Prevalence of reactive attachment disorder in a deprived population
Open accessAbstract
Background: Reactive attachment disorder (RAD) is associated with early childhood maltreatment and has unknown population prevalence beyond infancy. Aims: To estimate RAD prevalence in a deprived population of children. Method: All 1646 children aged 6-8 years old in a deprived sector of an urban UK centre were screened for RAD symptoms. Parents of high and low scorers were interviewed using semi-structured interviews probing for psychopathology and individuals likely to have RAD were offered face-to-face assessment. Results: Questionnaire data were available from 92.8% of teachers and 65.8% of parents. Assessments were conducted with 50% of those invited and missing data were imputed - based on the baseline data - for the rest. We calculated that there would be 23 children with definite RAD diagnoses, suggesting that the prevalence of RAD in this population was 1.40% (95% CI 0.94-2.10). Conclusions: In this deprived general population, RAD was not rare.
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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 [1]
Adverse childhood experiences, such as psychological and physical abuse and neglect, parental substance abuse and mental illness, all increase the risk of both physical and mental health problems, as well as health risk behaviours.
“Adverse childhood experiences, such as psychological and physical abuse and neglect, parental substance abuse and mental illness, all increase the risk of both physical and mental health problems, as well as health risk behaviours [36-41].”
From Mental disorders in foster children: a study of prevalence, comorbidity and risk factors (2013) · cites this paper as [40]
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“4% in a disadvantaged area (Minnis et al., 2013) or high heritability of inhibited and disinhibited types in a large twin study (Minnis et al.”
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“Our estimated RAD prevalence lies between the prevalence estimate found in a large sample of 6- to 8-year-old, socioeconomically deprived children [51], and the prevalence in severely maltreated toddlers in foster care [52].”
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ResultThe neurobiological effects of childhood maltreatment on brain structure, function, and attachment
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“As previously suggested (Kay and Green, 2013; Minnis et al., 2013; Zeanah and Gleason, 2015), a child may be given only a ‘suspected’ diagnosis of RAD because the diagnosis is not definitive.”
InfluentialLehmann, S., Breivik, K., Monette, S., & Minnis, H. (2020) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2020.104374 · Cited by 46 · see citing works
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“…with more symptoms of other mental health problems (SDQ total difficulties) and this chimes with findings from other studies of maltreated children that have demonstrated a range of comorbidities in maltreated children with attachment disorders (Kocovska et al., 2012; Minnis et al., 2013).”
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“…RADA interview alongside the teacher Relationship Problem Questionnaire (Minnis et al., 2002) and observational measures such as the waiting room observation procedure (McLaughlin et al., 2010), which explore the interaction between the child and stranger(s) on first meeting (Minnis et al., 2013).”
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“Other studies (Kay & Green, 2013; Selwyn et al., 2014) found a high rate of attachment disorder in similar samples, and Minnis et al. (2013) estimated the prevalence in a deprived population as lying in the range of .94–2.10.”
BackgroundInfluentialExploring Attachment and Internal Representations in Looked-After Children
Hillman, S., Cross, R., & Anderson, K. (2020) · Frontiers in Psychology · doi:10.3389/fpsyg.2020.00464 · Cited by 30 · see citing works
“The Relationship Problem Questionnaire (RPQ; Minnis et al., 2007) is a 10-item screening instrument for reactive attachment disorder (RAD).”
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“Thus, detailed observations of the child’s interactions are needed for a more robust diagnosis (Minnis et al., 2013).”
Maltreatment‐Associated Psychiatric Problems: An Example of Environmentally Triggered ESSENCE?
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“In our recent study of RAD prevalence in a deprived population, several home visits were sometimes required to achieve a face-to-face assessment of a child, even when parents had opted into the study [15].”
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“To date, we have little data to tie these deviations in behavior during infancy to the forms of disinhibited social behavior assessed in cross-sectional studies among maltreated children at later ages (Kay and Green, 2013; Minnis et al., 2013).”
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“There is a high prevalence of this disorder among fostered children, and it is associated with experiences of serious abuse and entry into centres in their early years of life (Minnis et al., 2013).”
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Schröder, M., Lüdtke, J., Fux, E., İzat, Y., Bolten, M. I., Gloger-Tippelt, G., Suess, G. J., & Schmid, M. (2019) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2019.152139 · Cited by 19 · see citing works
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“Using the metrics from the Minnis et al sample as a guide (Minnis et al., 2013), in which 16.04 % of screen-positive children had an actual RAD/DSED diagnosis using gold-standard diagnostic instruments, this might translate to approximately 24.7 cases of RAD/DSED in this population, or a prevalence…”
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“This complex interplay (Minnis, 2013) can require a degree of input that goes beyond the realm of ‘normal parenting, ’ requiring training and intervention that can have positive effects on child outcomes (Dozier, 2019; Dozier et al., 2013; Valadez, Tottenham, Tabachnick, & Dozier, 2020).”
