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Reactive Attachment Disorder
ICD-10 F94.1/2
ICD-9 313.89
OMIM {{{OMIM}}}
DiseasesDB {{{DiseasesDB}}}
MedlinePlus {{{MedlinePlus}}}
eMedicine {{{eMedicineSubj}}}/{{{eMedicineTopic}}}
MeSH {{{MeshNumber}}}


Reactive attachment disorder (also known as "RAD") is the broad term used to describe those disorders of attachment which are classified in ICD-10 94.1 and 94.2, and DSM-IV 313.89. RAD arises from a failure to form normal attachments to primary care giving figures in early childhood. Such a failure would result from unusual early experiences of neglect, abuse, abrupt separation from caregivers after about age 6 months but before about age 3 years, frequent change of caregivers, or lack of caregiver responsiveness to child communicative efforts. It is characterised by markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before the age of 5 years.

Differential DiagnosisEdit

It should be differentiated from pervasive developmental disorder or mental retardation, both of which conditions can affect attachment. RAD is likely to occur in the context of abusive or impoverished childcare although there can be no diagnosis on this basis alone as many children with such backgrounds do not develop RAD. (NOTE: CAN BE DISCUSSED IN ETIOLOGY SECTION)

RAD should also be differentiated from less than ideal attachment 'styles' or attachment difficulties which do not amount to the clinical disorder defined as RAD.

RAD was first defined in DSM in 1980. Important modifications have been made but the core remains the same. The definitions in ICD-10 and DSM-IV-TR are similar but not identical and are under constant review in this somewhat controversial area. Leading theorists in the field have proposed that a broader range of conditions arising from problems with attachment should be defined.

Theoretical framework EtiologyEdit

Main article: Attachment theory

The theoretical framework for Reactive Attachment Disorder is attachment theory based on work by Bowlby, Ainsworth and Spitz, from the 1940s to the 1980s. Attachment theory is an evolutionary theory whereby the infant or child seeks proximity to a specified attachment figure in situations of alarm or distress, for the purpose of survival. Attachment is not the same as love and/or affection although they often go together. Attachment and attachment behaviors tend to develop between the age of 6 months and 3 years. Infants become attached to adults who are sensitive and responsive in social interactions with the infant, and who remain as consistent caregivers for some time.

NEW: RAD is generally caused by early maltreatment (abuse, Child sexual abuse, neglect, or institutional care) within a caregiving relationship[1]

RAD requires one or both of the attachment behaviors of proximity seeking to a specified attachment figure to be missing. There are a number of attachment 'styles' namely 'secure', 'anxious-ambivalent', 'anxious-avoidant', (all 'organized') and 'disorganized.' some of which are more problematical than others, but none constitute a 'disorder' in themselves. NEW:However, these are not psychiatric diagnoses.

A disorder in the clinical sense is a condition requiring treatment, as opposed to risk factors for subsequent disorders.(AACAP 2005, p1208[2]) There is a lack of consensus about the precise meaning of the term 'attachment disorder' although there is general agreement that such disorders only arise following early adverse caregiving experiences. NOTE: DOES NOT BELONG IN THIS ARTICLE...MIGHT BELONG IN THE ARTICLE ABOUT ATTACHMENT DISORDER

Children who are adopted after the age of six months are at risk for attachment problems.[3] Normal attachment develops during the child's first two to three years of life. Problems with the caregiver-child relationship during that time, orphanage experience, or breaks in the consistent caregiver-child relationship interfere with the normal development of a healthy and secure attachment. There are wide ranges of attachment difficulties that result in varying degrees of emotional disturbance in the child. However, less than ideal attachment styles are not within the criteria for RAD.

Some authors have proposed a broader continuum of definitions of attachment disorders ranging from RAD, through various attachment difficulties to the more problematic attachment styles but there is as yet no consensus on this issue. In particular, Zeanah and Boris, building on the earlier work of Leiberman, propose three categories; firstly "disorder of attachment" to indicate a situation in which a young child has no preferred adult caregiver, parallel to Reactive Attachment Disorder as defined in DSM and ICD in its inhibited and disinhibited forms. Secondly "secure base distortion" where the child has a preferred familiar caregiver, but the relationship is such that the child cannot use the adult for safety while gradually exploring the environment. Such children may endanger themselves, may cling to the adult, may be excessively compliant, or may show role reversals in which they care for or punish the adult. Thirdly "disrupted attachment." This type of problem, which is not covered under other approaches to disordered attachment, results from an abrupt separation or loss of a familar caregiver to whom attachment has developed.[4] NOTE: MAY BELONG IN ARTICLE ON ATTACHMENT DISORDER BUT NOT IN AN ARTICLE ABOUT RAD

