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Cited by 265Attachment and Relationship DynamicsChild and Adolescent Psychosocial and Emotional DevelopmentPsychoanalysis and Psychopathology Research

Annual Research Review: Attachment disorders in early childhood – clinical presentation, causes, correlates, and treatment

Open access
Zeanah, Charles H., Gleason, Mary Margaret·2015·Journal of Child Psychology and Psychiatry
DOI 10.1111/jcpp.12347PMC PMC4342270
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Abstract

Background: Though noted in the clinical literature for more than 50 years, attachment disorders have been studied systematically only recently. In part because of the ubiquity of attachments in humans, determining when aberrant behavior is best explained as an attachment disorder as opposed to insecure attachment has led to some confusion. In this selective review, we consider the literature on reactive attachment disorder and disinhibited social engagement disorder and describe an emerging consensus about a number of issues, while also noting some areas of controversy and others where we lack clear answers. We include a brief history of the classification of the disorders, as well as measurement issues. We describe their clinical presentation, causes and vulnerability factors, and clinical correlates, including the relation of disorders to secure and insecure attachment classifications. We also review what little is known and what more we need to learn about interventions. Methods: We conducted a literature search using PubMed, Psyc INFO , and Cochrane Library databases, using search terms ‘reactive attachment disorder,’ ‘attachment disorder,’ ‘indiscriminate behavior,’ ‘indiscriminate friendliness,’ ‘indiscriminate socially disinhibited reactive attachment disorder,’ ‘disinhibited social engagement disorder,’ and ‘disinhibited social behavior.’ We also contacted investigators who have published on these topics. Findings: A growing literature has assessed behaviors in children who have experienced various types of adverse caregiving environments reflecting signs of putative attachment disorders, though fewer studies have investigated categorically defined attachment disorders. The evidence for two separate disorders is considerable, with reactive attachment disorder indicating children who lack attachments despite the developmental capacity to form them, and disinhibited social engagement disorder indicating children who lack developmentally appropriate reticence with unfamiliar adults and who violate socially sanctioned boundaries. Conclusions: Although many questions remain to be answered, especially regarding appropriate interventions, we know considerably more about attachment disorders than we did only a decade ago.

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Crossref · 10.1111/jcpp.12347

Cites

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Claims the paper makes

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  • Findingcitation

    In the same Bucharest Early Intervention Project study, there was no relationship between caregiving quality and signs of disinhibited social engagement disorder after placement into a family.

    “In the same study, however, there was no relationship between caregiving quality and signs of DSED after placement into a family.”
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    • cites Zeanah et al., 2005

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  • Findingcitation

    In the Bucharest Early Intervention Project, a composite variable of caregiving quality was associated with signs of reactive attachment disorder even after controlling for other child and environmental characteristics.

    “They found a composite variable of caregiving quality was associated with signs of RAD, even after controlling for other child and environmental characteristics.”
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    • cites Zeanah et al., 2005

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  • Findingcitation

    In the BEIP, some securely attached children showed high levels of indiscriminate behavior.

    “However, there were still some children with secure attachments who also showed high levels of indiscriminate behavior.”
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    • cites Gleason et al., 2011

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  • Findingcitation

    In the BEIP, ratings of fewer attachment behaviors in the Strange Situation converged with caregiver-reported signs of RAD.

    “As predicted, there was convergence between ratings of fewer attachment behaviors in the SSP and signs of RAD as reported by caregivers.”
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    • cites Zeanah et al., 2005

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  • Findingcitation

    In the BEIP, for toddlers living in institutions, attachment classifications were unrelated to indiscriminate behavior.

    “In the BEIP, for toddlers living in institutions, classifications of attachment were unrelated to indiscriminate behavior.”
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    • cites Gleason et al., 2011

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    Findingnone given

    There are no case reports of young children exhibiting the reactive attachment disorder phenotype as defined by ICD-10 or DSM-5 without at least a reasonable inference of serious emotional neglect, and no cases from abuse without neglect.

    “To date, there are no case reports of young children exhibiting the RAD phenotype as defined by ICD-10 or DSM-5 without at least a reasonable inference of serious emotional neglect, and no cases of the RAD phenotype from abuse without neglect.”
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    Findingcitation

    In a short-term longitudinal study of children adopted from 13 countries, a physical social engagement factor distinguished both adopted groups from non-adopted children, while a non-physical social engagement factor did not distinguish the groups.

    “Factor analysis of the child’s behavior at both time points yielded a non-physical social engagement factor (e.g., more responses to stranger overtures, reduced latency to approach), which did not distinguish the groups, and a physical social engagement factor (e.g., more physical intimacy with stranger and shorter latency to touch), which distinguished both adopted groups from the non-adopted”
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    • cites Lawler et al., in press

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    Findingcitation

    Most maltreated children and children raised in institutions have insecure or disorganized attachments to their caregivers.

