attachment disorders article

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Journal ofConsultingand Clinical Psychology1996, Vol. 64. No. 1.42-52 Copyright 1996 by the American PsychologicalAssociation, Inc.0022-006X/96/J3.00

Beyond Insecurity:A Reconceptualization ofAttachment Disordersof Infancy

CharlesH.ZeanahLouisiana StateUniversity

Some young children are not merely insecurely attachedand at risk for later problems;byvirtueofthe severity of their attachment disturbances they are already disordered. This article reviews andcritiques the approaches of the Diagnostic and Statistical Manual of Mental Disorders (4thed.;DSM-IV; American PsychiatricAssociation, 1994) and the InternationalClassification ofDiseases(10th ed.; ICD-10; World Health Organization, 1992) to attachment disorders and finds that theyhave not made use of findings from developmental research on attachment indeveloping theircri-teria. Analternative system of classifying attachment disorders that is compatible with the majorfindings from developmental research on infant-caregiver attachment is presented. Finally, manyareas inneedof empirical contributionsareindicated.

Ethological attachment theory, asoutlined by John Bowlby(Bowlby, 1969, 1973, 1980), has providedone of the most im-portant frameworks for understanding crucial risk and protec-tive factors in social and emotional development in the first 3years of life. Bowlby's (1951) monograph,Maternal Care andMental Health, reviewed the world literature on maternal de-privation and suggested that emotionally available caregivingwascrucial for infant developmentand mental health.

Developmental attachment research, which has formallyevaluated Bowlby'smajor premises,hasdemonstrated convinc-ingly that insecureattachment ininfancy isassociated withsub-sequent psychosocial maladaptation in preschool and middlechildhood years (Cassidy, 1988; Lewis, Feiring, McGuffog, &Jaskir, 1984;Easterbrooks&Goldberg, 1990;Erickson,Sroufe,& Egeland, 1985;Sroufe, 1983; Troy &Sroufe, 1987; Wartner,Grossmann, Fremmer-Bombik, & Suess, 1994). Infants whoare insecurely attached at 1year of age to their mothers demon-strate more interactive disturbances with theirmothersat homeand in the laboratory(Matas, Arend, &Sroufe, 1978;Solomon,George, &Ivins, 1989;Waters,Wippman, &Sroufe, 1979), lesssocial competence with peers (Arend, Gove, & Sroufe, 1979;Troy &Sroufe, 1987), and more problematic relationshipwiththeir teachers (Sroufe, 1983). Links between insecure attach-ment classifications in infancy and subsequent behavior prob-lems have been mixed when parents rate behavior problems(Bates, Maslin, & Frankel, 1985; Fagot & Kavanaugh, 1990;Lewiset al., 1984) but havebeen more consistentwhenteachersor observers rate behavior problems (Erickson et al., 1985;Fagot & Kavanaugh, 1990; Suess, Grossman,&Sroufe, 1992;Wartner,Grossman, Fremmer-Bombik, &Suess, 1994). Inves-

An earlier version of this article was presented in November 17-18,1992, at the National Institute of Mental Health Workshop "Attach-ment and Psychopathology," Washington, DC.

Correspondence concerning this article should be addressed toCharles H. Zeanah, Department of Psychiatry, Louisiana State Univer-sitySchool of Medicine, 1542 Tulane Avenue, NewOrleans, Louisiana70112-2822.

tigations in high-risk samples havesuggested strongassociationsbetween disorganized attachment classifications and preschoolbehavior problems (Hubbs-Tait et al., 1991; Lyons-Ruth, Ra-pacholi, McLeod, & Silva, 1991).

Overall, studiesofattachment havesupported the central the-ses of Bowlby's framework. Nevertheless, developmentalattach-ment research is grounded in a risk and protective factors ap-proach that typifies developmental psychopathology.Assuch, ithas focused on demonstrating probabilistic relationships be-tween attachment classifications in infancy and subsequent in-dices of psychological adaptation (Sroufe, 1988).

Bowlby'swork has also been important in the clinical tradi-tion ofattachment disorders.This tradition, typified by descrip-tions of attachment disorders in the Diagnostic and StatisticalManual of Mental Disorders (4thed.;DSM-IV; American Psy-chiatric Association, 1994)and the International Classificationof Diseases (10th ed.; ICD-10; World Health Organization,1992), has focused on young children who are not merely atincreased risk for subsequent disorders but who are disorderedalready. Clinically disordered attachment represents an ex-tremeand impaired subgroupofchildren with insecure attach-ments. Thus, disordered attachments are all insecure attach-ments, but most insecure attachments are not disordered. Clin-ically disordered attachments are the major focus ofthisarticle.

Reactive attachment disorder is one of the fewdiagnostic cat-egoriesapplicable to children under 3years of age in standardnosologies of psychological disorders. Despite its potential im-portance, there are no published studies about its validity. Infact, attachment disordersarementioned hardlyat all in litera-turepublished since it firstappeared in theDiagnosticand Sta-tistical Manual of Mental Disorders (3rd ed.; DSM-III; Amer-ican Psychiatric Association, 1980) 15years ago. During thissame period of time, there has been an unprecedented explo-sion of knowledge from developmental research on attachmentthat has not been included in criteria for diagnostic categoriesof attachment disorders. One purposeof this article is to reviewand critique the DSM-IVand ICD-10 criteria for attachmentdisordersand to suggest that they wouldbenefit from more sub-

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SPECIAL SECTION: ATTACHMENT DISORDERS OF INFANCY 43

stantively integratingthe knowledgebase availablefrom devel-opmental research on attachment.