ClassificationEdit

NOTE: PUT AS A LINK IN SEE ALSO SECTION

ICD-10 describes Reactive Attachment Disorder of Childhood, known as RAD, and Disinhibited Disorder of Childhood, less well known as DAD. DSM-IV-TR also describes Reactive Attachment Disorder of Infancy or Early Childhood divided into two subtypes, Inhibited Type and Disinhibited Type, both known as RAD. The two classifications are similar and both include:

  • markedly disturbed and developmentally inappropriate social relatedness in most contexts.
  • The disturbance is not accounted for solely by developmental delay and does not meet the criteria for Pervasive Developmental Disorder.
  • Onset before 5 years of age.
  • Requires a history of significant neglect.
  • Implicit lack of identifiable, preferred attachment figure.

There must be a history of 'pathogenic care' defined as disregard of the child's basic emotional or physical needs or repeated changes in primary caregiver that prevents the formation of a discrimination or selective attachment that is presumed to account for the disorder. Unusually therefore part of the diagnosis is history of care rather than observation of symptoms.

Additional DSM-IV criteriaEdit

In DSM-IV-TR the inhibited form is described as:

  • "Persistent failure to initiate or respond in a developmentally appropriate way to most social interactions, as manifest by excessively inhibited, hypervigilant, or highly ambivalent, or contradictory responses, eg the child may respond to caregivers with a mixture of approach, avoidance and resistance to comforting, or may exhibit frozen watchfulness.

Such infants do not seek and accept comfort at times of threat, alarm or distress, thus failing to maintain 'proximity', an essential element of attachment behavior.

The disinhibited form shows:

  • "Diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments, eg excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures"

There is therefore a lack of 'specificity', the second basic element of attachment behavior.

Additional ICD-10 criteriaEdit

The ICD-10 descriptions are comparable save that ICD-10 includes in its description several elements not included in DSM-IV-TR as follows:

  • psychological and physical abuse and injury in addition to neglect. This is somewhat controversial, being a commission rather than omission and because abuse of itself does not lead to attachment disorder.
  • associated emotional disturbance.
  • poor social interaction with peers.

It should be noted that 'disinhibited' and 'inhibited' are not opposites in terms of attachment disorder and can co-exist in the same child. The inhibited form has a greater tendency to ameliorate with an appropriate caregiver whilst the disinhibited form is more enduring. However, the disinhibited form can endure alonside structured attachment behavior towards the childs permanent caregivers.[5]

While RAD is likely to occur in relation to neglectful and abusive childcare, there should be no automatic diagnosis on this basis alone as children can form stable attachments and social relationships despite marked abuse and neglect. Abuse can occur alongside the required factors but on its own does not explain attachment disorder. It is associated with developed, albeit disorganized attachment. Within official classifications, attachment disorganization is a risk factor but not in itself an attachment disorder. Further although attachment disorders tend to occur in the context of some institutions, repeated changes of primary caregiver or extremely neglectful identifiable primary caregivers who show persistent disregard for the child's basic attachment needs, not all children raised in these conditions develop an attachment disorder.[5] NOTE: MAY NOT NEED THIS PARAGRAPH AND IT COULD BE DELETED, BUT I HAVE NO STRONG OPINION ON THIS...IF THE ARTICLE IS TOO LONG, I'D CUT THIS PARAGRAPH.

PrevalenceEdit

RAD is considered to be "very uncommon" under the DSM-IV-TR criteria although there is an estimate of prevalence amongst children freed for adoption within the USA foster care system of 10%.[6] Other estimates include a prevalence of less than 1% in the general population [citation: Richters,M.M., & Volkmar, F. (1994)....] There has been considerable recent research into prevalence amongst children cared for in orphanages, particularly in Romania, where conditions of extreme deprivation were not uncommon.