    “Although the majority of maltreated children and children raised in institutions have insecure or disorganized attachments to biological parents or institutional caregivers (Carlson et al., 1989; O’Connor et al., 2003; Vorria et al., 2003; Zeanah et al., 2005), most do not develop attachment disorders (Boris et al., 2004; Gleason et al., 2011; Zeanah et al., 2004).”
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    • cites Carlson et al., 1989

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    • cites O’Connor et al., 2003

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    • cites Vorria et al., 2003

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    Findingcitation

    In an institutional comparison, children on a special unit that restricted the number of caregivers had significantly fewer signs of both types of reactive attachment disorder than children on a standard unit, indicating that poorer caregiving was associated with more signs of reactive attachment disorder and disinhibited social engagement disorder.

    “Those children living on a special unit that restricted the number of caregivers each child encountered in a day had significantly fewer signs of both types of RAD than young children living on a standard unit in the same institution. Thus, the poorer caregiving condition on the standard unit was associated with more signs of RAD and DSED (Smyke et al., 2002).”
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    • cites Smyke et al., 2002

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    Findingcitation

    Most maltreated children and children raised in institutions do not develop attachment disorders.

    “Although the majority of maltreated children and children raised in institutions have insecure or disorganized attachments to biological parents or institutional caregivers (Carlson et al., 1989; O’Connor et al., 2003; Vorria et al., 2003; Zeanah et al., 2005), most do not develop attachment disorders (Boris et al., 2004; Gleason et al., 2011; Zeanah et al., 2004).”
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    • cites Boris et al., 2004

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    • cites Gleason et al., 2011

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    • cites Zeanah et al., 2004

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    Findingcitation

    In the ERAS, insecure-other attachment was associated with indiscriminate behavior, but some securely attached children also had high levels of indiscriminate behavior.

    “In the ERAS, although there was an association between insecure-other and indiscriminate behavior, there also were securely attached children who also had high levels of indiscriminate behavior (O’Connor et al. 2003).”
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    Findingcitation

    In girls adopted from China out of institutions and foster care, indiscriminate behavior was elevated compared to non-adopted children, but there was no relationship between indiscriminate behavior and either secure or disorganized attachment.

    “In a study of girls adopted from China out of institutions and foster care, on the other hand, indiscriminate behavior was elevated compared to non-adopted children, but there was no relationship between indiscriminate behavior and either a secure or a disorganized attachment (Van den dries, 2012).”
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    • cites Van den dries, 2012

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    Findingcitation

    Marcovitch et al. (1997) reported that almost half of securely attached 3-5 year old Romanian adoptees exhibited indiscriminate behavior with a stranger, while none of the securely attached control children did so.

    “Marcovitch and colleagues (Marcovitch et al., 1997) reported that almost half of 3–5 year old adoptees from Romanian institutions who were securely attached to their mothers also exhibited indiscriminate behavior with the stranger, but none of the securely attached control children did so.”
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    • cites Marcovitch et al., 1997

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    Findingcitation

    Lyons-Ruth et al. (2009) found more indiscriminate behavior associated with non-secure attachment, but some securely attached children also exhibited indiscriminate behavior.

    “Lyons-Ruth et al. (2009) studied an impoverished sample and found more indiscriminate behavior (coded from behavior towards the stranger in the SSP) in association with non-secure attachment. Even so, they found that some securely attached children also exhibited indiscriminate behavior.”
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    • cites Lyons-Ruth et al. (2009)

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    Findingcitation

    Bakersman-Kranenberg et al. (2011) found that the long allele of the serotonin transporter gene protected against disorganized attachment but did not protect against indiscriminate behavior.

    “They found that the long allele of the genotype protected against development of disorganized attachment but did not protect against development of indiscriminate behavior.”
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    • cites Bakersman-Kranenberg et al. (2011)

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    Findingcitation

    Drury et al. (2012) found that children with the s/s 5httlpr genotype and met66 carriers of BDNF had the lowest levels of indiscriminate behavior in foster care but the highest levels in care as usual, while children with other genotypes showed no difference.

    “They demonstrated that children with the s/s 5httlpr genotype and the met66 carriers of BDNF (“plasticity genotypes”) demonstrated the lowest levels of indiscriminate behavior in the children randomized to foster care but the highest levels in children randomized to care as usual (meaning more prolonged institutional care).”
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    Findingcitation

    In the BEIP, among children with elevated RAD scores, 53% were disorganized, 23% were secure, 22% were unclassifiable, and 5% were avoidant.