After briefly reviewing the historical perspective on clinicalattachment disorders, I consider the criteria for attachment dis-orders in the DSM-IVand ICD-10, and I highlight their simi-larities and differences. Adetailed critique of these criteria fol-lows, primarily from the standpoint of what is known aboutattachment from developmental research. The central thesis ofthisarticle is that ifattachment disorders are denned by criteriaderived from findings in attachment research, they become ap-plicable to a broader rangeof children inseverely disturbed re-lationships with their primary caregivers, rather than only tosome children who have been physically abused or extremelydeprived. In conclusion, an alternative system of classificationthat attempts tointegratefindingsfrom developmental researchinto criteria for attachment disorders is outlined briefly, andsome directions for research are highlighted.

Historical Perspective on Attachment DisordersClinicianshavebeen concerned at least since the beginning ofthe 20th century with the psychological development and well-

beingofchildren raised ininstitutions(Chapin, 1915). Still,forthe firsthalfof the century, most objectionstoinstitutional carefor infants went unheeded. Skeel's (1966) observations of im-provement and cognitive delaysand social functioning of insti-tutionalized infants weredismissed by the scientific communityuntil 25yearsafter heoriginally made them because heimpliedthat environment mighthave profound effects on intelligence.Similarly, many other demonstrations of the abysmal psycho-logical status of children in institutions had little impact, per-haps because the children's status wasthought to be the causeof rather than the result of institutional rearing. Some have ar-gued that it wasactuallythe moviesof Rene Spitz about infantsin institutions that awakened the consciences of thousands ofviewersand called attention to the problem in a way that publi-cations in professional journals during the preceding 50 yearshadnot.

Large numbers of European children who had been separatedfrom their parents or actually orphaned by World War II led theWorld Health Organization to commission a British child psychi-atrist,JohnBowlby, toprepare areport on themental health needsofhomeless children. Maternal Care andMental Health waspub-lishedin 1951,and it summarized theobservationsofSpitz(1945,1946), Goldfarb (1945), and many other clinicians about theharmful effects of institutionalization. It also contained the foun-dation ofBowlby's ideas about attachment that evolved into ethc-logical attachment theory, described in his now famous Attach-ment and Loss trilogy, Attachment (Bowlby, 1969), Separation(Bowlby, 1973), and Lo(Bowlby, 1980).

In the meantime, research findings about children raised in in-stitutions accumulated (Provence & Lipton, 1962; Tizard &Hodges, 1978; Tizard & Rees, 1974, 1975), case reports of chil-drenraised in extremely abusive and depriving environments con-tinued to appear (Curtiss, 1977;Koluchova, 1972;Skuse, 1984;Thompson, 1986), and social characteristics of maltreated chil-dren were delineated (Aber & Allen, 1987; Aber & Cicchetti,1984;Gaensbauer& Sands, 1979;George*Main, 1979;Main&George, 1985; Mueller & Silverman, 1989;Powell, Low, &Speers,1987).

As for the official nosologies, the Diagnostic and StatisticalManual of Mental Disorders (2nd ed.; DSM-II; American Psy-chiatric Association, 1968)did not mention attachment disorders,although it illustrated "adjustment reaction of infancy" with theprotest response of an infant separated from his or her mother anddescribed it as characterized by "crying spells, lossofappetite, andsevere social withdrawal(p. 49)."Attachment disorders alsowerenot described in the ninth edition of the ICD (ICD-9; WorldHealth Organization, 1978). Their first appearance in the officialnosologies was in 1980 in the DSM-III. At that time, reactiveattachment disorderwasequated withfailure to thrive,(Spitzer&Cantwell, 1980), although with the curious requirement that on-set of the disorder occurbefore 8monthsofage. Because selectiveattachments occur between 6 and 9 months of age, infants wererequired to developonset of a disordered attachment often beforetheyevenhad expressed apreferred attachment. Criteria were sub-stantially revised in the revised third edition of the DSM(DSM-IIl-R; American Psychiatric Association, 1987), includingdrop-pingfailure to thrive as a central featureof the disorder and chang-ing age ofonset to within the first 5yearsof life. In the DSM-Ill-Rtwoclinical typesof"inhibited"and"disinhibited"attachmentdisorders were introduced, types that have persisted in the newerclassifications oftheDSM-/Kand ICD-10. Reliabilityof diagnosisof reactive attachment disorder improved dramatically with thesechanges in criteria (Volkmar, in press).

Attachment Disordersand Contemporary NosologiesCriteria for attachment disorders as described in the DSM-IV

and ICD-10arepresented inAppendixesA and B.Ascan beseen,they both preserve the distinction, first introduced in the DSM-IH-R, between two major clinical types of attachment disorder.Zeanah and Erode (1994) have suggested that two major databases informed these criteria. Characteristics of social behavior inmaltreated children, identified in a numberof investigations dur-ing the past 15 years, are found in descriptions of the withdrawn,unresponsive child who seeks comfort in deviant ways(Gaensbauer & Sands, 1979; George & Main, 1979; Main &George, 1985;Mueller & Silverman, 1989; Powell et al., 1987).These characteristics areused to describe the inhibited ordevianttype of reactive attachment disorder in DSM-IV (see AppendixA)and todescribe reactive attachment disorder in theICD-10(seeAppendix B). Research on the characteristics of children raisedin institutions (Provence & Lipton, 1962; Skeels, 1966; Tizard &Hodges, 1978;Tizard & Rees, 1974,1975)has influenced the cri-teria for the disinhibited and indiscriminately social type of at-tachment disorder. In the Tizard and Rees (1975) investigation,for example, 10 of 26 children institutionalized for their first 4years of life were noted on evaluationat age 4.5 yearsto have su-perficial attachments to staff members, with attention-seeking,clinginess, and overfriendly behaviorwith strangers being notablesocial characteristics.

