. Thus, the earlier measurements may
not fully reflect the magnitude of cross-domain
impairment seen in children with RAD during
toddlerhood and the early preschool years. It is
also possible that the cumulative experience as-
sociated with having signs of RAD or the expe-
riences that facilitated the persistence of the signs
up to 54 months account for the strong associa-
tion at that time point.
In summary, the findings in this study demon-
strate that indiscriminately social/disinhibited
RAD is a distinct disorder that has minimal asso-
ciation with concurrent caregiving quality, can be
seen in the context of an organized attachment
relationship, is distinct from externalizing disor-
ders and cognitive inhibitory control, and is asso-
ciated with the same level of stability across at least
2 years as other DSM disorders in this age group.
Like other disorders, this type of RAD is associated
with functional impairment. In sum, RAD appears
to be a distinct clinical disorder whose underlying
core deficit warrants further examination.
To the best of our knowledge, this is the most
comprehensive assessment of emotionally with-
drawn/inhibited RAD reported to date, includ-
ing attention to coherence of the signs of the
disorder, association with expected risk factors
and clinical syndromes, distinguishing the disor-
der from other types of psychopathology, func-
tional impairment, and stability of signs over
time. The present results support the validity of
emotionally withdrawn/inhibited RAD as a dis-
tinct disorder.
First, we demonstrated that the emotionally
withdrawn/inhibited RDC have significant inter-
nal consistency at four different ages in the first 5
years of life. In addition, we demonstrated crite-
rion validity by finding that two different struc-
tured, independently administered psychiatric
interviews converged on the same diagnosis.
Second, we demonstrated construct validity
by demonstrating an association between poorer
caregiving quality and signs of emotionally with-
drawn/inhibited RAD at 30 and 42 months,
thereby extending previously reported findings
of institutionalized toddlers and children with
histories of institutional care living in the United
States, Great Britain, and Romania.
28,29,34
In ad-
dition, we demonstrated an inverse relation be-
tween signs of emotionally withdrawn/inhibited
RAD and security of attachment behavior at 42
months, extending previously reported findings.
28
As expected, emotionally withdrawn/inhib-
ited RAD was associated with signs of depressive
disorders, which share overlapping clinical pre-
sentations. Although the number of children who
met categorical RDC for emotionally with-
drawn/inhibited RAD was extremely limited
and the findings must be interpreted with cau-
tion, two of the five children who met RAD
criteria did not meet criteria for major depressive
disorder, suggesting that these may be distinct
diagnostic entities.
Like signs of indiscriminately social/disinhib-
ited RAD, emotionally withdrawn/inhibited
RAD showed stability at each interval in the
care-as-usual group. This finding is particularly
important because previous studies of children
after institutional care have identified almost no
children with emotionally withdrawn/inhibited
RAD. This is the first demonstration of the sta-
bility of emotionally withdrawn/inhibited RAD
in children in institutional care. Remaining in
institutional care throughout the study period
was not significantly associated with a higher
stability of RAD, an unexpected finding because
research focused on children with histories of
institutional care has demonstrated that that type
of RAD is extraordinarily rare.
24
At all four ages of assessment, signs of emo-
tionally withdrawn/inhibited RAD were associ-
ated with functional impairment. These associa-
tions not only demonstrate that these clinical
signs have clinical and statistical coherence, but
that they are clinically relevant and associated
with problems with functioning in a range of
domains, even when controlling for associated
developmental delays and depressive signs.
To summarize, signs of emotionally with-
drawn/inhibited RAD were distinct from the indis-
criminately social/disinhibited type of RAD, were
associated with poorer caregiving quality in infants
and toddlers and preschoolers, and were inversely
associated with attachment security. Taken to-
gether, these findings suggest that that the essence
of the emotionally withdrawn inhibited RAD is
lack of selective attachment. The disorder shares
some clinical signs with depression but can occur
independently of major depressive disorder. The
stability of the disorder between consecutive
time points in the care-as-usual group was dem-
onstrated and was associated with substantial
functional impairment at all ages assessed.
