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Cited by 181Child Welfare and AdoptionChild and Adolescent Psychosocial and Emotional DevelopmentChild Abuse and Trauma

A Randomized Controlled Trial Comparing Foster Care and Institutional Care for Children With Signs of Reactive Attachment Disorder

Open access
Smyke, Anna T., Zeanah, Charles H., Gleason, Mary Margaret, Drury, Stacy S., Fox, Nathan A., Nelson, Charles A., Guthrie, Donald·2012·American Journal of Psychiatry
DOI 10.1176/appi.ajp.2011.11050748PMC PMC4158103
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Abstract

OBJECTIVE: The authors examined signs of emotionally withdrawn (inhibited type) and indiscriminately social (disinhibited type) reactive attachment disorder in Romanian children enrolled in a randomized trial of foster care compared with institutional care and in a comparison group of never-institutionalized children. METHOD: At baseline and when children were ages 30, 42, and 54 months and 8 years, caregivers were interviewed with the Disturbances of Attachment Interview to assess changes in signs of reactive attachment disorder in three groups of children: those receiving care as usual (including continued institutional care) (N=68); those placed in foster care after institutional care (N=68); and those who were never institutionalized (N=72). The impact of gender, ethnicity, and baseline cognitive ability was also examined. RESULTS: On the Disturbances of Attachment Interview, signs of the inhibited type of reactive attachment disorder decreased after placement in foster care, and scores were indistinguishable from those of never-institutionalized children after 30 months. Signs of the disinhibited type were highest in the usual care group, lower in the foster care group, and lowest in the never-institutionalized group. Early placement in foster care (before age 24 months) was associated with fewer signs of the disinhibited type. Lower baseline cognitive ability was associated with more signs of the inhibited type in the usual care group and more signs of the disinhibited type in both groups. CONCLUSIONS: Signs of the inhibited type of reactive attachment disorder responded quickly to placement in foster care; signs of the disinhibited type showed less robust resolution with foster placement. Lower baseline cognitive ability was linked to signs of reactive attachment disorder.

Integrity signals

Registry

Crossref · 10.1176/appi.ajp.2011.11050748

Cites

37 of 37 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

7 of 46 cited sources checked · 2 supported · 0 flagged · accuracy not yet measured

  • Study design and conductcitation

    Confidence in caregiver reports is high because they converge with observer ratings.

    “Nevertheless, our confidence in caregiver reports for this sample is high because they converge with observer ratings (29).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
  • Interpretationcitation

    Results have implications for children who experienced maltreatment and other forms of neglect.

    “Results from this investigation have implications not only for young children raised in institutions but also for those who have experienced maltreatment (29, 37, 38) and other forms of neglect.”
    Quote in the paperSubstantial claim1 of 3 sources checked
    • cites [29] source

      The paper discusses attachment disorders in children who experienced maltreatment, so it provides some context for the proposed implications. But the Discussion (page not provided) says this study examined institutionalization only and its findings may not generalize to children exposed to other adverse caregiving, including other forms of neglect. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
    • cites [37] source
    • cites [38] source
  • Findingown data

    After age 30 months, foster care children's inhibited RAD scores were indistinguishable from never-institutionalized children.

    “scores were indistinguishable from those of never-institutionalized children after 30 months”
    • Also stated in: § Discussion · plain
      “signs were indistinguishable between children in the foster care group and those in the never-institutionalized group after age 30 months”
    Quote in the paperSubstantial claim
  • Findingown data

    Children in both groups with lower cognitive ability at baseline showed more disinhibited RAD signs.

    “more signs of the disinhibited type in both groups”
    • Also stated in: § Factors impacting change in signs of reactive attachment disorder · plain
      “children with better cognitive abilities at baseline had fewer signs of this type of reactive attachment disorder across the entire intervention period.”
    Quote in the paperNot a substantial claim
  • Findingown data

    In the usual care group, children with lower cognitive ability at baseline had more inhibited RAD signs.

    “Lower baseline cognitive ability was associated with more signs of the inhibited type in the usual care group”
    • Also stated in: § Factors impacting change in signs of reactive attachment disorder · plain
      “Post hoc comparisons revealed more signs of this type of reactive attachment disorder among children in the usual care group with lower baseline cognitive abilities, across the entire intervention period, compared with children in this group with higher baseline cognitive abilities (t=4.24, df=127, p<.0.001).”
    Quote in the paperNot a substantial claim
  • Classified as probably not a substantial claim. 14
  • May combine two claims. 22
  • The quote only partly states this claim. 1

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

    Premisecitation

    Both inhibited and disinhibited RAD types have been described in young children who were maltreated or raised in deprivation.

