Reactive Attachment Disorder following Early Maltreatment: Systematic Evidence beyond the Institution
Abstract
Reactive Attachment Disorder (RAD) remains one of the least evidence-based areas of DSM and ICD nosology. Recent evidence from severely deprived institutional samples has informed review of RAD criteria for DSM-V; however, this data is not necessarily generalizable to expectable child environments in the developed world. We provide the first systematic study of this important syndrome in maltreated non-institutionalized adolescents from a high-income country. 153 high-risk adolescents in English out-of-home Looked After Care (LAC: mean age 174 months, SD 23, 52 % male) and 42 low-risk (LR) community controls (mean age 168 months, SD 18, 38 % male) were assessed for RAD behaviors. Data on maltreatment and care history were collected from social work reports and concurrent psychopathology from caregiver report. Triangulated data sources informed independent researcher ratings of adaptive functioning. LAC adolescents showed high prevalence of RAD behaviors. Factor analysis showed four symptom groups; Disinhibited Indiscriminate, Attention Seeking, Superficial Relationships and Unpredictability. RAD was associated with multiple maltreatment experience, earlier entry to care and increased rates of psychopathology. Superficial Relationships and Attention Seeking factors showed strong independent association with particularly pervasive functional impairment. Disinhibited RAD behaviors are identifiable with high prevalence in non-institutionalized high-risk adolescents. They are strongly associated with psychopathology and functional impairment. Retention of this subtype in DSM-V is supported. Findings on the inhibited subtype in adolescence are less persuasive. RAD behavior is a relevant marker of developmental impairment, has significant clinical implications and is deserving of further study within non-institutionalized risk populations.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
RAD diagnostics are not fully clear; a child is typically given a 'suspected' RAD diagnosis.
“As previously suggested,1,7,52 a child is typically given a ‘suspected’ RAD diagnosis because such diagnostics are not fully clear.”
From Ventral striatum dysfunction in children and adolescents with reactive attachment disorder: functional MRI study (2015) · cites this paper as [7]
The RAD phenotype in the DSM-5 may be further encompassed by a broader phenotype.
“Furthermore, it has been suggested that the RAD phenotype in the DSM-5 may be further encompassed by a broader phenotype.7”
From Ventral striatum dysfunction in children and adolescents with reactive attachment disorder: functional MRI study (2015) · cites this paper as [7]
Children exposed to early adverse childhood experiences in general, and more specifically children placed in foster care, have a heightened risk of attachment difficulties.
“Findings indicate that children exposed to early adverse childhood experiences in general [22] and more specifically children placed in foster care have a heightened risk of attachment difficulties [23,24].”
From Mental disorders in foster children: a study of prevalence, comorbidity and risk factors (2013) · cites this paper as [22]
Cites
Diagnostic and Statistical Manual of Mental Disorders
Williams, J. B. W., & First, M. B. (2013) · Oxford University Press eBooks · doi:10.1093/acrefore/9780199975839.013.104 · Cited by 109,841 · see citing works
Diagnostic and Statistical Manual of Mental Disorders
(2012) · Springer eBooks · doi:10.1007/springerreference_121117 · Cited by 20,769 · see citing works
Diagnostic and Statistical Manual of Mental Disorders, 3rd ed
Cooper, A. M., & Michels, R. (1981) · American Journal of Psychiatry · doi:10.1176/ajp.138.1.128 · Cited by 7,417 · see citing works
Diagnostic and Statistical Manual of Mental Disorders, 3rd ed
Kendell, R. E. (1980) · American Journal of Psychiatry · doi:10.1176/ajp.137.12.1630 · Cited by 5,201 · see citing works
(1983) · Medical Entomology and Zoology · Cited by 4,251 · see citing works
A Children's Global Assessment Scale (CGAS)
Shaffer, D. (1983) · Archives of General Psychiatry · doi:10.1001/archpsyc.1983.01790100074010 · Cited by 3,716 · see citing works
The English indices of deprivation 2004
Noble, M., Wright, G., Dibben, C., Smith, G., McLennan, D., Anttila, C., Barnes, H., Mokhtar, C., Noble, S., & Gardner, J. (2004) · Cited by 1,494 · see citing works
Chisholm, K. (1998) · Child Development · doi:10.1111/j.1467-8624.1998.tb06162.x · Cited by 571 · see citing works
O'CONNOR, T. G., & RUTTER, M. (2000) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1097/00004583-200006000-00008 · Cited by 482 · see citing works
The Mental Health of Young People Looked After by Local Authorities in England
Meltzer, H., Gatward, R., Corbin, T., Goodman, R., & Ford, T. J. (2003) · PsycEXTRA Dataset · doi:10.1037/e616412007-001 · Cited by 394 · see citing works
Gowers, S. G., Harrington, R. C., Whitton, A., Lelliott, P., Beevor, A., Wing, J., & Jezzard, R. (1999) · British Journal of Psychiatry · doi:10.1192/bjp.174.5.413 · Cited by 378 · see citing works
Social and Family Relationships of Ex‐Institutional Adolescents
Hodges, J., & Tizard, B. (1989) · Journal of Child Psychology and Psychiatry · doi:10.1111/j.1469-7610.1989.tb00770.x · Cited by 343 · see citing works
Green, J., & Goldwyn, R. (2002) · Journal of Child Psychology and Psychiatry · doi:10.1111/1469-7610.00102 · Cited by 322 · cited 1× · see citing works
“An alternative proposal (Green 2003) has been to reframe the current IAD definition in terms of a core developmental social disorder of the kind recognised as following early disorganised attachment (Green and Goldwyn 2002).”