Similarities in Criteria for DSM-IV and ICD-10Attachment Disorders

A reviewof the DSM-IV anAICD-10 criteria inAppendixesA and B indicate substantial agreement about the major fea-tures of the disorders. In both nosologies, the disorders involve


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a persistent disturbance in the child's social relatednessthatbe-gins before age 5 and that extendsacross social situations. At-tachment disorders in both nosologies must be distinguishedfrom pervasive developmental disorders. As noted, both agreethat there are two distinct clinical pictures of attachment disor-ders. One type of disorder is designated as inhibited, whereinambivalent, inhibited, or hypervigilant responses are centeredon one or more adults. The other type is designated as disinhib-ited, wherein there is indiscriminate oversociability, a failure toshow selective attachments, a relative lack of selectivity in thepersons from whom comfort issought, and poorly modulatedsocial interactions with unfamiliar persons across a range of so-cial situations.

Although they give it varying emphasis, criteria in both no-sologies tie the disorders etiologically to parental abuse or ne-glect or to extremes of caregiving such as children raised in in-stitutions. Developers of the DSM-1V decided to maintain arequirement from the DSM-III-R (American Psychiatric As-sociation, 1987) that there be evidence of grossly pathogeniccaregiving (e.g., frank neglect, harsh treatment) or repeatedchanges in caregivers (see Appendix A). 1CD-10 also does notmake explicit the requirement of parental maltreatment, al-though the syndrome is believed to result from "severe parentalneglect, abuse or serious mishandling" (World Health Organi-zation, 1992, p. 279), and the clinician is urged to use cautionin making the diagnosis "in the absence of evidence of abuse orneglect" (World Health Organization, 1992,p. 281). Clearly,the linkwith parental maltreatment stronglyinfluences thecri-teria ofboth systemsof classification.

Differences in DSM-IV and ICD-10 Disorders ofAttachment

Differences in criteria for attachment disorders in the two no-sologiesare more subtle. TheD5M-/Flumpstogether two clinicalpicturesunder the singlecategoryof reactiveattachment disorder,whereasthe ICD-10makes eachofthe clinical pictures into a dis-tinctive type. In the ICD-10criteria, the child must have the ca-pacity for social responsivenessas revealed in interactions withnondeviant adults. In contrast, theDSM-IV emphasizes that ab-normal social behavior ought to be apparent in most socialcontexts. Thus, criteria in both systemsdeemphasize the child'sbehavior with the attachment figure, although the DSM-IV ismost explicit about a lackof relationship variability.Finally, theDSM-IV explicitly excludes children with mental retardationfrom a diagnosis of reactive attachment disorder if any of theprominent symptomsare believed to be due to cognitive delays(Appendix A). The ICD-10, on the other hand, makesno suchexclusion, although the child with reactive attachment disordermust demonstrate elementsof normal relatedness wheninteract-ing with responsive adults(Appendix B).

Critique ofAttachment Disorders inContemporaryNosologies

To organizea discussion of usefulness of DSM-IVanA ICD-10criteria for attachment disorders, I consider three questionsabout reactive attachment disorder here: Is it reactive? Is it at-tachment? Is it a disorder?

Is It Reactive?The emphasis in contemporary nosologies on attachment

disorders as"reactive" appears to serve two functions: First, itattempts to differentiate them from the pervasive developmen-tal disorders,whichalsoprofoundlyaffect the social behavior ofyoung children; second, it ties them etiologically to maltreat-ment. Serious questions may be raised about the usefulness ofthis emphasis.

The ICD-10 suggests that the attachment disorders may bedistinguished from pervasive developmental disorders in a num-ber ofways: (a) a normal capacity forsocial relatedness in reac-tive attachment disorder, (b) remission of social abnormalitiesin a normal rearing environment in reactive attachment disor-der, (c) distinctive communicative and language abnormalitiesin pervasive developmental disorders, (d) cognitive deficits thatimprove with improvements in the caregiving environmentonly in reactive attachment disorder, and (e) persistently re-stricted, repetitive, and stereotyped patterns of behavior, inter-ests, and activities are features of pervasive developmentaldis-orders but not attachment disorders (World Health Organiza-tion, 1992).

The reason for the effort to distinguish attachment disordersfrom pervasive developmental disorders is the belief that the so-cial behaviors in the two conditions are similar. The underlyingrationale for the distinction is that similar appearing aberrantsocial behaviors may be the result of different mechanisms ofpathogenesis. In the case of attachment disorders, children withintactcentral nervous systems who experience extremes of mal-treatment and deprivation are believed to develop socially un-responsive and deviant behaviors. In the case ofpervasivedevel-opmental disorders, children are presumed to havecentral ner-vous system abnormalities (as yet undelineated) that areresponsible for the socially deviant behaviors. Thus, the DSM-IV explicitly excludes children with pervasive developmentaldisorders (Appendix A) and the ICD-10emphasizes the capac-ity for normal social interaction in children with attachmentdisorders (discussed earlier; see Appendix B also).

Essentially, this emphasis represents a version of the func-tional versus organic dichotomy that characterized thinkingabout psychiatric disorders in the 1960s. As we have learnedmore about brain-behavior relationships, the functional versusorganic dichotomy has proven less useful. Our nosologies nolonger attempt to distinguish between endogenousand reactivedepression, for example, because it is widely recognized thatongoing interactions between life events and brain neurochem-istry contribute to the symptoms and to the amelioration ofsymptoms of affective disorders (Hirshneld & Goodwyn,1988). Many psychiatric disorders are reactive in the sense thattheir clinical picture represents a final common pathway of in-dividual biology and psychology expressed in a social context.