    “Both types of the disorder, emotionally withdrawn (inhibited) and the indiscriminately social (disinhibited), have been described in young children who have been maltreated or raised in conditions of deprivation (2–4).”
    Quote in the paperNot a substantial claim1 of 3 sources checked
    • cites [2] Bowlby J, 1951 source

      The Abstract describes two possible outcomes of early maternal deprivation: an affectionless character or profound emotional and physical apathy. This supports the broader point that deprived young children may show different patterns, but it does not identify them as inhibited and disinhibited RAD, describe indiscriminate sociability, or address maltreatment separately. (LLM, conf=0.82)

      Experimental — accuracy not yet measured
    • cites [3] source
    • cites [4] source

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

    Premisecitation

    The association of institutional deprivation and RAD has been noted since the mid-20th century.

    “The association of institutional deprivation and reactive attachment disorder has been noted in the literature since the mid-20th century (1–4).”
    Quote in the paperNot a substantial claim1 of 4 sources checked
    • cites [1] source
    • cites [2] Bowlby J, 1951 source

      The 1952 paper’s Abstract links early deprivation of a mother-figure to impaired emotional development and describes studies of deprived children’s behaviour. It does not specifically identify institutional deprivation or reactive attachment disorder, so it supports the historical connection only at a broader level. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
    • cites [3] source
    • cites [4] source

  • May combine two claims.

    Study design and conductcitation

    DAI has shown strong convergent and discriminant validity.

    “The instrument has shown strong convergent (9, 30) and discriminant (29) validity.”
    Quote in the paperNot a substantial claim2 of 3 sources checked
    • cites [9] source
    • cites [30] source

      In Part II, ‘PTSD and Secure Base Distortions’ (page unavailable), the paper describes the DAI and reports internal consistency for its secure-base-distortion items and an association between DAI scores and maternal PTSD severity. Neither that passage nor searches for ‘convergent validity’ and ‘discriminant validity’ establish that the DAI has strong validity of either kind. (LLM, conf=0.72)

      Experimental — accuracy not yet measured
    • cites [29] source

      The Results (page unavailable) examine discriminant validity and find no statistical association between disinhibited RAD and ADHD diagnoses. But the tests concern RAD diagnoses rather than the DAI instrument as a whole; the paper also reports an association between withdrawn RAD signs and depressive symptoms. Its findings therefore do not establish the DAI’s broadly ‘strong’ discriminant validity. (LLM, conf=0.82)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Interpretationcitation

    When placed with families, children form new attachments and inhibited RAD signs disappear.

    “When placed with families, children form new attachments (21) and signs of inhibited reactive attachment disorder disappear.”
    Quote in the paperNot a substantial claim1 of 1 sources checked

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims. The quote only partly states this claim.

    Findingown data

    All children under age 31 months in six Bucharest institutions were assessed; 51 met exclusion criteria; initial study population 136.

    “All children under age 31 months (N=187) at study initiation (April 2001) who were cared for in the six institutions in Bucharest were assessed for participation in the study.”
    • Also stated in: § Sample · plain
      “Fifty-one children met exclusion criteria, resulting in an initial study population of 136 children.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Disinhibited RAD signs were highest in usual care, lower in foster care, and lowest in never-institutionalized children.

    “Signs of the disinhibited type were highest in the usual care group, lower in the foster care group, and lowest in the never-institutionalized group.”
    Quote in the paperSubstantial claim

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

    Findingown data

    One child in foster care group was excluded after meeting exclusion criteria.

    “One child in the foster care group was subsequently found to meet exclusion criteria and was excluded from further analyses.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Disinhibited RAD repeated-measures showed significant main effects for time and group, not group-by-time.

    “The repeated-measures analysis showed significant main effects for change over time (F=12.72, df=4, 475, p<0.001) and for group (F=15.42, df=1, 133, p<0.001), but not for the group-by-time interaction, suggesting that scores did not decrease differentially for the usual care and foster care groups (Figure 1).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Baseline cognitive ability-by-group interaction for inhibited RAD significant, differential effect.

    “Results of repeated-measures ANOVA revealed a baseline cognitive ability-by-group interaction (F=5.89, df=1, 127, p<0.05), indicating a differential effect of baseline cognitive ability on signs of inhibited reactive attachment disorder.”
    Quote in the paperNot a substantial claim

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

    Findingown data

    Preliminary analyses found no significant effect of gender or ethnicity; these variables were excluded.

    “Preliminary analyses revealed no significant effect of gender or ethnicity and these variables were excluded from further analyses.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Significant age at placement by time interaction for disinhibited RAD, scores decreased differentially before versus after 24 months.