BackgroundSelf-citationTizard, B., & Rees, J. (1975) · Journal of Child Psychology and Psychiatry · doi:10.1111/j.1469-7610.1975.tb01872.x · Cited by 314 · see citing works
Effects of psychological deprivation in infancy and subsequent stimulation
GOLDFARB, W. (1945) · American Journal of Psychiatry · doi:10.1176/ajp.102.1.18 · Cited by 275 · see citing works
Chamberlain, P. (2003) · American Psychological Association eBooks · doi:10.1037/10596-000 · Cited by 250 · see citing works
Reactive attachment disorder in maltreated toddlers
Zeanah, C. H., Scheeringa, M., Boris, N. W., Heller, S. S., Smyke, A. T., & Trapani, J. (2004) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2004.01.010 · Cited by 237 · see citing works
Disinhibited social behavior among internationally adopted children
Bruce, J., Tarullo, A. R., & Gunnar, M. R. (2009) · Development and Psychopathology · doi:10.1017/s0954579409000108 · Cited by 214 · see citing works
Boris, N. W., & Zeanah, C. H. (2005) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1097/01.chi.0000177056.41655.ce · Cited by 144 · see citing works
Boris, N. W., Hinshaw-Fuselier, S. S., Smyke, A. T., Scheeringa, M. S., Heller, S. S., & Zeanah, C. H. (2004) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1097/00004583-200405000-00010 · Cited by 128 · see citing works
Genetic, environmental and gender influences on attachment disorder behaviours
Minnis, H., Reekie, J., Young, D., O’Connor, T., Ronald, A., Gray, A. J., & Plomin, R. J. (2007) · The British Journal of Psychiatry · doi:10.1192/bjp.bp.105.019745 · Cited by 128 · see citing works
Minnis, H., Green, J., O’Connor, T. G., Liew, A., Glaser, D., Taylor, E., Follan, M., Young, D., Barnes, J., Gillberg, C., et al. (2009) · Journal of Child Psychology and Psychiatry · doi:10.1111/j.1469-7610.2009.02075.x · Cited by 124 · see citing works
Self-citationIII. DEPRIVATION-SPECIFIC PSYCHOLOGICAL PATTERNS
Kumsta, R., Kreppner, J., Rutter, M. L., Beckett, C., Castle, J., Stevens, S. E., & Sonuga-Barke, E. J. S. (2010) · Monographs of the Society for Research in Child Development · doi:10.1111/j.1540-5834.2010.00550.x · Cited by 112 · see citing works
Indiscriminate Friendliness in Maltreated Foster Children
Pears, K. C., Bruce, J., Fisher, P. A., & Kim, H. K. (2010) · Child Maltreatment · doi:10.1177/1077559509337891 · Cited by 109 · see citing works
Lyons-Ruth, K., Bureau, J.-F., Riley, C. D., & Atlas-Corbett, A. F. (2009) · Development and Psychopathology · doi:10.1017/s0954579409000376 · Cited by 97 · see citing works
Attachment disorders in family and social context
Zeanah, C. H., & Smyke, A. T. (2008) · Infant Mental Health Journal · doi:10.1002/imhj.20176 · Cited by 83 · see citing works
Kreppner, J., Kumsta, R., Rutter, M. L., Beckett, C., Castle, J., Stevens, S. E., & Sonuga-Barke, E. J. S. (2010) · Monographs of the Society for Research in Child Development · doi:10.1111/j.1540-5834.2010.00551.x · Cited by 73 · see citing works
Reactive attachment disorder in looked‐after children
Millward, R., Kennedy, E., Towlson, K., & Minnis, H. (2006) · Emotional and Behavioural Difficulties · doi:10.1080/13632750601022212 · Cited by 70 · see citing works
Social use of language in children with reactive attachment disorder and autism spectrum disorders
Sadiq, F. A., Slator, L., Skuse, D., Law, J., Gillberg, C., & Minnis, H. (2012) · European Child & Adolescent Psychiatry · doi:10.1007/s00787-012-0259-8 · Cited by 64 · see citing works
Are attachment disorders best seen as social impairment syndromes?