    “Of children with elevated scores for RAD, 53% were disorganized, 23% were secure, 22% were unclassifiable, and 5% were avoidant.”
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    • cites Zeanah et al., 2003

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    Findingcitation

    In the BEIP, signs of DSED were associated with signs of ADHD and modestly associated with signs of disruptive behavior disorders at 54 months.

    “For example, in BEIP, signs of DSED were associated with signs of ADHD and modestly associated with signs of disruptive behavior disorders at 54 months (Gleason et al., 2011).”
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    • cites Gleason et al., 2011

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    Findingcitation

    In the BEIP, RAD was only modestly associated with DQ/IQ in children at 22, 30, and 42 months, and not associated at 54 months.

    “In BEIP, RAD was only modestly associated with DQ/IQ in children at 22, 30, and 42 months, and not associated at 54 months.”
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    Findingcitation

    Quasi-autism is differentiated by normal head circumference, equal distribution by sex, and improvement when the child is placed in families.

    “Quasi-autism is differentiated by normal head circumference, the equal distribution by sex, and most notably, improvement when the child is placed in families.”
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    • cites Rutter et al., 2007

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    Findingcitation

    In the BEIP, only 4 of the 20 children who met criteria for ADHD also met criteria for DSED, and only 4 of the 16 children who met criteria for DSED also met criteria for ADHD.

    “For example, in BEIP, only 4 of the 20 children who met criteria for ADHD also met criteria for DSED and only 4 of the 16 children who met criteria for DSED also met criteria for ADHD (Gleason et al., 2011).”
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    • cites Gleason et al., 2011

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    Findingcitation

    Among the continuously institutionalized group, stability of DSED signs was slightly higher.

    “Among the continuously institutionalized group, stability was slightly higher.”
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    Findingcitation

    At age 16, indiscriminate behavior with caregivers was reduced but evident with peers; peer relations were conflicted and superficial.

    “At age 16, indiscriminate behavior with caregivers was reduced but evident with peers. Relations with peers were conflicted and superficial, for example, naming a recent acquaintance as a close friend (Hodges & Tizard, 1989).”
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    • cites Hodges & Tizard, 1989

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    Findingcitation

    Both post-institutionalized and foster care children were more likely than non-adopted children to exhibit indiscriminate behavior.

    “Both post-institutionalized and foster care children were more likely than non-adopted children to exhibit indiscriminate behavior.”
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    • cites Tarullo et al., 2011

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    Findingcitation

    These structural findings are compatible with reduced electrical activity in higher frequencies and increased electrical activity in lower frequencies.

    “Consistent structural findings are reductions in both gray and white matter volumes in children who experienced institutional deprivation (Eluvinthingal et al., 2006; Mehta et al., 2009; Sheridan et al., 2012), compatible with reduced electrical activity in higher frequencies and increased electrical activities in lower frequencies (Marshall & Fox, 2004; Marshall et al., 2008; Tarullo et al., 2009”
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    Findingcitation

    Children with more prolonged institutional rearing showed reduced amygdala discrimination and more indiscriminate behavior.

    “Further, reductions in mother-stranger discriminations were moderately associated with indiscriminate behavior, and those children with more prolonged institutional rearing showed reduced amygdala discrimination and more indiscriminate behavior.”
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    • cites Olsavsky et al., 2013

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    Findingcitation

    Tizard and colleagues reported significant stability in over-friendly and attention seeking behavior from age 4 to 8 years in formerly institutionalized children, and noted that once established, over-friendly behavior was especially resistant to change.

    “Tizard and colleagues reported significant stability in “over-friendly” and attention seeking behavior from age 4 to 8 years in formerly institutionalized children, and noted that once established, over-friendly behavior was especially resistant to change (Tizard & Rees, 1975; Tizard & Hodges, 1978).”
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    • cites Tizard & Rees, 1975

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    • cites Tizard & Hodges, 1978

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    Findingcitation

    In the BEIP, for children randomized to foster care, signs of RAD diminished by the first follow-up at 30 months to levels comparable to never institutionalized children, and remained so at 42 and 54 months.

    “In contrast, for those randomized to foster care, signs of RAD diminished by the first follow-up at 30 months of age to levels comparable to never institutionalized children, and remained so at 42 and 54 months of age (Smyke et al., 2012).”
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    Findingcitation

    Rutter et al. (2007) reported an increase in use of mental health services and more special education in children with histories of institutional rearing who showed indiscriminate behavior.

    “Rutter et al. (2007) reported an increase in use of mental health services and more special education in children with histories of institutional rearing who showed indiscriminate behavior.”
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    Findingcitation

    In the BEIP, signs of DSED were concurrently associated with lack of social-emotional competence at 30 and 42 months and with functional impairment at 54 months.

