Child Abuse & Neglect xxx (2004) xxx–xxx

Reactive attachment disorder in maltreated toddlers

Charles H. Zeanah∗ , Michael Scheeringa, Neil W. Boris,
Sherryl S. Heller, Anna T. Smyke, Jennifer Trapani
Institute of Infant and Early Childhood Mental Health, Tulane University Health Sciences Center,
1440 Canal Street TB-52, New Orleans, LA 70112, USA

Received 25 November 2002; received in revised form 19 December 2003; accepted 16 January 2004

Abstract

Objective: To determine if Reactive Attachment Disorder (RAD) can be reliably identified in maltreated toddlers
in foster care, if the two types of RAD are independent, and to estimate the prevalence of RAD in these maltreated
toddlers.
Methods: Clinicians treating 94 maltreated toddlers in foster care were interviewed regarding signs of attachment
disorder at intake in an intervention program.
Results: Using categorical and continuous measures, both types of RAD can be reliably identified in maltreated
toddlers. Both continuous scores and categorical diagnoses indicated that a substantial minority of maltreated young
children do exhibit signs of attachment disorders sufficient to meet criteria in DSM-IV and ICD-10. The two types
were moderately convergent and at times co-occurred in the same child. Prevalence of RAD in this high-risk sample
was 38–40%. Indiscriminate/disinhibited RAD was identified in children with and without an attachment figure.
Within this maltreated group, toddlers whose mothers had a history of psychiatric disturbance were more likely to
be diagnosed with attachment disorders.
Conclusions: RAD may be reliably identified in maltreated toddlers. Emotionally withdrawn/inhibited and indis-
criminate/disinhibited types of RAD are not entirely independent.
© 2004 Elsevier Ltd. All rights reserved.

Keywords: Attachment; Maltreatment; Reactive attachment disorder

Introduction

Following Bowlby’s (Bowlby, 1969, 1973, 1980) seminal attachment theory, and Ainsworth, Blehar,
Waters, and Wall’s (1978), operationalization of attachment in toddlers using the Strange Situation
∗
Corresponding author.

0145-2134/$ – see front matter © 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.chiabu.2004.01.010
2 C.H. Zeanah et al. / Child Abuse & Neglect xxx (2004) xxx–xxx