There are no precise statistics on prevalence. According to the APSAC Taskforce Report (2006), some have suggested that RAD may be quite common because severe child maltreatment, which is known to increase risk for RAD, is frequent. The Taskforce did not agree with this view as severely abused children may exhibit similar behaviors to RAD behaviors and there are several far more common and demonstrably treatable diagnoses which may better account for these difficulties. Many children experience severe maltreatment but do not develop clinical disorders. The Taskforce states that it should not be assumed that RAD underlies all or even most of the behavioral and emotional problems seen in foster children, adoptive children, or children who are maltreated. Rates of child abuse and/or neglect or problem behaviors should not serve as a benchmark for estimates of RAD. The Taskforce further point out that according to the DSM, RAD is presumed to be a “very uncommon” disorder (APA, 1994).[7] NOTE: SEEMS UNNECESSARILY POLEMIC IN TONE AND TO BE MAKING SOME POV IN A NON-NPOV MANNER. PUT THE FIRST SENTANCE, NOT STRUCK-THROUGH, AS FIRST SENTENCE OF THIS SECTION.

According to Prior and Glaser (2006), in the absence of available and responsive caregivers it appears that some children are particularly vulnerable to developing attachment disorders. "The prevalence is unclear but is probably quite rare, other than in populations of children being reared in the most extreme, deprived settings such as some orphanages."[5] Many children who have experienced serious maltreatment at the hands of their primary caregiver may have formed a disorganized attachment which manifests itself in difficult behaviors, but they would not fulfil the current criteria for RAD. There is a lack of clarity about the presentation of attachment disorders over the age of 5 years and difficulty in distinguishing between aspects of attachment disorders, disorganized attachment or the sequalae of maltreatment. [5] NOTE: NOT ABOUT RAD MORE ABOUT ATTACHMENT DISORDERS AND BELONGS IN THAT ARTICLE.

Carlson,et. al. (1989)[8] found that 82% of maltreated children displayed disorganized/disoriented pattern of attachment, when measured using the Strange Situation procedure developed by Mary Ainsworth. Lyons-Ruth et al (1990) obtained figures of 55% among maltreated infants and 34% amongst low income controls (with clinical social work involvement). [9] Children with histories of maltreatment, such as physical and psychological neglect, physical abuse, and sexual abuse, are at risk of developing severe psychiatric problems[10] [11]. These children are likely to develop Reactive Attachment Disorder.[12] [13]. These children may be described as experiencing trauma-attachment problems and are likely to develop Reactive Attachment Disorder, which is a psychiatric diagnosis. The clinical formulation of [Complex post traumatic stress disorder]] is a clinical perspective on this set of problems[14]. The trauma experienced is the result of abuse or neglect, inflicted by a primary caregiver, which disrupts the normal development of secure attachment. As was mentioned earlier, such children are at risk of developing a disorganized attachment [15] [16] [17]. Disorganized attachment is associated with a number of developmental problems, including dissociative symptoms [18], as well as depressive, anxiety, and acting-out symptoms [19] [20].

According to one prevalence report, in interviews with clinicans treating 94 maltreated toddlers, 38-40% of the children were thought to show either inhibited or disinhibited forms of Reactive Attachment Disorder, whether or not they had experienced separation from caregivers or multiple caregivers [21]

DiagnosisEdit

According to the APSAC Taskforce Report (2006), RAD is one of the least researched and most poorly understood disorders in the DSM. They make the point that there is little systematically gathered epidemiologic information on RAD, its "course" is not well established and it appears difficult to diagnose RAD accurately. Several other disorders, such as conduct disorders, oppositional defiant disorder, anxiety disorders, PTSD and social phobia share many symptoms and are often comorbid with or confused with RAD leading to over and under diagnosis. RAD can also be confused with neuropsychiatric disorders such as autistic spectrum disorders, pervasive developmental disorder, childhood schizophrenia and some genetic syndromes. Some children simply have very different temperamental dispositions. The Taskforce specifically state "Because of these diagnostic complexities, careful diagnostic evaluation by a trained mental health expert with particular expertise in differential diagnosis is a must (Hanson & Spratt, 2000; Wilson, 2001)". [7]

In the absence of a standardised diagnosis system, many popular, informal classification systems, outside the DSM and ICD, were created out of clinical and parental experience. These are unvalidated and critics state they are inaccurate, too broadly defined or applied by unqualified persons. Many are found on the websites of attachment therapists. Common features of these lists such as lying, lack of remorse or conscience and cruelty do not form part of the diagnostic criteria under DSM-IV-TR or ICD-10. NOTE: NOT NEEDED. MATERIAL COVERED ADEQUATELY ABOVE.