    “Similarly, signs of DSED in the same study were concurrently associated with lack of social-emotional competence at 30 and 42 months and with functional impairment at 54 months.”
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    • cites Gleason et al., 2011

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    Findingcitation

    The BEIP RCT demonstrated that signs of RAD were evident in young children living in institutions (average age 22 months) and persisted through 54 months in children randomized to care as usual.

    “This RCT demonstrated that signs of RAD were evident in young children living in institutions (average age 22 months) (Zeanah et al., 2005) and that they persisted through 54 months of age (endpoint of the trial) in children randomized to care as usual (Smyke et al., 2012).”
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    • cites Zeanah et al., 2005

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    • cites Smyke et al., 2012

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    Findingcitation

    Dozier et al. (2001) found that maltreated young children placed in foster care could form secure attachments to caregivers at rates comparable to never maltreated children only if foster mothers were themselves securely attached; if not, the probability of disorganized attachments increased substantially.

    “Dozier et al. (2001) found that maltreated young children placed in foster care could form secure attachments to their caregivers at rates comparable to never maltreated children but only if foster mothers were themselves securely attached. If the mothers were not securely attached, the probability of disorganized attachments increased substantially.”
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    • cites Dozier et al. (2001)

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    Findingcitation

    In the Tizard study, the inhibited phenotype evident in institutionalized children at age 4 was no longer present at age 8 or 16, though indiscriminate behavior persisted in some children after adoption or return to biological parents.

    “In the Tizard study, although indiscriminate behavior persisted in some children after adoption or return to biological parents, the inhibited phenotype that was evident in institutionalized children at age 4 years was no longer present at age 8 or 16 years (Tizard & Rees, 1975; Tizard & Hodges, 1978; Hodges & Tizard, 1989).”
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    • cites Tizard & Rees, 1975

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    • cites Hodges & Tizard, 1989

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    Findingcitation

    Children with histories of institutional rearing who showed indiscriminate behavior had impaired peer relationships and higher rates of psychopathology.

    “Additionally, children showed impaired peer relationships and higher rates of psychopathology.”
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    • cites Rutter et al., 2007

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    Findingcitation

    In the BEIP, signs of RAD were associated with concurrently assessed lack of social competence at 30 and 42 months and with functional impairment at 54 months.

    “The most direct evidence on this point at least in early childhood, comes from BEIP, in which signs of RAD were associated with concurrently assessed lack of social competence at 30 and 42 months and with functional impairment at 54 months.”
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    • cites Gleason et al., 2011

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    Findingcitation

    In Canadian and English studies of children adopted from Romanian institutions, signs of DSED were readily apparent, but there were no reports of children with RAD, even in initial assessments.

    “In the Canadian and English studies of children adopted from Romanian institutions, signs of DSED were readily apparent, but there were no reports of children with RAD, even in the initial assessments (Chisholm et al., 1995; O’Connor et al., 1999).”
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    • cites Chisholm et al., 1995

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    • cites O’Connor et al., 1999

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    Findingcitation

    In the BEIP, signs of DSED at 42 months predicted impairment at 54 months, but signs at 22 and 30 months did not.

    “Signs of DSED at 42 months predicted impairment at 54 months, but signs at 22 months and 30 months did not (Gleason et al., 2011).”
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    • cites Gleason et al., 2011

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    Findingcitation

    Tizard's longitudinal study demonstrated both the persistence of indiscriminate behavior and its reduction following adoption.

    “Tizard’s longitudinal study demonstrated both the persistence of indiscriminate behavior and its reduction following adoption (Tizard & Rees, 1975; Tizard & Hodges, 1978; Hodges & Tizard, 1989).”
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    Interpretationnone given

    Disinhibited social engagement disorder is characterized by children lacking developmentally appropriate reticence with unfamiliar adults and violating socially sanctioned boundaries.

    “The evidence for two separate disorders is considerable, with reactive attachment disorder indicating children who lack attachments despite the developmental capacity to form them, and disinhibited social engagement disorder indicating children who lack developmentally appropriate reticence with unfamiliar adults and who violate socially sanctioned boundaries.”
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    Interpretationnone given

    In early childhood, attachment disorders encompass two clinical patterns: an emotionally withdrawn/inhibited phenotype and an indiscriminately social/disinhibited phenotype.

    “There is now broad consensus that in early childhood, attachment disorders result from inadequate caregiving environments and encompass two clinical patterns, an emotionally withdrawn/inhibited phenotype and an indiscriminately social/disinhibited phenotype.”
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    Premisereasoning

    The two attachment-disordered phenotypes from Tizard's study were later incorporated into formal nosologies, all of which defined two basic clinical presentations of disordered attachment in young children.