Procedure, there have been hundreds of studies published from around the world concerning attach-
ment from a developmental perspective (see Cassidy & Shaver, 1999). The majority of these studies have
used Strange Situation classifications as both risk and protective factors in development (Sroufe, 2000;
Weinfield, Sroufe, Egeland, & Carlson, 1999). Despite intense interest in the construct of attachment,
however, studies of clinical disorders of attachment are only just beginning to appear.
Concerns about clinical disorders of attachment in the scientific literature date back to the early 20th
century (see Chapin, 1915), but clinical disorders of attachment first appeared in official psychiatric
nomenclatures only in 1980, with the publication of Diagnostic and Statistical Manual—third edition
(American Psychiatric Association, 1980). Criteria describing attachment disorders were revised sub-
stantially in Diagnostic and Statistical Manual—third edition, revised (American Psychiatric Association,
1987), but only minor changes were made subsequently in Diagnostic and Statistical Manual—fourth
edition (American Psychiatric Association, 1994). There also appears to be substantial agreement be-
tween the DSM-IV criteria and that of the Tenth Revision of the International Statistical Classification
of Diseases (World Health Organization, 1992) defining attachment disorders (Zeanah, 1996). Although
there are controversies about the specific characteristics of attachment disorders, there is general con-
sensus that the disorders describe symptom clusters unaccounted for by other disorders (Rutter, 1995;
Volkmar, 1999).
Attachment disorders are described as involving a persistent disturbance in the child’s social relat-
edness that begins before age 5 years and that extends across social situations. In DSM-IV, attachment
disorders must be distinguished from pervasive developmental disorders. DSM-IV nosology also ties
these disorders etiologically to parental abuse/neglect or to extremes of caregiving, such as children
raised in institutions. ICD-10 cautions about making the diagnosis “in the absence of evidence of abuse
or neglect” (p. 281). Although “pathogenic care” is central to the disorder, there have been no pre-
vious studies of RAD in samples of maltreated children. An initial purpose of the current investiga-
tion is to determine how common it is for young, maltreated children to exhibit clinical disorders of
attachment.
Two clinical types have been described in DSM-IV and ICD-10: (1) an emotionally withdrawn/inhibited
type, in which the child rarely seeks or responds to comfort and fails to demonstrate a preference for a
caregiver, and (2) an indiscriminate/disinhibited type, in which the child is oversociable, seeking comfort
and affection non-selectively, even from unknown adults, and fails to exhibit expected reticence with
unfamiliar adults.
The first study that examined the criteria for RAD in young children was a retrospective review of 48
consecutive cases of children less than 3 years of age who were referred to an outpatient clinic (Boris,
Zeanah, Larrieu, Scheeringa, & Heller, 1998). Perhaps because the vast majority of the children in that
study were referred to the clinic by child protective services, 42% met criteria for an attachment disorder
(using alternative rather than DSM-IV criteria). Not surprisingly, children who met criteria for attachment
disorders had significantly more impairments in the parent-child relationship than other clinic-referred
children who did not meet criteria for attachment disorders.
Recent studies of children adopted out of institutions in Romania also have found signs of at-
tachment disorders at follow-up. Signs of both patterns of disordered attachment described in DSM-
IV have been identified in children adopted from Romanian institutions, although signs of the dis-
inhibited/indiscriminate pattern appear to be far more common than signs of the emotionally with-
drawn/inhibited pattern, at least in follow-up studies months to years after adoption (O’Connor, 2002;
Zeanah, 2000). On the other hand, in a study of young children still living in an institution in Romania,
 C.H. Zeanah et al. / Child Abuse & Neglect xxx (2004) xxx–xxx 3

children demonstrating signs of the emotionally withdrawn/inhibited pattern of RAD were readily
apparent (Smyke, Dumitrescu, & Zeanah, 2002). Another purpose of the current investigation is to
explore whether both patterns of RAD could be diagnosed in toddlers placed in foster care follow-
ing maltreatment. In our area, only 40% of children less than 48 months of age who were vali-
dated as having been maltreated are removed and placed in foster care (Zeanah et al., 2001). By
focusing on toddlers in foster care, we were presumably focusing on a more severely maltreated
cohort.
A persistent finding in contemporary studies of formerly-institutionalized children is that indiscrimi-
nate behavior seems clearly related to length of time that the child spent institutionalized, but curiously,
it persists long after these children have developed attachments in the more favorable caregiving en-
vironments of their adoptive homes. Virtually all of the children appear to become attached following
adoption, many securely attached, but the level of indiscriminate behavior remains elevated for years
(Chisholm, 1998; Chisholm, Carter, Ames, & Morison, 1995; O’Connor et al., 2003; O’Connor, Rutter,
& The English and Romanian Adoptees Study Team, 2000). That is, the recovery paths of indiscriminate
behavior and attachment appear to diverge (Zeanah, 2000; Zeanah & Smyke, 2002).
In addition, a recent study has documented that signs of indiscriminate RAD may be demonstrated
in young children in institutions whether or not they have a preferred attachment figure and whether
or not they have signs of emotionally withdrawn/inhibited RAD (Smyke et al., 2002). That is, some
currently institutionalized children were rated as having signs of both emotionally withdrawn/inhibited
and indiscriminate/disinhibited attachment disorders. A third purpose of the current investigation is to
determine how independent the two types of attachment disorders are in maltreated toddlers in foster
care.
In keeping with current approaches in the developmental psychopathology of early childhood (Zeanah,
Boris, & Scheeringa, 1997), we elected to explore these questions using both categorical and continuous
measures of disordered attachment. Thus, we included measures of a continuum of disordered attachment
derived from interview ratings, as well as a diagnostic, categorical approach involving DSM-IV and ICD-
10 diagnostic criteria. These approaches were used to address the following three questions regarding the
reliability and validity of attachment disorders in young children: (1) Can reactive attachment disorder be
identified reliably in a sample of maltreated toddlers in foster care? (2) What is the prevalence of disordered
attachment in maltreated toddlers in foster care? and (3) Are the emotionally withdrawn/inhibited pattern
and the indiscriminate/disinhibited pattern independent of one another?