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Page 14
Although these findings support all of our
hypotheses, several limitations must be acknowl-
edged. First, this study did not examine the
disorders in children exposed to pathogenic care-
giving conditions other than institutionalization
and may not be generalizable to children exposed
to other types of adverse caregiving. Second, we do
not have detailed information about caregivers’
history, such as psychiatric status or maltreatment
history, and thus cannot explore these factors as
predictors of signs of either type of RAD, and we
did not have access to information that would
allow us to characterize children’s preinstitutional
experiences and relationships. Third, caregivers re-
porting on the same child with different measure-
ments may conflate levels of agreement. However,
the convergence of interviews and observational
measurements for both types of RAD increases
confidence in the caregiver-report measurements
used. Fourth, the low rates of emotionally with-
drawn/inhibited RAD limited statistical analyses
using categorical measurements and raise ques-
tions about whether the threshold of the diagnostic
criteria may be too high. Fifth, biological markers
were beyond the scope of this study.
These findings provide support for the diagnos-
tic validity of indiscriminately social/disinhibited
RAD and emotionally withdrawn/inhibited RAD
in children with a history of institutional rearing.
The present findings provide significant support
for the criterion validity, construct validity, dis-
criminant validity, and predictive validity of these
two disorders. This study adds significantly to the
existing knowledge about the two types of RAD
through examination of the clinical constructs in a
group of vulnerable children who were followed
longitudinally using observational and interview
methodologies. Future studies will examine shared
and distinct characteristics of indiscriminately so-
cial/disinhibited RAD and of Williams syndrome,
which may serve as a biological model for the
disorder. In addition, further research will examine
biological markers associated with each type of
RAD and will explore effective treatments for each
type of RAD. &
Accepted December 20, 2010.
Drs. Gleason, Drury, Smyke, and Zeanah are with Tulane University
School of Medicine. Dr. Fox is with the University of Maryland. Dr.
Egger is with Duke University Medical Center. Drs. Nelson and
Gregas are with Harvard Medical School.
The Bucharest Early Intervention Project was funded by the John D. and
Catherine T. MacArthur Foundation through the Research Network on
“Early Experience and Brain Development.”
The authors are grateful to the research staff, children, caregivers, and
families involved in the Bucharest Early Intervention Project.
Disclosure: Drs. Gleason, Fox, Drury, Smyke, Egger, Gregas, Nelson,
and Zeanah report no biomedical financial interests or potential
conflicts of interest.
Correspondence to Mary Margaret Gleason, M.D., Department of
Psychiatry and Behavioral Sciences, 1440 Canal Street TB 52,
New Orleans, LA 70112; e-mail: Mgleason@tulane.edu
0890-8567/$36.00/©2011 American Academy of Child and
Adolescent Psychiatry
DOI: 10.1016/j.jaac.2010.12.012
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SUPPLEMENT 1: DISTURBANCES OF
ATTACHMENT INTERVIEW
This is a semistructured interview designed to be
administered by clinicians to caregivers who know
the child and the child’s behavior well. If possible,
it should be administered to the child’s primary
caregiver. Specific probes are designed to elicit
more information; they are not intended to be
exhaustive. Clinicians should feel free to probe
further. The scoring is completed at the close of the
interview based on the responses provided.
Interviewers talk with parents/caregivers
about their children and some of the things they
do, so the interviewers can better understand the
children. This interview takes about 20 minutes.
How old is the child?
1. Does s/he have one special adult that s/he
prefers? Who is it? How does s/he show
that s/he prefers that person? Can you
give me a specific example? Are there any
other adults that are special, like this? Who
does s/he prefer most of all?
0 Clearly differentiates among adults
1 Sometimes or somewhat differentiates
among adults
2 Rarely or minimally differentiates among
adults
2. When s/he falls down and hurts himself/
herself what does s/he do? Is s/he one to
sit where s/he is and wait for you or other
caregivers to come or does s/he come over
and tell you when s/he is hurt? Does she
ever go to people that she doesn’t know
well for comfort? Does she ever go to
someone unfamiliar for comfort even
when someone familiar is available?