    “The two attachment disordered phenotypes in the Tizard study – emotionally withdrawn and indiscriminately social -- were later incorporated into criteria in formal nosologies, all of which defined two basic clinical presentations of disordered attachment in young children.”
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    Premisereasoning

    DSM-5 requires a cognitive age of at least 9 months for a reactive attachment disorder diagnosis to avoid diagnosing children who are developmentally incapable of demonstrating focused attachment.

    “DSM-5 also requires that a child have a cognitive age of at least 9 months to ensure that an attachment disorder is not diagnosed in children who are developmentally incapable of demonstrating a focused attachment.”
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    Premisecitation

    Reactive attachment disorder resolves nearly completely with access to an adequate attachment figure, whereas disinhibited social engagement disorder can persist despite adequate caregiving and a selective attachment relationship.

    “For example, RAD resolves nearly completely with access to an adequate attachment figure, whereas DSED can persist in the context of adequate caregiving and a selective attachment relationship.”
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    Premisereasoning

    DSM-5 replaced the terms pathogenic care and parental abuse, neglect or serious mishandling with insufficient care to emphasize social neglect as the key necessary condition for reactive attachment disorder.

    ““Pathogenic care” in DSM-IV and “parental abuse, neglect or serious mishandling” in ICD-10 was replaced by “insufficient care” in DSM-5 in order to emphasize that social neglect that seems the key necessary condition for the disorder to occur.”
    Quote in the paperSubstantial claim

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    Premisecitation

    In Tizard's study of 26 children institutionalized for their first four years, 8 were emotionally withdrawn and socially unresponsive, 10 were indiscriminately social and clingy, and 8 formed selective attachments to caregivers.

    “Of the 26 children who remained institutionalized for the first four years of their lives, eight were described as emotionally withdrawn and social unresponsive, 10 others were indiscriminately social, attention seeking and clingy with everyone, including unfamiliar adults, and the remaining eight of the 26 actually formed selective attachments to caregivers (Tizard & Rees, 1975).”
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    • cites Tizard & Rees, 1975

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    Premisecitation

    Psychiatric comorbidities differ between reactive attachment disorder and disinhibited social engagement disorder, with depressive signs in reactive attachment disorder and impulsivity more commonly associated with disinhibited social engagement disorder.

    “Their psychiatric co-morbidities differ, with depressive signs seen in children with RAD and patterns of impulsivity more commonly associated with DSED.”
    Quote in the paperSubstantial claim

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    Premisenone given

    DSM-IV and ICD-10 criteria for attachment disorders generally converged, sharing cross-contextual aberrant social behavior caused by grossly inadequate care and the two inhibited and disinhibited phenotypes.

    “There was general convergence between the DSM-IV and the ICD-10 criteria for attachment disorders. Common features include cross-contextual aberrant social behavior caused by grossly inadequate care, and the two clinical phenotypes of inhibited and disinhibited behavioural patterns.”
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    Premisecitation

    Children may have ADHD without socially indiscriminate behavior, or socially indiscriminate behavior without ADHD, but there are often moderately strong correlations between the two symptom profiles.

    “Nevertheless, it is clear that children may have ADHD without socially indiscriminate behavior, or socially indiscriminate behavior without ADHD, but there are often moderately strong correlations between the two symptom profiles (Gleason et al., 2011; Roy, Pickles & Rutter, 2004).”
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    • cites Gleason et al., 2011

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    • cites Roy, Pickles & Rutter, 2004

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    Premisenone given

    ICD-10 divided the subtypes into two distinct disorders, reactive attachment disorder and disinhibited attachment disorder, and DSM-5 followed ICD-10 by separating reactive attachment disorder and disinhibited social engagement disorder.

    “However, ICD-10 divided the subtypes into two distinct disorders, reactive attachment disorder (RAD), similar to the emotionally withdrawn/inhibited type of RAD in DSM-IV and disinhibited attachment disorder (DAD), similar to the indiscriminately social/disinhibited type of RAD in DSM-IV. DSM-5 followed the lead of ICD-10, separating the disorders into RAD and DSED.”
    Quote in the paperNot a substantial claim

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    Study design and conductcitation

    The RAD and DSED behaviors have been reported in numerous studies and form a coherent set of objectively defined signs.

    “These behaviours have been reported in numerous studies and comprise a coherent set of objectively defined signs of disorder (O’Connor & Zeanah, 2003; Zeanah et al., 2002).”
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    • cites O’Connor & Zeanah, 2003

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    • cites Zeanah et al., 2002

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    Interpretationcitation

    There is evidence that disinhibited social engagement disorder predicts functional impairment, difficulties with close relationships, and greater need for special education services.