Methods

Participants

All children in a particular parish (county) adjacent to New Orleans, Louisiana, who were less than 48
months of age at the time they were placed in foster care were referred to an intervention program that has
been described elsewhere (Larrieu & Zeanah, 1998; Zeanah et al., 2001). For this study, those who were
between 10 and 47 months (M = 27.7 months) at the time they were placed in foster care and who were
referred between July of 1995 and June of 1998 to the program were included. These 94 children were
subjects of interviews regarding their attachment behaviors. Children were referred to the intervention
program after they had been adjudicated (establishing their maltreatment as a legal fact), usually about 3
4 C.H. Zeanah et al. / Child Abuse & Neglect xxx (2004) xxx–xxx

months after placement in foster care. The sample included 42 boys (44%) and 52 girls (56%) who were
60% African American, 28% European American, 8% biracial, and 4% other.
The 94 children had 48 mothers whose mean age was 25.4 years. They were 55% African American,
40% European American, and 4% other. Mothers had an average education of 10th grade. Twenty-one
percent were married and 37% were employed, and they had an average of 3.63 children (range 1–16) at
the time that the index child came into foster care.
The 94 children who were included as subjects comprised more than 75% of the children less than 48
months old who were placed in foster care in the particular parish making referrals (Zeanah et al., 2001).
The remaining children were either too young to make a diagnosis of attachment disorder (less than 10
months old and therefore prior to the establishment of preferred attachment which occurs typically at
7–9 months of age), transferred out of a parish to another court jurisdiction before they were assessed,
discharged from foster care prior to adjudication, or not referred to the intervention program because of
procedural error.
Procedures

Approval for the study was given by the Tulane University Health Sciences Center Institutional Review
Board. From July 1995 through December 1998, 14 primary clinicians from the intervention program
were interviewed regarding each child’s attachment behavior at the time of initial assessment (3 months
after the child came into foster care). The clinicians included psychiatrists (four), psychologists (six)
and clinical social workers (four) who were responsible for comprehensive assessments of the children,
their biological parents and their foster parents. One interviewer administered the interview to all 14
clinicians about children for whom they had been the primary clinician in the intervention program.
This interviewer coded each of the items pertinent for signs of attachment disorder described below. For
25 of the interviews, a second coder observed the interview and coded all items independently. For 63
(67%) of the children, the clinicians reported retroactively to the time that the child was first assessed
upon referral to the program (2–20 months previously). For the remaining 31 children (33%), clinicians
reported on current symptomatology. There was no difference between severity of symptoms for those
reported retroactively and those reported concurrently.
In a second step, three experienced child and adolescent psychiatrists used the interview data to
apply DSM-IV and ICD-10 diagnostic criteria for attachment disorders to each case. These psychiatrists
were aware that each child had been abused and/or neglected, and thus fulfilled the “pathogenic care”
criterion required by DSM-IV and recommended by ICD-10. Each child was diagnosed as either having
no attachment disorder or having RAD using DSM-IV criteria. The psychiatrists made the diagnoses
independently. Differences were resolved by conferencing. Each child was diagnosed as having RAD,
Disinhibited Attachment Disorder (DAD), or no attachment disorder using ICD-10 criteria (in ICD-10, the
emotionally withdrawn inhibited type is designated “RAD,” and the indiscriminately social/disinhibited
pattern is designated “DAD”).