If it were possible to determine the etiology of agivenclinicalpicture of young children who exhibit problems with related-ness with certainty, the distinction might be more valuable.Froma practical standpoint, it may not bepossible to makeanetiologic determination at a given time of assessment. Achildexhibiting symptomatic behavior who has a reliable history ofadequate caregiving with opportunities for attachment to oneor two figures suggests a central nervous system abnormality,


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SPECIAL SECTION: ATTACHMENT DISORDERS OF INFANCY 45but such a history isneither always nor even often available inthe clinical setting. Not uncommonly, a symptomatic child isreferred for evaluation with a clinical picture ofaberrant socialbehavior and a history of foster care of unknown quality (e.g.,see Zeanah, Mammen, & Lieberman, 1993; Richters & Volk-mar, 1994). If the child's symptoms improve significantly withchanges in the caregiving context, attachment disorders arelikely, but this, of course, cannot be known beforehand. Fur-thermore, it is not clear how much the clinical picture repre-sents neither a maineffect ofcentral nervous system abnormal-ities alonenor of environmental adversity alonebut some ongo-inginteraction between the two.

A better question for theclinician iswhether distinctionscan bemadebetweenthe socially deviant behaviors in pervasivedevelop-mental disorders and those inattachmentdisorders,asasserted inthe 1CD-10. Thereare fewdata availableto address this questiondirectly, inpart becauseof the vagueness about the abnormalitiesin social behavior that have characterized descriptions of attach-ment disorders. Children raised in institutions are problematic asthe sole source of data because it is not alwaysclear what factorsled parents to place the children there originally. If parents de-tectedearly signsofsocially aberrant behaviorintheirinfants, thenone of the reasons forplacement mayhavebeen the abnormalitiestheydetected. Adetailed examinationofthecharacteristics ofchil-dren with reactive attachment disorders, compared with thosedi-agnosedwith pervasive developmental disorderswho livein stable,secureenvironments, will be useful a start forexploring this ques-tion further.

Another aspect of the functional versus organic dichotomy inthe DSM-IV isthat the disturbed attachment behaviors are notsolely the result of developmental delays. However, if a child hasdelaysandaberrant socialbehavior,how do weknow that thedelaycauses theaberrant social behavior?In fact, as weknow from chil-dren raised inimpoverished institutionsand in extremesof depri-vation, significant cognitive impairments are likely tooccur alongwith disordered attachments (Provence &Lipton, 1962; Rosen-berg, Pajer, &Rancurello, 1992). Wealso know that children ininstitutions that aremore stimulatingand developmentally sensi-tive have normal intelligence but disordered attachments (Tizard&Hodges, 1978). Essentially, theDSM-IV criterion about cogni-tivedelays isanother manifestationof the attempt to limit attach-ment disorders tochildren with an intact central nervous system.There seems to be littlejustification for presuming that childrenwith cognitive delays or mental retardation cannot also have at-tachment disorders. Perhaps what could be included instead is arequirement that children with attachment disorders have a levelof cognitive abilities of at least 10 to 12months, since this wouldensure that they are cognitiveh/ capable of having a preferred at-tachment figure.

Finally, there is the problemof the "reactive" label invokingparent blaming. Maltreatment by parents is unmistakably re-lated to problem behaviors, unhappiness, and psychiatric dis-orders inchildren. Still, historiesofabuseor neglect may not beknown, and the problems associated with adequately definingemotional maltreatment, which may be an important contrib-utor to attachment disorders, are numerous and complex(Cicchetti, 1991;McGee &Wolfe, 1991). Volkmar (in press)has pointed out that focusing on parental maltreatment com-plicates determiningthe behavioral features that mayoccur in

the absence of severe adversity. Furthermore, the arbitrarinesswith which maltreatment is identified in the clinical and legalworldsis not sufficiently reliable fordiagnostic criteria. Finally,pejorative labeling ofparents, even implicitly, is unlikely to behelpful and runs counter to the prevailing clinical practice ininfant mental health of evaluating the fit between parent andinfant, with attention to thestrengthsand weaknesses each part-ner brings to their relationship. On balance, there is little justi-fication for singling out attachment disorders and specifyingonly their etiology in classification systems that are explicitlyphenomenologic.The innumerable complexities inherent in de-termining the etiology of psychiatric disorders are no less trueof attachment disorders.

Is It Attachment?Perhaps the most strikingcharacteristic ofboth DSM-IV'and

ICD-10criteria for disordersofattachment istheirdepictionofthe disorders in terms of socially aberrant behavior in generalrather than focusing more specifically on attachment behaviorsper se. TheD5'M-/Kemphasizes afailuretoinitiateor respondto social interactions across a rangeof relationships (AppendixA), and the ICD-10similarly focuses on contradictory or am-bivalent social responses that extend across social situations(Appendix B). This emphasis has the effect ofdeemphasizingattachment inattachment disorders.

Bowlby (1969, 1988) has described attachment as a behav-ioral control system concerned with maintaining infants' safetyand survival through access to the care, nurturance, and espe-cially, protection given by an attachment figure. Feelings of se-curity, safety, and value become associated with the qualitativefeaturesof the infant's relationship with attachment figure. Be-tween the ages of 1 and 3years, the attachment behavioral sys-tem is responsible for motivating a child to attain felt security(Bischof, 1975), initially through physical proximity to the at-tachment figure when needed. As representational processesmature during the second and third years, literal proximity tothe caregiver becomes gradually less necessary to attain felt se-curity, and psychological availability of the attachment figurebecomes even more pronounced.