AssessmentEdit

NEW: Assessment requires a multi-modal approach using clinical interviews and clinical judgement, a thorough review of history, a review of current behavior and symptoms, screening for co-morbid issues, the use of psychometics, and interviews with current care-givers.

The Randolph Attachment Disorder Questionnaire or "RADQ" is one of the better known checklists and is used by attachment therapists and others, but critics consider it lacks specificity and is unvalidated.[22]NOTE: DEL POLEMICAL AND POV LINES. JUST LIST SOME APROACHES IN ALPHA ORDER The checklist includes 93 discrete behaviours, many of which either overlap with other disorders, like Conduct Disorder and Oppositional Defiant Disorder or are not related to attachment difficulties. [23]

Recognised assessment methods of attachment styles, difficulties or disorders include:

NEW: Attachment Story Completion Test

TreatmentEdit

There is a variety of effective prevention programs and treatment approaches for attachment disorder based on Attachment theory. All these approaches concentrate on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, changing the caregiver. Approaches with a sound evidential and theoretical base include:

There is considerable controversy over the diagnosis and treatment of attachment disorders including reactive attachment disorder, by attachment therapists, a form of diagnosis and treatment that is largely unvalidated and has developed outside the scientific mainstream.[7]These therapies have little or no evidence base and vary from mild therapeutic work to more extreme forms of physical and coercive techniques, of which the best known are :

In general these therapies are aimed at adopted or fostered children with a view to creating attachment in these children to their new carers. Critics maintain that the link between this kind of therapy and attachment theory is at best tenuous.[5] Many of these therapies concentrate on changing the child rather than the caregiver. (Chaffin et al 2006[7])

==Recent research on deprived populations== A 1998 study showed that children adopted from poorly run Romanian orphanages had a higher frequency of insecure patterns of attachment than control groups, although this difference improved in the follow-up study 3 years later. [27][28] However they continued to show significantly higher levels of indiscriminate friendliness.

A later study looked at chidren adopted in the UK who had suffered early severe deprivation in Romania, some 'early placed' and some 'late placed'. The 'late-placed' children showed a far higher incidence of atypical insecure patterns such as displaying both strong avoidant and strong dependent attachment behavior patterns. [29]

A 2002 study of children in residential nurseries in Bucharest, using the DAI, challenged the current DSM and ICD conceptualisations of disordered attachment and showed that inhibited and disinhibited disorders could co-exist in the same child. It also showed higher incidence of RAD in the standard care group in the institution than in the 'pilot group' receiving more consistent care, or in the non-institutionalised group. [30]

A 2005 study comparing institutionalised and community children in Bucharest, using the DAI, again showed significantly higher levels of both forms of RAD in the institutionalised children, regardless of how long they had been there. Further, only 22% of the institutionalised children had organised attachments as opposed to 78% of the community children, and all the children in the community group showed clear attachment patterns as opposed to only 3% in the institutionalised group. It would appear that children in institutions like these are unable to form selective attachments to their caregivers. The study also concluded the signs of RAD related to how fully developed and expressed attachment behaviors are rather than the organisation of a particular pattern.[31]

There are two important studies relating to high risk and maltreated children in the USA. The first, in 2004, compared ill-treated children in foster care, children in a homeless shelter with their mothers and low income children in the Head Start programme. The children were assessed using DSM and ICD and Zeanah and Boris' alternative proposed criteria. The study reports that children from the maltreatment sample were significantly more more likely to meet criteria for one or more attachment disorders than children from the other groups, however this was mainly disrupted attachment disorder rather than DSM or ICD classified disorder. Under DSM and ICD classifications there was little difference between the foster care and homeless shelter groups.[32]

The second study, also in 2004, was for the purposes of ascertaining prevalence of RAD, whether RAD could be reliably identified in maltreated rather than neglected toddlers and whether the two types of RAD were independent. The DAI and DSM and ICD were used. 35% were identified as having ICD RAD and 22% as having ICD DAD. 38% fulfilled the DSM criteria for RAD. [33]The study found that RAD could be reliably identified and also that the inhibited and disinhibited forms were not independent. However, there are some methodological concerns with this study. A number of the children identified as fulfilling the criteria did in fact have a preferred attachment figure.[5] This study also showed that mothers with a history of psychiatric problems were more likely to have children exhibiting signs of inhibited/emotionally withdrawn RAD but mothers with a history of psychiatric problems and substance misuse had children more likely to exhibit signs of disinhibited/indiscriminate RAD. [33] NOTE: NOT RELEVANT HERE. MAYBE HAVE A NEW ARTICLE ON THE EFFECTS OF INSTITUTIONAL CARE.