Measures

The interview which we used with clinicians, has been validated preliminarily on caregivers of severely
neglected children in institutions (Smyke et al., 2002; Zeanah, Smyke, & Dumitrescu, 2002). The inter-
view is semi-structured and includes probes concerning signs of both emotionally withdrawn RAD and
indiscriminate (disinhibited) RAD.
 C.H. Zeanah et al. / Child Abuse & Neglect xxx (2004) xxx–xxx 5

Following specific probes and follow-ups sufficient to characterize the child’s behavior in a variety of
situations, ratings were made using anchored criteria. Ratings relevant for emotionally withdrawn RAD
included: (1) absence of a discriminated, preferred adult, (2) lack of comfort seeking for distress, (3)
failure to respond to comfort when offered, (4) lack of social and emotional reciprocity, and (5) emotion
regulation difficulties. Each item was rated as “0” for “not or rarely present,” “1” for “somewhat or
sometimes present,” and “2” for “definitely or often present.” Thus, continuous scores for emotionally
withdrawn RAD could range from 0 to 10. Internal consistency for these items in all 94 interviews was
alpha = .83. Interrater reliability for two independent raters who coded these 5 items on 25 randomly
selected interviews was r = .71.
Ratings relevant to indiscriminate RAD included: (1) not having a discriminated, preferred attachment
figure, (2) not checking back after venturing away from the caregiver, (3) lack of reticence with unfamiliar
adults, and (4) a willingness to go off with relative strangers. Each item was rated as “0” for “not or rarely
present,” “1” for “somewhat or sometimes present,” and “2” for “definitely or often present.” Continuous
scores could range from 0 to 8. Internal consistency for these items in all 94 interviews was alpha = .81.
Interrater reliability for two independent raters on these four items on 25 randomly selected interviews
was r = .79.
Other interview probes concerned self-endangering behavior, vigilance/hypercompliance (i.e., “frozen
watchfulness”), excessive clinging, and role reversal. These were also coded using the same 3-point Likert
scale.
We used Cohen’s kappa to assess interrater reliability of clinical diagnoses. Kappas between .4 and .6
are considered moderate and between .6 and .8 they are considered substantial (Landis & Koch, 1977).
We used Pearson’s r to assess convergence of continuous ratings of interview data. We analyzed interview
ratings using cluster analysis (Ward’s method of agglomeration using squared Euclidean distance). This
method allowed us to examine how the signs of RAD clustered together in children. Clinical clusters were
derived from continuous ratings of signs of RAD. We used Cohen’s kappa to assess convergence between
diagnoses of RAD and DAD and clinical clusters of signs of RAD and DAD. Finally, to assess which
maternal characteristics were associated with types of RAD, we computed stepwise logistic regressions.

Results

Results are organized and reported in the following way. First, we report categorical diagnoses of
the three psychiatrists who applied diagnostic criteria to the interview data, including their interrater
reliabilities on the categorical data. Second, we reported convergence of the two types of RAD (inhibited
and disinhibited). Third, we performed a cluster analysis of the interview ratings to look for patterns of
disordered attachment behavior in children. Fourth, we report the convergence between clinical clusters
and the diagnoses made by psychiatrists for the emotionally withdrawn/inhibited attachment disorder
scores and to the indiscriminate/disinhibited attachment disorder scores. Finally, we examine correlates
of the categorical and continuous diagnoses.

Categorical attachment disorders

Interrater reliabilities were acceptable for all pairs of clinicians who applied diagnostic criteria, as
shown in Table 1. Final determination of diagnosis was made by consensus in cases about which there
was less than perfect agreement.
6 C.H. Zeanah et al. / Child Abuse & Neglect xxx (2004) xxx–xxx

Table 1
Interrater Reliabilities and prevalence of attachment disorders among maltreated toddlers
Disorder Rater 1 Rater 2 Rater 1 Prevalence
versus 2 (K) versus 3 (K) versus 3 (K) (%)
ICD-10 Reactive Attachment Disorder .75 .71 .67 35
ICD-10 Disinhibited Attachment Disorder .58 .71 .70 22
ICD both (RAD and DAD) 17
DSM-IV Reactive Attachment Disorder .80 .76 .78 38