The attachment system and the exploratory system operate intandem within the child to produce an attachment-explorationbalance; that is, at times when the child feels secure, he or she ismotivated to explore. If the child becomes frightened in thecourse of exploration, however, the motivation to explore di-minishes as the motivation to seek proximityand comfort in-tensifies. Disruptions of this balance represent disturbances inthe use of the attachment figure as a secure base from which toexplore withconfidenceor disturbances in the use of the attach-ment figure as a safe haven (Ainsworth, 1967) to which to re-treat in timesofdanger. The Strange Situation Procedure devel-oped byAinsworth and her colleagues (Ainsworth, Blehar,Wa-ters, & Wall, 1978) makes it possible to observe the child'sattachment-exploration balance with a particular caregiver.This perspective hasbeen elaborated and clarified byover2 de-cadesof empirical research involving attachment classificationsderived from the organization of the child's behavior and theStrange Situation (see Bretherton & Waters, 1985; Sroufe,


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46 ZEANAH1988; Zeanah &Erode, 1994, for reviews)and has great valuein the clinical arena as well.

Controversies about the interpretation of research using theStrange Situation Procedure (see Lamb, Thompson, Gardner,Scarnov, & Estes, 1984; Sroufe, 1988) notwithstanding, thereare a number of well-replicated findings from attachment re-search that can usefully be applied to clinical disorders of at-tachment. Despite an enormous developmental literature withcareful operationalizationof attachment in these terms, there islittleattention in the nosologies to the broad range of behaviorsthat might indexdisorderedattachment relationships. Drawingon clinical experience and developmental attachment research,Zeanah et al. (1993) have proposed several domains of childbehavior expressed towardcaregivers that ought to beevaluatedin considering disordered attachment. These include lack ofaffection or promiscuous affection; absent, odd, orambivalentcomfort-seeking from the caregiver; excessive dependence orfailure to use the supportive presence of the caregiver whenneeded; noncompliance or overcompliance; excessively inhib-ited exploratorybehavioror exploration without checking back;oversolicitous and inappropriate caregiving of the excessivelybossy and punitive attempts by the child to control the parent'sbehavior; and failure to reestablish affective contact after briefseparations including ignoring, angry, or unaffectionate re-sponses. Although some of these behaviors are indices of inse-cure attachments, they become clinical indicators only at ex-tremes of thenormal distribution. When these behaviors repre-sent extremes, and when they indicate together a pattern of thechild's behavior expressed toward attachment figures, these as-pects of child behavior may be useful in identifying disorderedattachments (seecaseexamples in Zeanah etal., 1993, &Lieb-erman &Zeanah, 1995).

Another problem is that, although developmental researchhas demonstrated clearly that attachment may vary acrossdifferent relationships, theDSM-IVand the ICD-10 emphasizethe continuity of socially aberrant behavior across contexts.Thisemphasis mayreflect an attempt to distinguish attachmentdisorders from relational problems that are coded as V codesrather than as Axis I disorders inDSM-IV( Volkmar, inpress).Nevertheless, in addition to broad support from developmentalresearch, clinical experience also suggests that an infant mayhave a disordered attachment relationship with one particularcaregiver without manifesting severely deviant or symptomaticbehavior outside of the context of that relationship. A broaderdefinition of attachment disorders would make it possible toinclude children who do not have obviously symptomatic be-haviorwith day-care providers, preschool teachers, or peers, forexample.

Certainly, peer relations do not appear to be central to a con-ceptualization of the disorders as disturbances of attachment.Even if research indicates that disturbed peer relations are com-mon inchildren with attachment disorders, this probably shouldbe an associated feature, with disturbed behaviors inattachmentrelationships forming thecore features of thedisorders.

All of this contributes to the impression that the disorders asdescribed by theDSM-lVanA ICD-10 are more maltreatmentsyndromes rather than attachment disorders. The emphasis onmaltreatment is evident in the data bases used to develop thecriteria, in the explicit or implicit emphasis on parental mal-

treatment, and in the description of general problems with de-viant social behaviors ingeneral rather than a more specific fo-cus on attachment behaviors. Defining attachment disordersbyusingcriteriathat are drawn primarily from children who havebeen physically abused, whohavesuffered extremes of depriva-tion, and who have been deprived in institutions limits the dis-orders to children in extreme situations and does not accountfor children who are in stable, albeit unhealthy, relationshipswithout overt abuse or neglect. Focusing on unusual social be-haviors across a rangeofsituations tends to restrict the diagno-sis of the disorder to severely mistreated children. Althoughmaltreatment is probably one important contributor to sometypes of attachment disorders, it is neither necessary nor suffi-cient to make the diagnosis. Similarly, not all maltreated chil-dren will exhibit attachment disorders. Focusing on disorderedattachment behaviors rather than on maltreatment avoids theproblem of attempting to determine what constitutes emo-tional maltreatment, recognizes that attachment is only oneamong severalpossible sequela ofmaltreatment,and recognizesthat maltreated children havediverse outcomes.Is It a Disorder?

Both DSM-IV(Volkmar, in press) and the ICD-10 (WorldHealth Organization, 1992) note the lack of direct validitydataabout disorders of attachment. They justify inclusion of thisgroup of disorders provisionally because of their obvious clini-cal importanceandbecause the signs and symptoms cannot beexplained byother disorders. One of the difficulties for the tra-ditional nosologies is that, asnoted earlier, attachment disordersare relational in nature. A long tradition in science and medi-cine, exemplified by the DSM-IVaM the ICD-10, defines dis-orders within individuals. A newer but less well-accepted scien-tific paradigm, representedby systems theory,defines disordersbetween, rather than within, individuals.