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Autism and attachment disorders – how do we tell the difference?
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“…point was chosen based on ROC analysis indicating sensitivity and specificity of the Disinhibited subscale to identify a group at high risk of RAD performed on parent reports of 169 children who participated in a prevalence study on RAD (data re-analysed by HM for this study) (Minnis et al., 2013).”
MethodSelf-citationFACTORS ASSOCIATED WITH INDISCRIMINATE FRIENDLINESS IN HIGH-RISK CHILDREN
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“It is persistent [9] and is associated with significant psychiatric morbidity [10, 11], suggesting increased vulnerability of these children, in both early childhood and the future.”
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“Focusing on the full set or subsets of behaviors qualifying for DSED, disinhibited social engagement behavior (DSEB) has also been found in children growing up with their biological parents, where extremes of insufficient care are less prevalent and more difficult to assess (Minnis et al., 2013; Pears, Bruce, Fisher,…”
BackgroundMonette, S., Cyr, C. P., Terradas, M. M., Couture, S., Minnis, H., & Lehmann, S. (2020) · Assessment · doi:10.1177/1073191120981763 · Cited by 10 · see citing works
“The RPQ is designed as a short screening tool and is not recommended for estimating AD prevalence or for clinical diagnosis (Minnis et al., 2013).”
MethodSelf-citationTakiguchi, S., Makita, K., Fujisawa, T. X., Nishitani, S., & Tomoda, A. (2023) · Frontiers in Child and Adolescent Psychiatry · doi:10.3389/frcha.2022.1056115 · Cited by 9 · see citing works
“…and neglect are critical risk factors for reactive attachment disorder (RAD), which is characterized by socially and emotionally withdrawn/inhibited and aberrant attachment behaviors, with a failure to seek and respond to comfort (1), affecting approximately 1% of the general population (2, 3).”
InfluentialStability and change of attachment disorder symptoms and interpersonal problems in foster children
Symanzik, T., Lohaus, A., Job, A., Chodura, S., Konrad, K., Heinrichs, N., & Reindl, V. (2018) · Mental Health & Prevention · doi:10.1016/j.mhp.2018.12.001 · Cited by 9 · see citing works
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“(Skovgaard, 2010; Minnis et al., 2013) In high-risk populations, they are quite common: 49 % in adopted children aged 6 – 11 (Kay et al., 2016); 16 % in adolescents in residential care (Seim et al., 2020); 52 % in young offenders attending specialist child mental health services (Moran et al.,…”
BackgroundSelf-citationDunn, A., Bird, P. K., Endacott, C., Bywater, T. J., Howes, J., & Dickerson, J. (2022) · Wellcome Open Research · doi:10.12688/wellcomeopenres.17552.1 · Cited by 7 · see citing works
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“© 2017 Taylor & Francis populations who have experienced deprivation (Kay & Green, 2013; Minnis et al., 2013).”
BackgroundConstruct validity of a service-setting based measure to identify mental health problems in infancy
Ammitzbøll, J., Skovgaard, A. M., Holstein, B. E., Andersen, A., Kreiner, S., & Nielsen, T. (2019) · PLoS ONE · doi:10.1371/journal.pone.0214112 · Cited by 9 · see citing works
“in mixed emotional and behavioral disorders, disorders of social functioning [82], and in disorders of hyperactivity [8].”
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“This prevalence is substantially higher than what is found in the general population (1%, Minnis et al., 2013; Zilberstein, 2015) and higher than what is found in post-institutionalized children (3–5%; Gleason et al., 2011), but lower than what is found in a sample of maltreated toddlers in foster…”
ResultSchröder, M., Fux, E., Lüdtke, J., İzat, Y., Bolten, M. I., & Schmid, M. (2019) · Psychopathology · doi:10.1159/000504675 · Cited by 7 · see citing works
Current Perspectives on the Management of Reactive Attachment Disorder in Early Education
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Chapter 15. Trauma- and Stressor-Related Disorders
Stoddard, F. J., Simon, N. M., & Pitman, R. K. (2019) · American Psychiatric Association Publishing eBooks · doi:10.1176/appi.books.9781615372980.lr15 · Cited by 5 · see citing works
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“All cases had associated developmental/neurodevelopmental problems and extremely problematic relationship functioning, as found by previous studies (Helen Minnis et al., 2013; Kay & Green, 2013; Kocovska et al., 2012; Moran et al., 2017).”