In addition to demonstrating that both types of disorders could be diagnosed in this sample, the data in
Table 1 also indicate that some children received a diagnosis of both types of disorders. As indicated in
Table 1, 17% of the children were diagnosed with both the emotionally withdrawn/inhibited and indiscrim-
inate/disinhibited type of disorder, according to ICD-10 criteria. Using DSM-IV criteria, the diagnosis
of RAD was made if either the emotionally withdrawn/inhibited or the indiscriminate/disinhibited type
were evident, and the overall rate of attachment disorder was similar (38% for DSM-IV and 40% for
ICD-10).
One might expect sibling concordance to be high in RAD, given that the disorder is believed to result
from pathogenic care. In order to address this question, we examined cases in which there were two or
three children in the same family who were maltreated and placed in foster care. There were 20 sibling
pairs in this sample. Using DSM-IV criteria, the RAD concordance between these sibling pairs was 75%.
Using ICD-10 RAD criteria, concordance between these sibling pairs was 70%, and the DAD concordance
was 80%. We also had six families with three children. All three children were concordant on DSM-IV
diagnosis of RAD in 4/6 families (67%). All three children were concordant on ICD-10 RAD in 3/6
families (50%) and on ICD-10 DAD in 3/6 families (50%).

Convergence of continuous scores of emotionally withdrawn and indiscriminate patterns

To address question #3 regarding the independence of RAD types, we used continuous scores of signs
of RAD and found moderate to substantial convergence between signs of emotionally withdrawn RAD
and indiscriminate RAD, r = .69, p < .001. Because these two types shared one item in common (i.e.,
“has or does not have a preferred adult”), we dropped this item from the indiscriminate RAD score and
still found moderate convergence between the types, r = .61, p < .001.

Cluster analysis of signs of RAD

In an effort to assess more fully the clinical patterns of attachment disorders, and specifically to pursue
the question of the independence of the two types, we analyzed interview ratings using cluster analysis
(Ward’s method of agglomeration using squared Euclidean distance). This method allowed us to examine
how the signs of RAD clustered together in children. Clinical clusters were derived from continuous
ratings of signs of RAD. A four-cluster solution was selected as most appropriately describing the sample
(see Figure 1). This solution suggested widespread signs of attachment disorder in this sample that were
clustered as follows:
• Cluster 1 (mixed attachment disorder signs [n = 20]): No preferred attachment figure and signs of both
emotionally withdrawn RAD and indiscriminate RAD.
 C.H. Zeanah et al. / Child Abuse & Neglect xxx (2004) xxx–xxx 7

Figure 1. Cluster analysis of signs of attachment disorder.

• Cluster 2 (no attachment disorder signs [n = 37]): No signs of attachment disorder.

• Cluster 3 (emotionally withdrawn/inhibited attachment disorder signs [n = 22]): Some evidence of
having a preferred caregiver, but signs of emotionally withdrawn/inhibited attachment disorder.
• Cluster 4 (indiscriminate/disinhibited attachment disorder signs [n = 15]): Some evidence of having
a preferred caregiver, but signs of indiscriminate attachment disorder.

Convergence of disorders and clinical clusters

In order to determine whether or not the children who had clusters of signs of RAD were the same
children who were diagnosed with RAD, we examined convergence. We examined the association between
the inhibited/emotionally withdrawn cluster (cluster 3) and the diagnosis of RAD using DSM-IV and
ICD-10 diagnoses, but neither was significant. We also compared the disinhibited/indiscriminate cluster
(cluster 4) to DSM-IV RAD and ICD-10 DAD. Again, neither was significant.
Correlates of RAD: To explore the question which maltreated children develop signs of RAD and
which do not, we examined child and maternal variables as predictors.
Child characteristics and RAD: There was no relationship between gender, ethnicity, or length of time
in care for either categorical or continuous ratings of signs of attachment disorder.