A variant of the systems approach has been proposed by agroup of developmental investigators (Sameroff & Emde,1989). Forchildren under 3years ofage, they proposed a con-tinuumofdysfunctional parent-infant relationships, culminat-ing in the most severe dysfunctions, which they designated "re-lationship disorders." These are disorders between rather thanwithin individuals, which involve rigidpatterns of maladaptiveinteractions and which are associated with a failure to attainage-and stage-appropriate developmental tasks for one orbothpartners (Anders, 1989).The rationale forconsidering psycho-pathology in terms of relationship disorders is theassertionthatmost clinical problems in infancy are firmly rooted in impor-tant relationships and that intervening in these relationships iswhat helps clinically (Emde & Sameroff, 1989). Relationshipdisorders may result from, lead to, co-occur with, or be inde-pendent from individual psychopathology and symptomatology(Zeanah, 1994).

Whether this proposed conceptualization reflects a paradig-matic shift or apassingfadremainsto beseen. TheZero-to-ThreeTask Forceon DiagnosticClassification in Infancy (1994) has in-corporated both a parent-infant relationship global assessmentscale and a specific axis of relationship disorders into its system.Validationof these approaches is needed.

Allof this is relevant to a consideration of attachment disorders


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because they are invoked to describe a disorder involving thechild's primary relationships. Nevertheless, it is not essential toconceptualize attachment disorders as relationship disorders.Symptoms and signsofattachment disorders need not bemanifestacross all or even multiple contexts; that is, at least some typesofdisordered attachment behaviors and symptomatology may existwithin an individual infant but be elicited only in the context ofthe primarycaregivmg relationship. A young child who allowsadaycare center staff membertocomfort him somewhatwhendis-tressedbut whodoes not seekcomfort from his primarycaregiverwhen distressed may have an attachment disorder. Note thatDSA/-/Fcriteria would not permit diagnosing this child with anattachment disorder because his comfort-seeking behavior is vari-able indifferent relationships.

One of the most important difficulties in considering a diag-nosis of attachment disorders is the problem of caseness, that is,when signs and symptoms of a disorder are severe enough towarrant a diagnosis. The difficulty arises in part because theorientation to the first 3 years oflife, aswell as the vast majorityof research in developmental psychopathology in this period,has been framed in terms of risk and protective factors as theyimpact developmental trajectories. The risk and protective fac-tors approach invites consideration of symptoms, not in termsof current distress but instead in terms of whether the infant'scurrent behaviorsareprobabilistically related toimpairment ata laterdate.This has been an enormously valuable approach forclinicians and researchers, and one that should be preserved, tothe degree that it is possible, in determining caseness of attach-ment disorders. Before discussing what a case of disordered at-tachment is, it is important to revisit the distinction betweeninsecure and disordered attachments.

It is important not to have caseness of attachment disorderstied directly to Strange Situation classifications of insecure at-tachments (Ainsworth et al., 1978)for a number of reasons(Zeanah &Emde, 1994). The Strange Situation Procedure wasdesigned to classify infant attachment among groups of infantsina research setting rather than to diagnosea particular infantin a clinical setting. Clinicians must be concerned with behav-iors innaturalistic rather thanlaboratory settings,and the linksbetween infant behaviors in the Strange Situation Procedureand those innaturalistic settings are too variable for individualinfants to beuseful clinically. It isalso problematicto over-relyon separation and reunion behaviors, which as noted earlier,constitute only one aspect of attachment relationships salientfor evaluating attachment disorders (Gaensbauer & Harmon,1982). In addition, behavior of the adult caregiver is con-strained in the Strange Situation, making evaluation ofadult-child interaction problematic. Consider, for example, that in-fants who avoid their caregivers in the Strange SituationProce-dure have not been observed to avoid them in naturalistic set-tings (Ainsworthet al., 1978). Finally, as Sroufe (1988) hasemphasized, insecure classification in the Strange Situation isnot indicativeofpsychopathology but risk forpsychopathology.

Ifthereis aclassification that most approaches psychopathol-ogyon its own, it is the disorganized-disoriented classification(Main &Solomon, 1986, 1990). Twolinesofevidence supportthis association.First, theproportionof infants classifiedasdis-organized is clearly increased in high-risk samples of infants(Carlson, Cicchetti, Barnett, &Braunwald, 1989; DeMulder &

Radke-Yarrow, 1991; Hubbs-Taitetal., 1991; Lyons-Ruth, Re-pacholi, & Silva, 1991; O'Connor, Sigman, & Brill, 1987; Rod-ning, Beckwith, & Howard, 1989). Second, preliminary evi-dence suggests that it may be strongly linked to disruptivebe-havior disorders in later childhood (Lyons-Ruth, Alpern, &Repacholi, 1993). Still, determining howeven this classificationrelates to caseness isproblematicfor three reasons. First, thereis a lack ofdata about the distinctive naturalistic correlates ofinfants classified disorganized or disoriented in the Strange Sit-uation. Second, the classification is found in roughly 20% ofinfants in nonclinical samples, suggestingthat it is not synony-mous with caseness. Finally, the classification itself is deter-mined by a continuous rating scale that reflects a judge's cer-tainty about the presence of disorganized or disoriented attach-ment behavior rather than the severity of disorganized ordisoriented behavior. Because thereare no data examining ad-aptation of children with different levels of disorganized ordis-oriented attachment behavior in the Strange Situation, it is notclear how many childrenat different levels satisfy the require-ments of caseness.