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A quick and reliable waiting room checklist for symptoms of disinhibited social engagement disorder
McMorran-Young, G., Moran, K., Young, D., Batchelor, G., & Minnis, H. (2021) · Developmental Child Welfare · doi:10.1177/25161032211050734 · Cited by 4 · see citing works
“…were accessed on 56 children aged 5–12 years with diagnoses of DSED, collated from three previous studies (Kocovska et al., 2012; Minnis et al., 2009; Minnis et al., 2013) as follows: · 34 children recruited by CAMHS clinicians and social workers who had been asked to refer children with symptoms…”
BackgroundMethodInfluentialSelf-citationWall, S. (2021) · Emotional and Behavioural Difficulties · doi:10.1080/13632752.2021.1979322 · Cited by 4 · see citing works
“Thus, such presentations are not ‘rare’ (Minnis et al. 2013, 346) and, arguably, while not directly comparable due to the differing attachment measures used, in an area with ‘high levels of deprivation . . . in which child maltreatment may be more common’ (Minnis et al. 2013, 342) it was estimated…”
BackgroundResultInfluentialZimmermann, J., Kliewer-Neumann, J. D., Bovenschen, I., Lang, K., Gabler, S., Nowacki, K., & Spangler, G. (2024) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2024.106872 · Cited by 4 · see citing works
Beckett, C., Cross, R., Hewitt‐Taylor, J., & McConnell, P. (2015) · Journal of Children s Services · doi:10.1108/jcs-06-2014-0032 · Cited by 4 · see citing works
Doku, P. N. (2016) · Journal of Child and Adolescent Behaviour · doi:10.4172/2375-4494.1000278 · Cited by 4 · see citing works
“RAD closely resembles internalizing disorders and so children with RAD exhibit watchful, wary and emotionally withdrawn behaviours [14-16].”
BackgroundResultInfluentialCommunication and language in abused and institutionalized minors. A scoping review
Palazón-Carrión, E., & Sala‐Roca, J. (2020) · Children and Youth Services Review · doi:10.1016/j.childyouth.2020.104904 · Cited by 4 · see citing works
Hillman, S., Villegas, C., Anderson, K., Kerr-Davis, A., & Cross, R. (2022) · Journal of Child Psychotherapy · doi:10.1080/0075417x.2022.2088824 · Cited by 4 · see citing works
“Six and seven are two recommended cut off scores for a likely diagnosis of RAD (Minnis et al., 2013).”
BackgroundSocial competencies of children with disinhibited social engagement disorder: A systematic review
Davidson, C., Islam, S., Venturini, E., Lowit, A., Gillberg, C., & Minnis, H. (2024) · JCPP Advances · doi:10.1002/jcv2.12226 · Cited by 3 · see citing works
“RAD (DSM ‐ 5) (the inhibited form) on its own has been demonstrated to be rare in the population (Minnis et al., 2013; Zeanah, 2000); it is DSED that is persistent, 2.”
InfluentialSelf-citationParenting groups can be effective across the social spectrum: the next step is access
Minnis, H. (2019) · The Lancet Psychiatry · doi:10.1016/s2215-0366(19)30165-8 · Cited by 3 · see citing works
Self-citationTroubles de l’attachement : validation d’un questionnaire basé sur le DSM-5
Monette, S., Terradas, M. M., Boudreault, M. Y., Carrier, A., Ruest-Bélanger, A., Robert, A., Archambault, M., Cyr, C. P., & Couture, S. (2018) · Enfance · doi:10.3917/enf2.184.0511 · Cited by 3 · see citing works
Preterm Birth’s Effects on Attachment
Oral, E. Y., & Karaçetin, G. (2024) · Cam and Sakura Medical Journal · doi:10.4274/csmedj.galenos.2024.2024-7-1 · Cited by 4 · see citing works
“Minnis et al. (38) conducted the first epidemiological study focusing on the prevalence of RAD in the general population.”
Archambault, M., Cyr, C. P., Minnis, H., Lehmann, S., & Monette, S. (2024) · Assessment · doi:10.1177/10731911241276625 · Cited by 2 · see citing works
“As for RAD, no study has reported rates for the general population—and establishing population prevalence of RAD is challenging because prevalence appears to be extremely low (Minnis et al., 2013).”