Maternal risk and RAD

We conducted a stepwise regression using the following maternal variables as predictors: education,
teen parent (ever), partner violence, criminal history, depressed mood, maltreatment as a child, psychiatric
8 C.H. Zeanah et al. / Child Abuse & Neglect xxx (2004) xxx–xxx

Table 2
Maternal characteristics associated with RAD diagnoses
R
R2
F df
RAD Inhibited
Step 1 .347 .120 8.893∗∗ 1,65
Psychiatric problems

RAD Disinhibited
Step 1 .325 .106 7.688∗∗ 1,65
Psychiatric problems
Step 2 .436 .084 6.629∗ 1,64
Substance abuse history

ns = non-significant. ∗∗∗ p <.001.

∗
p<.05.
∗∗
p<.01.

history, and substance abuse history. For the continuous measure of RAD signs of inhibited/emotionally
withdrawn as a dependent variable, only mothers’ psychiatric history was significant (b = 2.32, t =
2.90, p < .005). The model we developed, RAD emotionally withdrawn/inhibited score = 2.62 + 2.32 ×
Psychiatric History, for predicting RAD inhibited/withdrawn scores was significant and explained 12%
of the variance in inhibited/withdrawn scores (see Table 2). For the continuous measure of RAD signs
of disinhibited/indiscriminate as a dependent variable, mothers’ psychiatric history (b = 1.32, t = 2.67,
p < .01) and substance abuse (b = 1.60, t = 3.26, p < .002) were significant. The model we developed,
RAD indiscriminate/disinhibited score = 1.96 + 1.32 × Psychiatric History − 1.60 × Substance Abuse
History, for predicting RAD indiscriminate/disinhibited scores was significant and exaplained 21% of
the variance in indiscriminate/disinhibited scores (see Table 2).
Our regression model predicts that, based solely on the presence of maternal psychiatric history, RAD
inhibited/withdrawn scores will be 2.32 points higher [CI 95% (.72, 3.93)] than those of children whose
mothers did not report such a history. RAD indiscriminate/disinhibited scores for those children whose
mothers had a psychiatric history were 1.32 points higher [CI 95% (.33, 2.30)] than children whose
mothers did not report such a history. Based solely on maternal substance abuse history, children whose
mothers had a history of substance abuse had, on average, RAD indiscriminate/disinhibited scores 1.60
points lower than children whose mothers did not report such a history.

Discussion

Results from this investigation make several important contributions to a growing literature regarding
attachment disorders in early childhood. First, both types of RAD were reliably identified in maltreated
children. Both elevated continuous scores and categorical diagnoses indicated that a substantial minority
of maltreated young children do exhibit signs of attachment disorders sufficient to meet criteria in
DSM-IV and ICD-10. These results confirm a previous retrospective chart review study of clinic-referred
children (Boris et al., 1998). Both types of attachment disorders also have been identified in young chil-
dren in Romanian institutions (Smyke et al., 2002; Zeanah et al., 2002). Interestingly, signs of emotionally
 C.H. Zeanah et al. / Child Abuse & Neglect xxx (2004) xxx–xxx 9