    “repeated-measures analysis showed a significant interaction of age at placement by time (f=3.39, df=4, 239, p<0.05), indicating that scores decreased differentially for the children placed in foster care before age 24 months compared with those placed after that age.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductreasoning

    Including pre-removal assessments and well-validated longitudinal measures reduces selection bias and addresses responsiveness questions.

    “By including assessments of reactive attachment disorder prior to removal from institutions and by using well-validated measures administered longitudinally, this randomized controlled trial reduces selection bias and directly addresses questions about the responsiveness of children with reactive attachment disorder to enhanced caregiving.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Comparison groups in two recent studies were Canadian and British rather than ethnically matched, so cultural differences may affect outcomes.

    “Third, the comparison groups for two recent studies (11, 15) were Canadian and British children, respectively, rather than ethnically matched children, introducing the possibility that cultural differences may affect outcomes.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [11] source
    • cites [15] source

  • May combine two claims.

    Premiseown data

    The study children had been relinquished around birth and were in government-run institutions.

    “Children in the study had been abandoned at or soon after birth and placed in institutional care in the custody of the government.”
    Quote in the paperNot a substantial claim

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

    Premisecitation

    Many children globally live in institutions due to maltreatment, abandonment, or loss or incapacity of parents.

    “Interest in the effects of institutional care persists to the present day because many children throughout the world are raised in institutions as a result of abuse or neglect, abandonment, or parental incapacity or death (5–7).”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [5] source
    • cites [6] source
    • cites [7]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    No child once placed in foster care through BEIP would be returned to institutional setting during or after study.

    “We did, however, ensure that no child, once placed in foster care through the Bucharest Early Intervention Project, would be returned to an institutional setting, either during or after the study.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Rutter and colleagues found no inhibited RAD signs in children adopted before age 4, but a minority showed indiscriminate behavior.

    “Similarly, Rutter and colleagues (4, 14–16) found no signs of the inhibited type of reactive attachment disorder in children adopted before age 4, but a minority of children showed signs of indiscriminate behavior.”
    Quote in the paperSubstantial claim0 of 4 sources checked
    • cites [4] source
    • cites [14] source
    • cites [15] source
    • cites [16] Rutter M, 2010

      Not checked in the free run.

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

    Premisecitation

    Adopted children from institutions have higher attachment disorder rates than never-institutionalized children, but lower rates than those still in institutions.

    “For children adopted from institutions, rates of attachment disorders are elevated but lower than those for children living in institutions (11).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [11] source

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    Intent-to-treat approach followed in all analyses so original group assignment maintained.

    “We followed an intent to treat approach in all analyses so that original group assignment was maintained.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    After baseline assessments, children were randomly allocated to usual care or to foster placement.

    “They were assessed comprehensively at baseline and then randomly assigned to care as usual (including continued institutional care) or to placement in foster care, which was created as part of the project.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationcitation

    Because both RAD types are readily identifiable in children currently in institutions, the absence of inhibited signs and persistence of disinhibited signs after placement in better caregiving are notable.

    “Since studies of children currently living in institutions have demonstrated that both types of the disorder are readily identifiable (9, 13), the absence of the inhibited type, and the persistence of the disinhibited type in children after they are placed in more favorable caregiving environments are notable.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [9] source
    • cites [13] source

  • May combine two claims.

    Premisecitation

    Institutions commonly house many children with several caregivers on rotating shifts, which hinders a child forming a focused attachment to one caregiver.

    “Often, these institutions are large group settings with multiple caregivers whose rotating schedules do not support the development of a focused attachment relationship between a child and a given caregiver (8, 9).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [8] source
    • cites [9] source

  • May combine two claims.

    Premisecitation

    In Tizard's follow-up, none of the adopted or returned children showed inhibited RAD signs, and a minority still showed disinhibited signs.

    “Of those who had been returned to their parents or been adopted, none exhibited signs of the inhibited type, and a minority continued to exhibit signs of the disinhibited type (13).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [13] source

  • May combine two claims.

    Premisecitation

    The BEIP was designed as an RCT of foster care versus care as usual for institutionalized young children and addressed many limitations of earlier studies.

    “The Bucharest Early Intervention Project, which was designed as a randomized controlled trial of foster care as an alternative to care as usual among institutionalized young children, addressed many of the limitations of previous studies (17).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [17] source

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

    Study design and conductown data

    Randomization used drawing numbers from a hat and alternating assignment to groups.

    “Each child was given a number (siblings were placed together) and numbers were drawn from a hat and alternately assigned to the two groups.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    Lack of timing effect on inhibited RAD suggests children raised in institutions retain capacity for forming attachments, with no obvious sensitive period.