Self-citationTraumaassoziierte Störungen, ADHS, externalisierende und Zwangsstörungen
Bindt, C., Möhler, E., & von Gontard, A. (2026) · Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie · doi:10.1024/1422-4917/a001090 · Cited by 2 · see citing works
Addressing the Complex Needs of Students With Attachment Disorders
Losinski, M. L., Katsiyannis, A., White, S. A., & Wiseman, N. (2015) · Intervention in School and Clinic · doi:10.1177/1053451215585800 · Cited by 2 · see citing works
“Attachment disorders, while considered rare within the general population (i.e., 0.9%–1.4% of the school-age population), appear at a rate between 38% and 40% of children who are adopted or who reside in foster care (Minnis et al., 2013; Skovgaard, 2010; Stinehart, Scott, & Barfield, 2012).”
BackgroundInfluentialHome or Care? A Comparison of Educational Outcomes for Maltreated Children
Cusworth, L., Tracey, L., Baldwin, H., & Biehal, N. (2020) · The British Journal of Social Work · doi:10.1093/bjsw/bcaa177 · Cited by 2 · see citing works
Hillman, S., Anderson, K., Demetri, C., & Cross, R. (2021) · Child Care in Practice · doi:10.1080/13575279.2021.1986806 · Cited by 2 · see citing works
“This combination of measures had previously been used in a study by Helen Minnis (Minnis et al., 2013) but not exclusively for a “ looked after ” population.”
MethodHaune, M., Nissen, A., Christiansen, Ø., Myrvold, T. M., Ruud, T., & Heiervang, E. R. (2023) · Child Psychiatry & Human Development · doi:10.1007/s10578-023-01619-5 · Cited by 2 · see citing works
Emotional and behavioural development in Glasgow primary schools
Pritchett, R., Nowek, G., Neill, C., & Minnis, H. (2014) · Educational Psychology in Practice · doi:10.1080/02667363.2014.933736 · Cited by 2 · see citing works
“Study findings were then used to develop whole school approaches and any child that was identified as having severe problems (during a later stage of this study, described in Minnis et al., 2013) was referred to their Child and Adolescent Mental Health Service (CAMHS).”
MethodResultSelf-citationReactive attachment disorder in the classroom
Embury, D. C., Clarke, L. S., & Leaver, C. (2020) · Preventing School Failure Alternative Education for Children and Youth · doi:10.1080/1045988x.2020.1732281 · Cited by 2 · see citing works
“Within the past 20 years, caregivers and professionals have seen an increase in the number of children diagnosed with Reactive Attachment Disorder (RAD) and displaying RADlike characteristics (Hanson & Spratt, 2000; Minnis et al., 2013).”
BackgroundTrauma- and Stressor-Related Disorders
Stoddard, F. J., Simon, N. M., & Pitman, R. K. (2019) · American Psychiatric Association Publishing eBooks · doi:10.1176/appi.books.9781615371501.lr15 · Cited by 2 · see citing works
Care practices and approaches with children experiencing attachment difficulties: A scoping review
Kaur, L., Gendron‐Cloutier, L., & Montreuil, M. (2023) · Children and Youth Services Review · doi:10.1016/j.childyouth.2023.107265 · Cited by 1 · see citing works
Chadwick, G. (2016) · International Journal of Culture and Mental Health · doi:10.1080/17542863.2016.1250798 · Cited by 1 · see citing works
“It was previously thought to be extremely rare; however, a study by Minnis et al. (2013b) found its prevalence to be 1.4% in a deprived north Glasgow population, about the same as autism (Baron-Cohen et al., 2009).”