withdrawn/inhibited RAD have been quite unusual in follow-up studies of children adopted out of
institutions (O’Connor et al., 2000, 2003), perhaps because the disorder remits relatively quickly when
adequate caregiving is provided. In contrast, in this investigation, clear signs of the disorder were
identifiable after children had received about 3 months of foster care, although it is unclear how long
these signs might persist.
A second contribution of this investigation is that it provides several lines of evidence suggest that
the emotionally withdrawn/inhibited and indiscriminate/disinhibited RAD types are not completely in-
dependent. In addition to moderate convergence of continuous scores, cluster analyses also indicated a
cluster in which signs of both types of RAD co-occurred. Finally, categorical diagnoses of emotionally
withdrawn/inhibited RAD and indiscriminate/disinhibited co-occurred in the same child in 17% of cases.
A third contribution of this investigation is to add to a growing body of evidence that indiscriminate
behavior may be identified both in children with and without preferred attachment figures (Chisholm,
1998; O’Connor et al., 2003; Smyke et al., 2002), and with and without emotionally withdrawn/inhibited
attachment disorder (Smyke et al., 2002). As noted, indiscriminate behavior also demonstrates a different
recovery curve than attachment following removal from deprivation and placement in more adequate
caregiving environments (Chisholm, 1998; O’Connor et al., 2000). Taken together, these data suggest
that indiscriminate behavior might be more appropriately considered an associated feature of disordered
attachment rather than a type of disordered attachment.
The fact that emotionally withdrawn/inhibited RAD and indiscriminately social/disinhibited RAD arise
in similar conditions of deprivation and neglect probably contributed to their grouping as different types
of the same disorder. The fact that they are so differentially responsive to improvements in environmental
conditions, however, raises questions about whether they are two different disorders rather than different
types of the same disorder.
The prevalence of RAD among these children who had a history of maltreatment and foster care place-
ment appears to be increased substantially. Although no control group was included in this investigation,
attachment disorders are believed to be rare, at least in samples not recruited from child protective ser-
vices. For example, using an interview and observational measure of RAD, Boris et al. (2004) found no
cases of RAD in 25 non-referred preschool children recruited from HeadStart and no cases of RAD in
23 preschool children who were homeless and living with their mothers in a shelter.
Finally, this is the first investigation that has examined both child and maternal correlates of RAD. As in
other studies, child variables such as age, ethnicity, and gender did not discriminate signs of attachment
disorders. Within this sample of maltreated toddlers, however, mothers with a history of psychiatric
problems were more likely to have children exhibiting signs of inhibited/emotionally withdrawn RAD.
Also, mothers with a history of psychiatric problems and substance use disorders had children more
likely to exhibit signs of disinhibited/indiscriminate RAD. Prospective studies of maltreated toddlers and
control groups, using a combination of interviews and observational measures of disordered attachment,
are needed to confirm these findings, and to address the methodological limitations of this investigation.
These limitations are important to acknowledge. The clinicians who were interviewed, the interview
coders, and the psychiatrists who applied diagnostic criteria were all aware of the children’s history
of maltreatment. Indeed, it would be difficult for them not to know because of the requirement in the
RAD criteria for “pathogenic care.” Still, this knowledge may have served to inflate the number of
signs of attachment disorder reported. In addition, the retrospective recall necessary for clinicians to
respond also may have led to inflated reports of signs of attachment disorders. For these reasons, it would
be misleading to accept the prevalence figures in this study uncritically. Second, for two-thirds of the
10 C.H. Zeanah et al. / Child Abuse & Neglect xxx (2004) xxx–xxx

children, clinicians reports of their attachment behaviors were retrospective rather than concurrent, and
it is unclear how much error this might have introduced. Prospective studies, in which children’s current
symptomatology is reported on and followed over time, are likely to enhance our ability to determine
the prevalence of these disorders in young, maltreated children. Finally, signs of attachment disorder in
this study were limited to reports on a semi-structured interview rather than on direct observation of the
child’s behavior. When possible, multiple-methods are desirable when evaluating psychopathology in
young children (Zeanah et al., 1997).
If these findings are replicated subsequently, they will indicate that signs of attachment disorders are
quite common in maltreated toddlers and that a significant minority may have clinical disorders of attach-
ment. Other important questions remain. Among the most pressing is to determine the course of attachment
disorders and the degree of recovery of attachment that is possible following early maltreatment. To date,
the only data about recovery from signs of attachment disorders comes from studies of children adopted
out of institutions. Secure attachments are reduced, and atypical, insecure patterns are increased in Strange
Situation classifications of currently institutionalized (Vorria et al., 2003; Zeanah, Smyke, Koga, &
Carlson, 2003) and adopted, formerly institutionalized children (Chisholm, 1998; Marcovitch et al., 1997;
O’Connor et al., 2003). This suggests that there may be lasting impairments in at least some children,
although the procedures used to classify patterns of attachment in these children are not well validated.
Although there are already data examining the relationship between classifications of attachment using
the Strange Situation Procedure and clinical disorders of attachment (Boris et al., 2004; O’Connor et al.,
2003), the relationships between these two approaches remain to be elucidated. Future studies employing
integrated developmental and clinical approaches to disturbed attachment appear to hold great promise.