    “The lack of a timing effect suggests that children raised in institutional settings retain a capacity for forming attachments, with no obvious sensitive period.”
    Quote in the paperSubstantial claim

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

    Study design and conductcitation

    Two Romanian-speaking research assistants trained to reliability coded each interview; discrepancies resolved by conferencing and consensus.

    “Two Romanian-speaking research assistants who were trained to reliability on the interview (10) coded each interview. Discrepancies were resolved by conferencing, and a consensus code was obtained for each item.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [10] source

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

    Premisecitation

    Earlier foster placement has been linked to better cognitive recovery after institutional care.

    “The timing of placement in foster care has been shown to have an impact on cognitive recovery for children who experienced institutional care (20)”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [20] source

  • May combine two claims.

    Interpretationreasoning

    Effect of lower cognitive ability on inhibited RAD not evident in foster care, suggesting foster care beneficial regardless of cognitive abilities.

    “This effect was not evident among children in the foster care group, suggesting that the intervention of foster care was beneficial to children regardless of their cognitive abilities.”
    Quote in the paperSubstantial claim

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

    Study design and conductown data

    Never-institutionalized group younger at baseline than study groups.

    “On average, children in the never-institutionalized group were younger at the baseline assessment than children in the study groups (data not shown).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    Placement in families eliminates inhibited RAD signs as measured by DAI among young children raised in institutions, but has more attenuated effect on disinhibited type.

    “These findings indicate that placement in families clearly eliminates signs of the inhibited type of reactive attachment disorder, as measured by the Disturbances of Attachment Interview, among young children raised in institutions, but it has a more attenuated effect on the disinhibited type.”
    Quote in the paperSubstantial claim
31 of 31

  • The paper relies on this without support.

    Before this study, no planned intervention studies of attachment disorders had been conducted.

    “To our knowledge, there have been no previous planned intervention studies of attachment disorders, although some natural experiments have provided valuable data.”

  • The paper relies on this without support.

    No previous studies had examined the impact of the intervention on attachment disorders.

    “No previous studies have examined the impact of the intervention on attachment disorders.”

  • The paper relies on this without support.

    No randomized trial comparing foster care and institutional care had been conducted until the BEIP was initiated in 2001.

    “Despite 60 years of research comparing young children in foster care and those in institutional care, no randomized trial had been conducted until the Bucharest Early Intervention Project was initiated in 2001.”

  • The authors state this as an assumption.

    The repeated-measures analyses assume data are missing at random.

    “repeated-measures analysis of variance (ANOVA; likelihood model, data missing at random, SAS PROC MIXED, two groups and 5 assessments)”
4 of 4

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.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Claim of lasting similarity conflicts with the eight-year comparison

    Major

    The abstract says the foster-care and never-institutionalized groups had indistinguishable inhibited-type scores after 30 months, but the results report a difference between those groups at eight years.

1 of 1

Cites

Flagged first, then by citations

1 of the 38 references couldn’t be matched to a known paper.

Research works printed but not linked: 2

  1. Bakermans-Kranenburg MJ, 2011, Int J Behav Dev, 36, 1
  2. 10.1002/(SICI)1097-0355(199921)20:1<42::AID-IMHJ4>3.0.CO;2-B · DOI · Paper page

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Related

Authors
Smyke, A. T., Zeanah, C. H., Gleason, M. M., Drury, S. S., Fox, N. A., Nelson, C. A., & Guthrie, D.
Affiliations
Tulane University (US)
ORCID
Venue
American Journal of Psychiatry
Publisher
American Psychiatric Association Publishing
Published
2012-05
Volume
169
Issue
5
Pages
508-514
ISSN
  • 0002-953X (ISSN-L)
  • 1535-7228
DOI
10.1176/appi.ajp.2011.11050748
PMC
PMC4158103
OpenAlex
W2096000669
Cited by
181
References
38
Citations by year
2026: 10 · 2025: 8 · 2024: 10 · 2023: 8 · 2022: 11 · 2021: 11 · 2020: 13 · 2019: 14 · 2018: 20 · 2017: 18 · 2016: 14 · 2015: 15 · 2014: 13 · 2013: 8 · 2012: 6
FWCI
34.91
Type
journal article
Language
en
Open access
Locations
  • American Journal of Psychiatry (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Institute of Mental Health (R01MH091363)
Topics
  • Social Sciences › Safety Research › Child Welfare and Adoption
  • Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
  • Social Sciences › Psychology › Clinical Psychology › Child Abuse and Trauma
Keywords
reactive attachment disorder, foster care, institutional care, Romanian orphans
MeSH terms
Child, Child, Preschool, Female, Foster Home Care, Humans, Institutionalization, Interview, Psychological, Male, Neuropsychological Tests, Romania, Reactive Attachment Disorder, Early Diagnosis

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