See alsoEdit


ReferencesEdit

  1. Cook, A., Spinazzola, J., Ford, J., Lanktree, C., et al., (2005) Complex trauma in children and adolescents. Psychiatric Annals, 35, 390-398.
  2. 2.0 2.1 Practice Parameter for the Assessment and Treatment of Children and Adolescents with Reactive Attachment Disorder of Infancy and Early Childhood. AACAP 2005
  3. Brodzinsky, D., Schechter, M., & Henig, R.,(Eds.) (1992) On Being Adopted, Doubleday, NY.
  4. O'Connor TG, Zeanah CH (Sep 2003). Attachment disorders: Assessment strategies and treatment approaches. Attachment & Human Development 5 (3): 223-244.
  5. 5.0 5.1 5.2 5.3 5.4 5.5 5.6 Prior V., Glaser D., book "Understanding Attachment and Attachment Disorders. Theory, Evidence and Practice. 2006. Child and Adolescent Mental health series, RCPRTU, Jessica Kingsley Publishers.
  6. Boris N. W, Zeanah C. et al (1998) Attachment Disorders in Infancy and Early Childhood: A Preliminary Investigation of Diagnostic Criteria. American Journal of Psychiatry February 1998.
  7. 7.0 7.1 7.2 7.3 Chaffin M, et al. (Feb 2006). Report of the APSAC Task Force on Attachment Therapy, Reactive Attachment Disorder, and Attachment Problems. Child Maltreatment 11 (1): 76-89.
  8. Carlson, V., Cicchetti, D., Barnett, D., & Braunwald, K. (1995). Finding order in disorganization: Lessons from research on maltreated infants’ attachments to their caregivers. In D. Cicchetti & V. Carlson (Eds.), Child maltreatment: Theory and research on the causes and consequences of child abuse and neglect (pp. 135–157). NY: Cambridge University Press.
  9. Lyons-Ruth, K., Connell, D., Grunebaum, H., & Botein, S. (1990) "Infants at social risk: Maternal depression and family support services as mediators of infant development and security of attachment". Child Development, 61 pp85-98
  10. Gauthier, L., Stollak, G., Messe, L., & Arnoff, J. (1996). Recall of childhood neglect and physical abuse as differential predictors of current psychological functioning. Child Abuse and Neglect, 20, 549–559.
  11. Malinosky-Rummell, R., & Hansen, D. J. (1993). Long-term consequences of childhood physical abuse. Psychological Bulletin, 114, 68–69.
  12. Greenberg, M. (1999). Attachment and psychopathology in childhood. In J. Cassidy & P. Shaver (Eds.), Handbook of attachment (pp. 469–496). NY: Guilford Press.
  13. Lyons-Ruth, K., & Jacobvitz, D. (1999). Attachment disorganization: Unresolved loss, relational violence and lapses in behavioral and attentional strategies. In J. Cassidy & P. Shaver (Eds.), Handbook of attachment (pp. 520–554). NY: Guilford Press.
  14. Cook, A.; Blaustein, M.; Spinazzola, J.; and van der Kolk, B., (2003) Complex trauma in children and adolescents. White paper from the National Child Traumatic Stress Newtork Complex Trauma Task Force
  15. Lyons-Ruth, K., & Jacobvitz, D. (1999). Attachment disorganization: Unresolved loss, relational violence and lapses in behavioral and attentional strategies. In J. Cassidy & P. Shaver (Eds.), Handbook of attachment (pp. 520–554). NY: Guilford Press.
  16. Solomon, J. & George, C. (Eds.) (1999). Attachment disorganization. NY: Guilford Press.
  17. Main, M., & Hesse, E. (1990). Parents’ unresolved traumatic experiences are related to infant disorganized attachment status. In M. T. Greenberg, D. Ciccehetti & E. M. Cummings (Eds.), Attachment in the preschool years: Theory, research, and intervention (pp. 161–184). Chicago: University of Chicago Press.