0 Clearly seeks comfort preferentially from
a preferred caregiver
1 Sometimes or somewhat seeks comfort
preferentially from a preferred caregiver
2 Rarely or minimally seeks comfort pref-
erentially from a preferred caregiver
[The following item is rated but does not
count in scoring.]
0 Actively seeks comfort from an available
caregiver when hurt or upset
1 Sometimes or somewhat seeks comfort
from an available adult caregiver when
hurt or upset
2 Rarely or minimally seeks comfort from
an available caregiver when hurt or dis-
tressed; sits and cries or does not cry at
all when hurt or distressed
3. When s/he does come to you/or the pre-
ferred caregiver (or when you go to him/
her), does s/he accept being comforted or
is s/he one to take a while to calm down?
0 Clearly responds to comfort from caregiv-
ers when hurt, frightened, or distressed
1 Sometimes or somewhat responds to
comfort from caregivers when hurt,
frightened, or distressed
2 Rarely or minimally responds to comfort
from caregivers when hurt, frightened,
or distressed
4. Does s/he share things back and forth with
you, let’s say, talk with you or show you
that s/he’s excited about something or is
s/he one to not really share back and
forth? Does s/he take turns talking or
gesturing with you?
0 Clearly responds reciprocally with fa-
miliar caregivers
1 Sometimes or somewhat responds recip-
rocally with familiar caregivers
2 Rarely or minimally responds recipro-
cally with familiar caregivers
5. How are his/her moods? Is s/he generally
happy or is s/he one to be more irritable or
sad or serious? Would you say s/he is like
that most of the time or some of the time?
How much of the time is s/he sad, serious,
or irritable.
0 Clearly regulates emotions well with
ample positive affect and developmen-
tally expectable levels of irritability and/
or sadness
1 Sometimes or somewhat has difficulty
regulating emotions with less positive
affect and more irritability and/or sad-
ness than is expected developmentally
2 Rarely or minimally regulates emotions
well; instead, has little positive affect
and definitely elevated levels of irritabil-
ity and/or sadness
6. When you are in a place that is not familiar
for [child], what does s/he do? Does s/he
check back with you or is s/he one to just
go off without checking back? Does s/he
tend to wander off without any particular
purpose? If s/he finds him/herself sepa-
rated from you does s/he get upset or does
it seem to not really bother him/her?
0 Clearly checks back with caregiver after
venturing away, especially in unfamiliar
settings
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1 Sometimes or somewhat checks back
with caregiver after venturing away, es-
pecially in unfamiliar settings
2 Rarely or minimally checks back with
caregiver after venturing away, espe-
cially in unfamiliar settings
7. How does s/he behave around adults that
s/he doesn’t know? Does s/he tend to be
friendly or is s/he one to stand back and
observe or to approach? Does s/he tend to
be sort of shy around strangers or is s/he
one to go right up to people s/he doesn’t
know? (If yes, why do you think s/he does
this?) Does s/he cry or cling to you or does
she just seem wary/cautious? Does s/he
do this all the time or some of the time? Is
his/her reaction sort of mixed so that at
some times s/he is friendly but other times
she might cry or s/he is friendly with some
unfamiliar adults but not with others?
Could you give me a specific example of a
time when s/he was around an adult that
s/he didn’t know?
If shy, does s/he seem to be shy at first
and then tend to warm up or does s/he
stay shy? Has she been consistently shy
over time or has that been variable? For
example, was she at one time more shy or
less shy than she is now? [For adopted/
foster children: Has s/he been the same in
terms of shyness since you have known
him/her or has her/his level of shyness
changed at all?]
0 Clearly exhibits reticence with unfamil-
iar adults
1 Sometimes or somewhat exhibits reti-
cence with unfamiliar adults
2 Rarely or minimally exhibits reticence
with unfamiliar adults
8. Do you think s/he would be willing to go
off with a stranger? Why do you think so?
Could you give me a specific example? Do
you think s/he would do this some of the
time or most of the time? Has this way of
interacting with strangers changed? Was
s/he more/less willing at an earlier age to
go off with someone s/he didn’t know?
0 Clearly is not willing to go off readily
with relative strangers.