Disordersof attachment ought to represent more profoundand pervasive disturbances in the child's feelings of safety andsecurity than arereflected byinsecure attachments. Ifinsecureattachment is not synonymous with disordered attachment,then one must ask, when is a child's attachment behavior indic-ative of disordered attachment? In other words, at what point,if any, does a risk factor (insecure attachment) become a case(attachment disorder) ? Zeanah et al. (1993)haveproposed thatattachment problems become psychiatric disorderswhenemo-tionsand behaviors displayed inattachmentrelationships are sodisturbed as to indicate, or substantially to increase the risk of,persistent distress or disability in the infant. This definitionmaintainsa focus ondisturbed feelings and behaviors withinanindividual, attempts to preserve risk as a legitimate aspect ofthe diagnosis, and makes persistent distress and disability corefeatures of thedisorder.

Admittedly, this definition leaves wide latitude for clinicaljudgment about a particular case, which at the current state ofthe art is probably appropriate for two related reasons.First, asnoted previously, there are nodata availablefor evaluating theusefulness of any of the criteria. Second, there are no standard-ized and validated measures for assessing attachment disordersnor methods for quantifying symptoms of attachment disor-ders. Parent report measures of psychiatric symptoms and dis-orders are often used for children less than 10years of age, butthese seem especiallyunlikely to be helpful in cases of attach-ment disorders which are so closely tied to the relationship be-tween parent and child. Possibly, an observational or clinicalinterview instrument for assessing behaviors to be salient forattachment disorders would be most desirable, but no suchmeasure exists at present. Proposing arbitrary cutoff levels forsymptoms other than theclinicians' estimation of sufficient de-gree of or risk for persistent distress and disability seems ill ad-vised. Most of the disorders in the AWand the ICD, in fact,allow latitude for clinical judgmentwith regard to caseness.

There is still the question of whether insecure attachmentsever can be considered disordersof attachment. If the fact that40%to 50% of infants in low-risk samples areclassified insecurein the Strange Situation is taken seriously, then it is likely that


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48 ZEANAH

each category of insecureattachment represents a broad rangeof adaptive functioning. There are undoubtedly extremes ofmaladaptation that indicate psychopathology at some pointwithin the range of each type of insecurity. It is possible thatextremes of avoidant or resistant behavior during reunions inthe StrangeSituation procedure, forexample, represent "cases"ofdisordered attachment, but this has not been examined em-pirically. In summary, disordered attachments are always inse-cure attachments (or the absence of attachments altogether),but insecure attachments are likely to be disordered onlyat theextremes ofeach type.

Alternative ConceptualizationsSeveral alternative conceptualizations to disordered attach-

ment have appeared besides those appearingin the official no-sologies. Greenspan and his colleagues (Greenspan, 1981;Greenspan & Lieberman, 1988; Greenspan & Lourie, 1981)considered attachment disorders as phase-specific disturbanceswithin theirdevelopmental-structuralistframework Call(1980,1983), on the other hand, considered attachment disordersfrom the psychodynamic perspectiveof the developmentalpro-cesses of separation and individuation. These two approacheshave provided alternative conceptualizations to the criteria inDSM-IV standard nosologies by focusing disordered attach-ment more specifically on the infant's behavior with the pri-mary attachment figure and by including abroader focus thanresponses to maltreatment alone. Nevertheless, neither theGreenspan nor theCall approaches to attachment disorders in-corporatedfindings from developmental attachment research ineither their definitions or in the criteria used tooperationalizethem, neither has had the reliability or validity of their criteriaassessed, and neitherhas wonwidespreadacceptance.

In contrast to these approaches, Liebermanand Pawl (1988,1990)drew upon developmental attachment research in defin-ing attachment disorders as secure base distortions. They de-scribed threepatterns of disordered attachment and illustratedeach of themwith clinical vignettes. The first, recklessness andaccident proneness, described infants who failed to checkbackwith their caregivers at times when their infants' attachmentsystems ought to have been aroused. In the second type, inhibi-tion of exploration, infants seemed unwilling to venture awayfrom the secure base that their caregivers were to provide. Fi-nally, in the third pattern, precocious competence in self-pro-tection, infants seemed to have inverted the secure base so thattheywereexcessivelyself-reliantand providing careand protec-tion to the parent.This system of classifying attachment disor-ders, although not fully developed in the form of criteria,formed the foundation for the expanded system of classifyingattachment disorders described by Zeanah, Mammen, andLieberman (1993) and more recently by Liebermanand Zea-nah (1995).

Thismost recent alternative systemforclassifying disorderedattachment also wascreated from clinical observation but alsowith the explicit attempt to fashion criteria for attachment dis-orders that incorporated the major findings ofdevelopmentalattachment research. The system of classification identifiesthree different major types of disorders of nonattachment, dis-

ordered attachments, and disruptedattachment disorder. Theseare described briefly later (see Table 1).

Nonattached attachment disorder describes infants who donot exhibit a preferred attachment to anyone, despite havingattained acognitiveage of 10 to 12 months.Thereare twotypes,an emotionally withdrawn, inhibited subtype and an indiscrim-inately social subtype. These two subtypes are similar to theDSM-IVand ICD-10descriptions of attachment disorders.