  18. Carlson, V., Cicchetti, D., Barnett, D., & Braunwald, K. (1995). Finding order in disorganization: Lessons from research on maltreated infants’ attachments to their caregivers. In D. Cicchetti & V. Carlson (Eds.), Child maltreatment: Theory and research on the causes and consequences of child abuse and neglect (pp. 135–157). NY: Cambridge University Press.
  19. Lyons-Ruth, K. (1996). Attachment relationships among children with aggressive behavior problems: The role of disorganized early attachment patterns. Journal of Consulting and Clinical Psychology, 64, 64–73.
  20. Lyons-Ruth, K., Alpern, L., & Repacholi, B. (1993). Disorganized infant attachment classification and maternal psychosocial problems as predictors of hostile-aggressive behavior in the preschool classroom. Child Development, 64, 572–585.
  21. Zeanah, C.H., Scheeringa, M.S., Boris, N.W., Heller, S.S., Smyke, A.T., & Trapani, J.2004), Reactive attachment disorder in maltreated toddlers. Child Abuse & Neglect,28(8),877-888
  22. Randolph, Elizabeth Marie. (1996) Randolph Attachment Disorder Questionnaire:Institute for Attachment, Evergreen CO.
  23. "The findings showed that children in foster care have reported symptoms within the range typical of children not involved in foster care. The conclusion is that the RADQ has limited usefulness due to its lack of specificity with implications for treatment of children in foster care".Cappelletty, G., Brown, M., Shumate, S. "Correlates of the Randolph Attachment Disorder Questionnaire (RADQ) in a Sample of Children in Foster Placement". Child and Adolescent Social Work Journal, Volume 22, Number 1, February 2005 , pp. 71-84(14)
  24. Becker-Weidman, A., (2006a) “Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy,” Child and Adolescent Social Work Journal. Vol. 23 #2, pp. 147-171.
  25. Becker-Weidman, A.,(2006b) “Dyadic Developmental Psychotherapy: A multi-year Follow-up”, in, New Developments In Child Abuse Research, Stanley M. Sturt, Ph.D. (Ed.) Nova Science Publishers, NY, 2006, pp. 43 – 60.
  26. Becker-Weidman, A., (2006c) “Treatment For Children with Reactive Attachment Disorder: Dyadic Developmental Psychotherapy,” Child and Adolescent Mental Health. Published article online: 21-Nov-2006 doi: 10.1111/j.1475-3588.2006.00428.x
  27. Chisholm K. Carter M., Ames E.,and Morison S.,(1995) 'Attachment Security and indiscriminately friendly behavior in children adopted from Romanian orphanages.' Development and psychopathology 7, 283-294
  28. Chisholm K., (1998) 'A three year follow-up of attachment and indiscriminate friendliness in children adopted from Romanian orphanages.'
  29. O'Connor T., Marvin R., Rutter M., Olrick J., BritnerP. and the English and Romanian Adoptees Study Team (2003b) 'Child-parent attachment following early institutional deprivation.' Development and Psychopathology 15, 19-38.
  30. Smyke,A., Dumitrescu,A. and Zeanah,C (2002) 'Attachment disturbances in young children.: The continuum of caretaking casualty.' Journal of the American Academy of Child and Adolescent Psychiatry 41, 972-982.
  31. Zeanah,C., Smyke,A., Koga,S,. and Carlson,E. (2005) 'Attachments in institutionalised and Community Children in Romania' Child Development 76, 1015-1028.
  32. Boris,N., Hinshaw-Fuselier,S., Smyke,A., Scheeringa,M., Heller,S., and Zeanah,C. (2004) 'Comparing criteria for attachment disorders: establishing reliability and validity in high risk samples.' Journal of the American Acxademy of Child and Adolescent psychiatry 43, 568-577
  33. 33.0 33.1 Reactive Attachment Disorder in Maltreated Toddlers", "Zeanah,C,. Scheeringa,M,. Boris,N,. Heller,S,. Smyke,A,. and Trapani,J. (2004) Child Abuse & Neglect: The International Journal", 2004-28-8. Retrieved on April 25, 2007.
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