BackgroundInfluentialBeobachtung von Bindungsstörungssymptomen in der mittleren Kindheit
Iwanski, A., & Zimmermann, P. (2018) · Praxis der Kinderpsychologie und Kinderpsychiatrie · doi:10.13109/prkk.2018.67.4.333 · Cited by 1 · see citing works
The role of parental factors in the mental health problems experienced by refugee children
Eruyar, Ş. (2018) · Figshare · Cited by 1 · see citing works
Klyce, D. W. (2018) · Springer eBooks · doi:10.1007/978-3-319-57111-9_9181 · Cited by 1 · see citing works
An Examination of Risk Factors Among Male Children and Youth with Complex Special Needs
Billawala, A. (2016) · Scholarship@Western (Western University)
Renk, K. (2018) · Cambridge University Press eBooks · doi:10.1017/9781108140416.028
友田, 明. (2017) · 児童青年精神医学とその近接領域 · doi:10.20615/jscap.58.5_623
友田明美 (2018) · 児童青年精神医学とその近接領域 · doi:10.20615/jscap.59.3_260
فعالية برنامج ارشادي أسرى لخفض اعراض اضطراب التعلق الارتکاسي لدي اطفال الروضة المساء معاملتهم
القاضي, خ. س. س., & حفني, ع. ث. إ. (2020) · المجلة التربوية لکلية التربية بسوهاج · doi:10.21608/edusohag.2020.96961
Klyce, D. W. (2017) · Springer eBooks · doi:10.1007/978-3-319-56782-2_9181-1
Reactive Attachment Disorder and Disinhibited Social Engagement Disorder
Scott, E. L., Keary, C. J., King, J. M., Zeanah, C. H., & McDougle, C. J. (2018) · Oxford University Press eBooks · doi:10.1093/med/9780190457136.003.0002
Baynes, K. T., & O’Connor, T. G. (2017) · Springer eBooks · doi:10.1007/978-3-319-57196-6_13
Ziegenhain, U., & Steiner, M. (2018) · Springer eBooks · doi:10.1007/978-3-662-57369-3_20
Troubles de l’attachement chez le jeune enfant
Guédeney, A., & Guédeney, N. (2021) · Elsevier eBooks · doi:10.1016/b978-2-294-77630-4.00005-3
Schlattmann, N., van der Hoeven, M. L., & Hein, I. M. (2023) · Bohn Stafleu van Loghum eBooks · doi:10.1007/978-90-368-2841-3_1
Adolescent psychosis and transdiagnostic delimitations to other clinical syndromes
Gillberg, C. (2023) · Elsevier eBooks · doi:10.1016/b978-0-323-89832-4.00001-9
Self-citationFrey, M. (2023) · Elsevier eBooks · doi:10.1016/b978-3-437-21307-6.00021-5
Attending to the voices of parents of children with Reactive Attachment Disorder
Schlein, C., & Taft, R. J. (2023) · Frontiers in Education · doi:10.3389/feduc.2023.1146193
Scott, E. L., Raykar, V., & Zeanah, C. H. (2023) · Springer eBooks · doi:10.1007/978-3-030-42825-9_25-1
Scott, E. L., Raykar, V., & Zeanah, C. H. (2024) · Springer eBooks · doi:10.1007/978-3-030-51366-5_25
Gill, C. S., Dailey, S. F., Karl, S. L., & Minton, C. A. B. (2025) · Wiley eBooks · doi:10.1002/9781394346684.part2a
Davidson, C., Minnis, H., Gillberg, C., McCool, S., Elder, B., & Lowit, A. (2025) · Child & Youth Care Forum · doi:10.1007/s10566-025-09874-4
“DSED was first reported in samples of international adoptees post institutionalisation (Tizard & Rees, 1975; O’Connor & Rutter, 2000; Smyke et al., 2009) but has also been found in community samples of maltreated children (Kay & Green, 2013; Minnis et al., 2013; Kay et al., 2016).”
Self-citation
- Authors
- Minnis, H., Macmillan, S., Pritchett, R., Young, D., Wallace, B., Butcher, J., Sim, F., Baynham, K., Davidson, C., & Gillberg, C.
- Affiliations
- University of Glasgow (GB)
- University of Strathclyde (GB)
- Glasgow City Council (GB)
- Corresponding author
- Minnis, Helen
- Venue
- British Journal of Psychiatry
- Publisher
- Royal College of Psychiatrists
- Published
- 2013-05
- Volume
- 202
- Issue
- 5
- Pages
- 342-346
- ISSN
- 0007-1250 (ISSN-L)
- 1472-1465
- OpenAlex
- W2148201105
- Cited by
- 107
- References
- 18
- Citations by year
- 2026: 7 · 2025: 2 · 2024: 6 · 2023: 9 · 2022: 7 · 2021: 4 · 2020: 17 · 2019: 9 · 2018: 20 · 2017: 7 · 2016: 6 · 2015: 8 · 2014: 3 · 2013: 2
- FWCI
- 7.04
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- The British Journal of Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Scottish Government
- Topics
- Social Sciences › Psychology › Clinical Psychology › Child Abuse and Trauma
- Social Sciences › Safety Research › Child Welfare and Adoption
- Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
- Keywords
- reactive attachment disorder, prevalence, early childhood maltreatment, child poverty, children aged 6-8, psychopathology, parent interviews
- MeSH terms
- Child, Humans, Pilot Projects, Scotland, Urban Health, Prevalence, Reactive Attachment Disorder, Health Status Disparities
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