    “In fact, in keeping with the suggestions of social cognitive and behavioral abnormalities of the disorder (Green, 2003; Minnis et al., 2006; Rutter et al., 2009; Tarullo & Gunnar, 2005), there is now evidence that DSED is predictive of functional impairment, difficulties with close relationships, and more need for special education services (Gleason et al., 2011; Rutter et al., 2007).”
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    • cites Gleason et al., 2011

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    • cites Rutter et al., 2007

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    Premisecitation

    Core behavioral features of disinhibited social engagement disorder include inappropriate approach to unfamiliar adults and lack of wariness of strangers.

    “Core behavioural features of DSED include inappropriate approach to unfamiliar adults and lack of wariness of strangers, and a willingness to wander off with strangers.”
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    • cites O’Connor & Zeanah, 2003

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    Premisecitation

    DSM-5 indicates that disinhibited social engagement disorder includes socially disinhibited behavior that must be distinguished from ADHD because evidence suggests some signs of ADHD and disinhibited social engagement disorder overlap.

    “DSM-5 indicates that DSED includes socially disinhibited behavior that must be distinguished from the impulsivity that accompanies ADHD because several lines of evidence suggest that some signs of ADHD and of DSED overlap.”
    Quote in the paperSubstantial claim

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    Premisecitation

    Oliveira et al. (2012) found that a composite score of maternal prenatal risk predicted indiscriminate behavior, as did emotional neglect.

    “Specifically, a composite score of maternal prenatal risk, operationalized as having a physical disease, abusing substances, limited prenatal care and preterm birth, predicted indiscriminate behavior, as did emotional neglect.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Oliveira et al., 2012

      Not checked in the free run.

  • May combine two claims.

    Study design and conductcitation

    Indiscriminate behavior with an unfamiliar adult has been demonstrated during the Strange Situation Procedure in foster care and institutionalized children and has converged with caregiver report.

    “Indiscriminate behavior with an unfamiliar adult also has been demonstrated during the SSP both in young children in foster care (Lyons-Ruth et al., 2009) and in institutionalized children and has converged with caregiver report (Oliveira et al., 2012).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Lyons-Ruth et al., 2009

      Not checked in the free run.

    • cites Oliveira et al., 2012

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Dobrova-Krol et al. (2010) found higher levels of positive caregiving among institution-reared children with indiscriminate behavior, an association opposite in direction to that seen in home-reared controls.

    “Dobrova-Krol et al. (2010) found higher levels of positive caregiving among institution-reared children with indiscriminate behavior, an association in the opposite direction as that seen in home-reared controls.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Dobrova-Krol et al. (2010)

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationreasoning

    Social neglect is a necessary but not sufficient requirement for the diagnosis of attachment disorders.

    “Thus, social neglect is noted as a necessary though not sufficient requirement for the diagnosis to be entertained.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationcitation

    Severe caregiving deficiencies are necessary but not sufficient for the development of RAD or DSED.

    “Although severe caregiving deficiencies seem necessary for RAD or DSED to develop, they clearly are not sufficient (Bakersman-Kranenberg et al., 2011; Soares et al., 2013; Zeanah & Smyke, in press).”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites Bakersman-Kranenberg et al., 2011

      Not checked in the free run.

    • cites Soares et al., 2013

      Not checked in the free run.

    • cites Zeanah & Smyke, in press

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Kay and Green found additional factors reflecting attention seeking behavior and superficial relationships beyond the indiscriminate behavior described in DSM-5.

    “In advocating for a broader phenotype, they found in addition to the indiscriminate behavior described in DSM-5, factors reflecting attention seeking behavior and superficial relationships.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Kay and Green (2013)

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisereasoning

    Attachment disorders include specification of etiology in their diagnostic criteria.

    “Along with other trauma and stress related disorders, attachment disorders include specification of etiology in the criteria.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Minnis and colleagues' studies demonstrated reliable identification of reactive attachment disorder in middle childhood, but their measures include a broader phenotype with an unclear relationship to measures used in early childhood.

    “These studies have demonstrated reliable identification of RAD in middle childhood, but the measures they used to identify RAD include a broader phenotype and have an unclear relationship to measures used to assess RAD in early childhood.”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites Millward et al., 2006

      Not checked in the free run.

    • cites Minnis et al., 2007

      Not checked in the free run.

    • cites Minnis et al., 2009

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationcitation

    The investigators concluded that physical social engagement may reflect the core of disinhibited social engagement disorder.