1 Sometimes or somewhat is willing to go
off readily with relative strangers
2 Willing to go off readily with relative
strangers
9. Is s/he one to get him/herself is risky
situations? Could you give me a specific
example? Is s/he one to run out into traffic
or maybe pull stuff off of the stove? Does
s/he seem to try to provoke you with
his/her dangerous behavior? Does s/he do
this with everyone or does s/he do this
mostly around one particular person? Why
do you think s/he does it?
0 Clearly does not engage in a pattern of
self-endangering behavior that is more
pronounced in the presence of one par-
ticular caregiver
1 Sometimes or somewhat engages in a
pattern of self-endangering behavior
that is more pronounced with one par-
ticular caregiver
2 Definitely engages in a pattern of self-
endangering behavior that is more pro-
nounced with one particular caregiver
10. Does s/he tend to cling to you or stay right
up under you? When does this seem to
happen? Does it seem to happen if there is
an adult around who she doesn’t know? Or
does it tend to happen at other times, too?
Could you give me a specific example?
0 Clearly does not engage in a pattern of
excessive clinging to a particular care-
giver in unfamiliar settings or with un-
familiar people
1 Sometimes or somewhat engages in a
pattern of excessive clinging to a partic-
ular caregiver in unfamiliar settings or
with unfamiliar people
2 Definitely engages in a pattern of excessive
clinging to a particular caregiver in unfamil-
iar settings or with unfamiliar people
11. Does s/he tend to watch you or other
caregivers a lot of the time, like watching
to see what your or their moods are? Does
she ever seem to be a bit afraid of any
caregivers, or to do exactly what they
want, in a sort of automatic way?
0 Clearly does not engage in a pattern of
fearful, inhibited, and hypervigilant be-
havior with any particular caregiver
1 Sometimes or somewhat engages in a
pattern of fearful, inhibited, and hyper-
vigilant behavior with any particular
caregiver
2 Definitely engages in a pattern of fearful,
inhibited, and hypervigilant behavior
with any particular caregiver
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12. Does s/he seem to know when you or
other caregivers are sad or mad or upset?
What will s/he do? Could you give me a
specific example? Does s/he ever seem
worried about you (or other caregivers) or
worried for you (or other caregivers)?
Could you give me an example? Does s/he
seem almost preoccupied by how you (or
other caregivers) are doing? Why do you
think s/he does this? Do you ever think
that it may be a bit too much for a child
his/her age?
0 Clearly does not engage in a pattern of
controlling or role inappropriate behavior
suggesting excessive preoccupation with
caregiver’s emotional well-being
1 Sometimes or somewhat engages in a pat-
tern of controlling or role inappropriate
behavior suggesting excessive preoccupa-
tion with caregiver’s emotional well-being
2 Definitely engages in a pattern of control-
ling or role inappropriate behavior sug-
gesting excessive preoccupation with care-
giver’s emotional well-being
GLEASON et al.
JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY
VOLUME 50 NUMBER 3 MARCH 2011231.e3 www.jaacap.org
Page 19
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    • "This is the first study to demonstrate that children affected by HIV/ AIDS in the community, are at heightened risk for psychiatric disorders including RAD and that experiencing more neglect and psychological abuse among OVC increases the likelihood of RAD symptoms five-fold. This is interesting because most previous research on RAD has been in institutionalized samples [9,10,11,12,25]. Future research should examine whether RAD symptoms precede and are a risk factor for other mental health problems or whether comorbidity between RAD and other mental health problems is common in children affected by HIV/AIDS. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Orphans and vulnerable children (OVC) affected by HIV/AIDS frequently experience placement/ residential changes, inconsistent caregivers, abuse, neglect, disruptions in their lives and several mental health problems. This may lead to a disorder of emotional functioning, reactive attachment disorder (RAD), where the child exhibits wary, watchful, and emotionally withdrawn. Despite its clinical importance, nothing is known about RAD among OVC. This study investigated: (1) whether RAD symptoms can occur in children affected by HIV/AIDS; (2) association between RAD and other psychiatric symptoms; (3) possible aetiological or contextual factors for high RAD symptom; and (4) any interactive, cumulative effects between the aetiological or contextual factors (both risks and protective) for higher RAD symptoms. Method: In a cross-sectional survey, caregivers of 191 OVC and 100 non-OVC completed questionnaires on mental health problems including RAD and contextual variables. Results: The results demonstrated that RAD is present in OVC and that RAD symptoms may be as a result of environmental factors. The study also found high levels of RAD comorbidity with other disorders including depression, conduct problems and hyperactivity. Finally, the results indicate that experiencing more neglect and psychological abuse among OVC increases their likelihood of exhibiting RAD symptoms five-fold. Conclusion: The paper discusses the clinical implications of these findings for service development for this vulnerable group in the community and concluded that among children affected by HIV/AIDS, RAD was not rare.