Green, J. (2003) · Attachment & Human Development · doi:10.1080/14616730310001593956 · Cited by 40 · see citing works
Self-citationThe Outcomes of Late Permanent Placements: The Adolescent Years
Rushton, A., & Dance, C. (2004) · Adoption & Fostering · doi:10.1177/030857590402800107 · Cited by 39 · see citing works
Follan, M., Anderson, S. M., Huline‐Dickens, S., Lidstone, E., Young, D., Brown, G., & Minnis, H. (2011) · Research in Developmental Disabilities · doi:10.1016/j.ridd.2010.12.031 · Cited by 38 · see citing works
Residential and Foster Family Care
Rushton, A., & Minnis, H. (2008) · doi:10.1002/9781444300895.ch32 · Cited by 37 · see citing works
Biehal, N., Green, J., Sinclair, I., Roberts, C., Dixon, J., Kay, C., Parry, E., Roby, A., Rothwell, J., & Kapadia, D. (2012) · Digital Education Resource Archive (University College London) · Cited by 30 · see citing works
Self-citationEmpirical Studies on Foster Care: Review and Assessment
Horan, S., Kang, G., Levine, M., et al. (1993) · The Journal of Sociology & Social Welfare · doi:10.15453/0191-5096.2061 · Cited by 21 · see citing works
Attachment disturbances and disorders in children exposed to early severe deprivation
O'Connor, T. G., Bredenkamp, D., Rutter, M., & The English and Romanian Adoptees (ERA) Study Team (1999) · Infant Mental Health Journal · doi:10.1002/(sici)1097-0355(199921)20:1
Flagged first, then by citations
Cited by
Sorted by citations
Zeanah, C. H., & Gleason, M. M. (2015) · Journal of Child Psychology and Psychiatry · doi:10.1111/jcpp.12347 · Cited by 265 · see citing works
Mental disorders in foster children: a study of prevalence, comorbidity and risk factors
Lehmann, S., Havik, O. E., Havik, T., & Heiervang, E. R. (2013) · Child and Adolescent Psychiatry and Mental Health · doi:10.1186/1753-2000-7-39 · Cited by 236 · see citing works
Takiguchi, S., Fujisawa, T. X., Mizushima, S., Saito, D. N., Okamoto, Y., Shimada, K., Koizumi, M., Kumazaki, H., Jung, M., Kosaka, H., et al. (2015) · BJPsych Open · doi:10.1192/bjpo.bp.115.001586 · Cited by 63 · see citing works
RetractedSchröder, M., Pérez, T., Buderer, C., & Schmid, M. (2017) · Kindheit und Entwicklung · doi:10.1026/0942-5403/a000223 · Cited by 18 · see citing works
- Authors
- Kay, C., & Green, J.
- Affiliations
- University of Manchester (GB)
- Corresponding author
- Kay, Catherine
- ORCID
- Green, Jonathan
- Venue
- Journal of Abnormal Child Psychology
- Published
- 2012-12-19
- Volume
- 41
- Issue
- 4
- Pages
- 571-581
- ISSN
- 0091-0627 (ISSN-L)
- 1573-2835
- OpenAlex
- W2053458406
- Cited by
- 74
- References
- 36
- Citations by year
- 2026: 3 · 2025: 1 · 2024: 4 · 2023: 4 · 2022: 2 · 2021: 5 · 2020: 9 · 2019: 5 · 2018: 13 · 2017: 11 · 2016: 6 · 2015: 6 · 2014: 3 · 2013: 2
- FWCI
- 9.15
- Type
- journal article
- Language
- en
- Open access
- closed
- Licence
- www.springer.com/tdm (tdm)
- Locations
- Research on Child and Adolescent Psychopathology (publishedVersion)
- PubMed (publishedVersion)
- Research Explorer (The University of Manchester) (publishedVersion)
- Funders
- University of Manchester
- Coordenação de Aperfeiçoamento de Pessoal de Nível Superior
- Medical Research Council
- Topics
- Social Sciences › Safety Research › Child Welfare and Adoption
- Social Sciences › Psychology › Clinical Psychology › Child Abuse and Trauma
- Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
- Keywords
- reactive attachment disorder, child abuse, institutional deprivation, attention seeking, unpredictability, psychopathology, functional disability, at-risk youth
- MeSH terms
- Adolescent, Child, Child Abuse, Child Care, England, Factor Analysis, Statistical, Female, Humans, Male, Psychiatric Status Rating Scales, Residential Facilities, Risk, Prevalence, Reactive Attachment Disorder, Diagnostic and Statistical Manual of Mental Disorders
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