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Résumé

Objectif: Déterminer si les troubles réactionnels de l’attachement (RAD) peuvent être identifiés de façon
sûre chez les jeunes enfants placés dans des familles d’accueil, si les deux types de RAD sont indépendants,
et si l’on peut estimer la prévalence du RAD chez ces enfants maltraités.
12 C.H. Zeanah et al. / Child Abuse & Neglect xxx (2004) xxx–xxx

Méthode: On a interrogé les cliniciens qui avaient en traitement 94 jeunes enfants maltraités et placés en
famille d’accueil au sujet des signes de troubles de l’attachement au début d’un programme d’intervention.
Résultats: A l’aide de mesures continues et par catégorie, les deux types de RAD ont pu être identifiés
de façon sûre chez les jeunes enfants maltraités. A la fois les scores continus et les diagnostics par
catégorie ont indiqué qu’une minorité importante de jeunes enfants maltraités montrait des troubles de
l’attachement suffisants pour correspondre aux critères DSM-IV et ICD-I0. Les deux types convergeaients
modérément et parfois étaient présents en même temps chez le même enfant. La prévalence de RAD chez
cet échantillon à haut risque était de 38 à 40%. On a identifié un RAD indistinct ou peu présent chez des
enfants ayant ou n’ayant pas une figure d’attachement. A l’intérieur de ce groupe maltraité, les jeunes
enfants dont la mère avait un passé posychiâtrique étaient le plus susceptibles d’être diagnostiqués comme
présentant des troubles de l’attachement.
Conclusion: On peut identifié de façon fiable le RAD chez les jeunes enfants maltraités. Les types de RAD
comportant retrait et inhibition ainsi que absence de distinction et d’inhibition ne sont pas entièrement
indépendants.

Resumen

Objetivo: Determinar si el Desorden del Apego Reactivo (RAD) puede identificarse con confiabilidad
en los niños maltratados en cuidado sustituto, si los dos tipos de RAD son independientes, y estimar la
prevalencia de RAD en estos niños maltratados.
Métodos: Se entrevistaron los clı́nicos que atendı́an a 94 niños maltratados en cuidado sustituto en
relación a señales de desorden del apego al registrarlos en un programa de intervención.
Resultados: Utilizando medidas categóricas y contı́nuas, ambos tipos de RAD pueden ser identificados
con confiabilidad en los niños maltratados. Tanto los puntajes contı́nuos y los diagnósticos categóricos
indicaron que una minorı́a substancial de los niños pequeños maltratados si exhiben señales de desórdenes
del apego suficientes para confirmar los criterios en el DSM-IV y el ICD-10. Los dos tipos fueron
moderadamente convergentes y en algunos momentos co-ocurrentes en el mismo niño. La prevalencia
de RAD en esta muestra de alto riesgo fue de 38–40%. RAD indiscriminado/desinhibido fue identificado
en niños con y sin una figura de apego. En este grupo de maltrato, los niños cuyas madres tenı́an una
historia de perturbaciones psiquiátricas tenı́an mayor probabilidad de ser diagnosticados con desórdenes
del apego.
Conclusiones: El RAD puede ser diagnosticado con confiabilidad en los niños maltratados. Los tipos de
RAD emocionalmente reservado/inhibido y indiscriminado/desinhibido no son completamente indepen-
dientes.