    Full-text · Article · Feb 2016
    • "There is no generally accepted, and well-tested, measure of DSE, and we found that a combination of parent report and investigator ratings worked best. Others have shown that the most commonly used parent report measures of indiscriminate behavior were largely convergent (Zeanah, Smyke, & Dumitrescu, 2002 ), and that a behavioral measure substantially converged with parent report (Gleason et al., 2011). "
    [Show abstract] [Hide abstract] ABSTRACT: The English & Romanian Adoptees (ERA) study follows children who spent their first years of life in extremely depriving Romanian institutions before they were adopted by families in the UK. The ERA study constitutes a "natural experiment" that allows the examination of the effects of radical environmental change from a profoundly depriving institutional environment to an adoptive family home. The cohort has been assessed at ages 4, 6, 11, and 15 years, and has provided seminal insights into the effects of early global deprivation. The current paper focuses on the long-term psychological sequelae associated with deprivation experiences. These deprivation-specific problems (DSPs) constitute a striking pattern of behavioral impairments, in its core characterized by deficits in social cognition and behavior, aswell as quasi-autistic features, often accompanied by cognitive impairment and symptoms of attention-deficit/hyperactivity disorder (ADHD). Possible moderating influences, including variations in family environment, pre-adoption characteristics, and genetic variation, will be discussed to answer the question why some individuals have prospered while others have struggled. Apart fromfindings on themoderating effect of variation in genes associated with serotonergic and dopaminergic signaling involving specific phenotypes, heterogeneity in outcome is largely unexplained. The review concludes with an outlook on currently ongoing and future research of the ERA study cohort, which involves the investigation of neurobiological and epigeneticmechanisms as possiblemediators of the long-term effects of institutional deprivation.
    No preview · Article · Jun 2015 · European Psychologist
    • "In addition to being capable of separating two subtypes of attachment-related symptoms, it offers a tool to evaluate a child's clingy behavior. The three factors of inhibited symptoms (RAD, 3 items), disinhibited symptoms (DSED, 3 items), and clingy behavior (2 items) made a discriminate effect with associations with criteria measuring psychopathology previously associated with attachment-related symptoms (Gleason et al., 2011). The first two items in the complete scale (readily goes off with a stranger, lack of checking back with parent even in a stressful situation) are commonly described as typical clinical features suggesting disinhibited behavior (Boris & Zeanah, 2005; Rutter et al., 2007;). "
    [Show abstract] [Hide abstract] ABSTRACT: We examined the associations between attachment-related symptoms (symptoms of reactive attachment disorder (RAD), symptoms of disinhibited social engagement disorder (DSED), and clinging) and later psychological problems among international adoptees. The study population comprised internationally adopted children (591 boys and 768 girls, 6–15 years) from the ongoing Finnish Adoption (FinAdo) study. Data were gathered with self-administered questionnaires both from adoptive parents and from adoptees aged over 9 years. Attachment-related symptoms were measured using of a short (8-item) questionnaire and later behavioral/emotional problems were assessed using the Child Behavior Checklist (CBCL) and the Five to Fifteen (FTF) scale for attention-deficit/hyperactivity disorder (ADHD) symptoms. RAD and DSED symptom subscales were associated with an increased risk of emotional and behavioral problems and ADHD. Especially the mixed type of attachment-related symptoms was strongly associated with later emotional and behavioral problems.
    No preview · Article · Oct 2014 · Scandinavian Journal of Psychology
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