    “The investigators concluded that physical social engagement may reflect the core of DSED.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Lawler et al., in press

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    The preponderance of evidence suggests that the two phenotypes are robust and that similar constructs are identified across studies of different samples, locations, and research groups.

    “Nevertheless, the preponderance of evidence to date suggests that the two phenotypes are robust and that similar constructs are being identified across studies of different samples in different locations conducted by different research groups.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Garvin et al. (2012) found that initiation of joint attention at 18 months was inversely correlated with indiscriminate behavior at 30 months when adoptive parents had lower emotional availability, but there was no relationship at higher emotional availability.

    “In a study of post-instututionalized toddlers, Garvin et al. (2012) found that initiation of joint attention at 18 months was inversely correlated with indiscriminate behavior in post-institutionalized toddlers at 30 months if adoptive parents had lower levels of emotional availability. At higher levels of parents’ emotional availability, however, there was no longer a relationship between joint”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Garvin et al. (2012)

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationreasoning

    The context in which social engagement occurs is related to the meaning of the child's sociable behavior and may affect whether it is considered excessive or deviant.

    “The context in which the social engagement occurs undoubtedly is related to the meaning of the child’s sociable behavior and may affect the degree to which it may be considered excessive or deviant.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductnone given

    In neither the Zeanah et al. (2002) nor the Soares et al. (2014) study was attachment to caregivers formally assessed.

    “In neither study was attachment to caregivers formally assessed.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    Children with signs of DSED may have no attachments, disorganized attachments, insecure attachments, or even secure attachments.

    “In fact, children with DSED may have no attachments, disorganized attachments, insecure attachments or even secure attachments (Bakersman-Kranenberg et al., 2011; Zeanah & Gleason, 2010).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Bakersman-Kranenberg et al., 2011

      Not checked in the free run.

    • cites Zeanah & Gleason, 2010

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Insecure or disorganized attachments may be associated with interpersonal difficulties concurrently or subsequently, but they are relationship-specific patterns of behavior.

    “Insecure or disorganized attachments may be associated with interpersonal difficulties concurrently or subsequently, but they are relationship specific patterns of behavior, so the child’s behavior with one adult may be secure and with another insecure.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationnone given

    In children with disorganized or insecure-other attachment, the prevalence of DSED is increased, but attachment disordered behaviors are largely distinct from behaviors seen in different attachment classifications.

    “In children with more extreme or aberrant forms of attachment, such as disorganized or insecure-other, the prevalence of DSED is increased, but attachment disordered behaviors are largely distinct from behaviors seen in different attachment classifications.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Inhibitory control is dependent upon ventral frontostriatal circuitry.

    “Because of demonstrated associations between signs of ADHD and indiscriminate behavior (Roy, Pickles & Rutter, 2004; Gleason et al., 2011), several studies have examined inhibitory control, a construct demonstrated to be dependent upon ventral frontostriatal circuitry (Durston et al., 2002).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Durston et al., 2002

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Because inadequate care is etiologic, fostering or adoption will lead to elimination or at least substantial reduction of signs of attachment disorders.

    “Because inadequate care is etiologic, it is reasonable to consider that fostering or adoption will lead to elimination or at least substantial reduction of signs of the disorders.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    Adequate caregiving appears both to prevent and to ameliorate DSED.

    “Although adequate caregiving seems both to prevent and to ameliorate DSED, the persistence of signs of DSED in some children indicates that additional strategies and approaches beyond an enhancement of caregiving are needed.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Sensitive and responsive care, in which a parent identifies and responds to the child's needs, leads to secure attachment formation.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given

    Deprivation occurring before the first 6 months or after 24 months of age appears far less likely to lead to the clinical picture of DSED.

    “There is a question of a sensitive period in the vulnerability to DSED, as deprivation that occurs before the first 6 months and after 24 months of age seem far less likely to lead to the clinical picture, but the data remain thin on which this preliminary conclusion rests.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Severe social neglect is necessary for RAD and DSED to occur.

  • Classified as probably not a substantial claim.

    Interpretationcitation

    The incomplete remediation for DSED could reflect individual differences in responsiveness to caregiving.

    “The incomplete remediation for those with DSED could reflect individual differences in responsiveness to caregiving (see Drury et al., 2012) or incomplete remediation in those who were most severely affected initially.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Drury et al., 2012

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    There may be a threshold of caregiving quality beyond which remediation of DSED is not further enhanced.

    “This could mean that there is a threshold of caregiving quality after which remediation of DSED is not further enhanced.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Interpretationnone given

    The extent to which enhanced care and symptom reduction reduces later social and emotional problems in these children is not yet established.

    “The degree to which enhanced care and symptom reduction in these children reduces subsequent social and emotional problems is not yet established.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    Social cognitive abnormalities plausibly underlie the social boundary violations and disinhibition that characterize DSED.

    “Given that social cognitive abnormalities plausibly underlie the social boundary violations and disinhibition that characterize the disorder, interventions that target these features seem promising areas to explore.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    The incomplete remediation for DSED could reflect incomplete remediation in those who were most severely affected initially.

    “The incomplete remediation for those with DSED could reflect individual differences in responsiveness to caregiving (see Drury et al., 2012) or incomplete remediation in those who were most severely affected initially.”
    Quote in the paperNot a substantial claim
73 of 73

  • The paper relies on this without support.

    No reports to date have identified genetic risks for RAD.

    “No reports to date have identified genetic risks for RAD, but preliminary studies have explored them for DSED.”

  • The paper relies on this without support.

    Research is limited that addresses the natural course of RAD.

    “Research is limited that addresses the natural course of RAD.”

  • The paper relies on this without support.

    Studies designed as interventions for RAD and DSED are limited.

    “Studies designed as interventions for RAD and DSED are limited.”

  • The paper relies on this without support.

    Sensitive and responsive care, in which a parent identifies and responds to the child's needs, leads to secure attachment formation.

    “the caregiving that should be provided for children with DSED, as best we can determine, is the same caregiving that is known to lead to secure attachment formation. That is, sensitive and responsive care, in which the parent identifies and responds to the child’s needs.”

  • The paper relies on this without support.

    Severe social neglect is necessary for RAD and DSED to occur.

    “Given that severe social neglect seems necessary for these disorders to occur, a vexing question is what vulnerability factors might give rise to the very different phenotypes in RAD and DSED.”
5 of 5

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?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

  • Attachment-classification percentages exceed 100%

    Minor

    The four reported classifications are presented as an exhaustive breakdown of children with elevated RAD scores, but their percentages total 103%. Rounding four percentages to whole numbers cannot account for a three-point excess.

    Reported 100 · recomputed 103

1 of 1

Cites

Flagged first, then by citations

Research works printed but not linked: 5

  1. Bakermans‐Kranenburg M.J., 2011, Children without permanent parental care: Research, practice, and policy, 62
  2. Nelson C.A., 2011, Children without permanent parental care: Research, practice, and policy, 127
  3. Tarullo A.R., 2005, Institutional rearing and deficits in social relatedness: Possible mechanisms and processes, Cognition, Brain and Behavior, 9, 329
  4. World Health Organization, 1992, The ICD‐10 classification of mental and behavioral disorders: Clinical descriptions and diagnostic guidelines
  5. Zeanah C.H. &Gleason M.M.(2010).Reactive attachment disorder: A review for DSM‐5. Available from:www.nrvcs.org/nrvattachmentresources/documents/APA%20DSM-5%20Reactive%20Attachment%20Disorder%20Review%5B1%5D.pdf[last accessed 15 October 2014].

Cited by

Sorted by citations

Related

Authors
Zeanah, C. H., & Gleason, M. M.
Affiliations
Tulane University (US)
Corresponding author
Zeanah, Charles H.
ORCID
Venue
Journal of Child Psychology and Psychiatry
Publisher
Wiley
Published
2014-10-31
Volume
56
Issue
3
Pages
207-222
ISSN
  • 0021-9630 (ISSN-L)
  • 1469-7610
DOI
10.1111/jcpp.12347
PMC
PMC4342270
OpenAlex
W2047233375
Semantic Scholar
d4c02effebb34268213898ec3005c9fd9798c1c4
Cited by
265
References
114
Citations by year
2026: 16 · 2025: 19 · 2024: 15 · 2023: 21 · 2022: 16 · 2021: 15 · 2020: 54 · 2019: 25 · 2018: 37 · 2017: 23 · 2016: 18 · 2015: 6
FWCI
2.20
Type
journal article
Language
en
Open access
Licence
onlinelibrary.wiley.com/termsAndConditions#vor (vor)
Locations
  • Journal of Child Psychology and Psychiatry (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
NIMH (1RO1MH091363-01, 1R01MH091363-02)
Topics
  • Social Sciences › Psychology › Social Psychology › Attachment and Relationship Dynamics
  • Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
  • Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
Keywords
attachment disorders, reactive attachment disorder, disinhibited social engagement disorder, early childhood, insecure attachment, vulnerability factors
MeSH terms
Child Abuse, Child, Preschool, Humans, Infant, Social Behavior, Stress, Psychological, Reactive Attachment Disorder

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.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-05.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-05.

Statistics and arithmetic are recomputed, not judged.

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