Disordered attachments, on the other hand, are distortions inthe child's use of the caregiver as a secure base from which toexplore the world and a safe haventowhich to return in times ofdanger.What is characteristic of secure-base distortions is that thesymptomatic behaviors are relationship-specific and confined tothe disordered attachment relationship. The young child who isexcessivelyclingyand extremely inhibited about exploringtypifiesan attachment disorder with inhibition. The child who movesaway from the caregiver too easily withoutcheckingback even intimesofdangerand whoexhibitsa patternofrecklessand danger-ous behavior characterizes attachment disorder with self-endan-germent. Finally, if the attachment relationship is inverted so thatthe child tends to and worriesexcessivelyabout the emotionalwell-beingof the attachment figure to adevelopmentally inappropriatedegree, then disordered attachment with role reversal ought to beconsidered.

Disrupted attachment disorder describes the grief response ofyoungchildren who lose their major attachment figure. Thesereactions were originallydescribed by Robertson and Robert-son's (1989) work with children separated from their parents.Because of the central importance of the attachment figure inthe first 3years of life, the loss of an attachment figure at thistime may be qualitatively different than if the loss occurs atother points in the lifecycle.

Each of these types of attachment disorders has specific cri-teria to be used in its identification. What is characteristic ofthis system isthat it is more specifically focused on the child'sattachment behaviors and attachment relationships rather thanon social behaviorsin a variety of contexts. Althoughthe cri-teria in this systemhave not yet been validated, the criteria areoperationalized sufficiently to permit such investigations.

It is likely that focusing disordered attachment more specifi-cally on relationship disturbances between infants and parents

Table1An AlternativeConceptualization of Disorders of Attachment

Disorder AlternativeconceptualizationNonattachment

Disordered attachment

Disruptedattachment

Nonattachment with indiscriminatesociability

Nonattachment with emotionalwithdrawalDisordered attachment with inhibitionDisordered attachment with self-endangermentDisordered attachment with rolereversalGrief reaction following loss

Note. From Child and Adolescent Psychiatric Clinics of North Amer-ica, by A. Lieberman and C. H. Zeanah, 1995, Philadelphia: W. B.Saunders.Copyright 1995 by W. B.Saunders. Adaptedwith permission.


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and less specifically on aberrant social behavior would meanthat attachment disorders will become applicable to a largernumber of symptomatic young children. For example, in theseven cases of infants with disturbed attachment relationshipspresented by Zeanah, Mammen, and Lieberman (1993), onlyone could be diagnosed with attachment disorders using DSM-IV and ICD-10criteria. Attention to attachment behaviors inthese symptomatic infants also is useful in focusing treatmentefforts.

SummarySeveral related theses have been set forth in this article re-

garding disorders of attachment in early childhood. First, thecriteria used todescribedattachment disorders in DSM-IVanAICD-10 more properly define maltreatment syndromes thanat-tachment disorders. They implicitly (ICD-10) or explicitly(DSM-IV) require parental maltreatment or absenceof stablecaregiving. As such, their clinical usefulness isdiminished bythe narrownessof the population towhom theycan be usefullyapplied. By incorporating research findings and definitionsfrom basic developmental research, it ispossible to modify thecriteria and to describe the clinical features of a larger groupofchildren who are in stable but disordered attachment relation-ships (Zeanah, Mammen, &Lieberman, 1993). Furthermore,these assertions are testable in groups of high-risk and clinic-referred infants.

Second, inaddition tobroadeningthe criteria of attachmentdisorders beyond maltreatment, the criteria forattachment dis-orders should be focused morespecifically on thechild's attach-ment-explorationbalance and use of the attachment figure as asecurebase and a safe haven. These behaviors provide clinicallyapparent and meaningful guidelines to the evaluating the con-struct of attachment innaturalistic settings and avoid the con-fusion introduced by diffusing the features of the disorder tobroad indices of social functioning. By focusing more specifi-cally on infant-caregiver attachment, thedisorder isbroadenedto include not only children with no attachment relationshipsbut also those with extremely disturbed attachment relation-shipswith their caregivers.

Third, the requirement that disordered attachment be pres-ent across social contexts shouldbedropped inrecognition thatattachment, whether disordered or not, may be expresseddifferentially indifferent relationships. It ispossible to define adisorder within an individual even if its expression is not cross-contextual. This perspective requires acknowledgementof thechild's capacity to construct differing relationships with differ-ent caregiving adults, which hasbeen repeatedly demonstratedin developmental research.

Fourth, asnoted repeatedly inthis article, theabsence of effortsto validate these disorders, using any of the available criteria, iscurrentlya major problem for the field. The validity data relevantto all classifications of attachment disorders are all indirect, andtheeffort tovalidate attachment disorders should be a top researchpriority. As a part of that effort, these disorders must be distin-guished frominsecure attachment and fromother typesofpsychi-atricdisorders affecting youngchildren. Thismayrequiredevelop-ment ofstructured interviewsand observational rating paradigms

to facilitate evaluationofpatterns of the child's behavior relevanttoattachment disorders.

Fifth, another area in need of attention is how to distinguishcleariybetween insecureand disordered attachment. Anotherwayof framing the question is, When do risk factors (insecureattachments) become clinical disorders (attachment disorders)?Thisis the question of caseness described earlier, and in the future,investigatorsshould address this question empirically. At present,it islikely that aconsensus ofclinical judgment about what consti-tutesacaseofattachment disorder willbemost useful asa startingpoint.

Finally, integrationof findings fromdevelopmental attachmentresearch into criteria for clinical disorders of attachment may en-rich the perspective on important clinical problems and alsopro-vide us with even more pressing questions for developmentalresearch.

ReferencesAber, J. L., & Allen, J. (1987). Effects of maltreatment on young chil-

dren's socioemotional development: An attachment theory perspec-tive. Developmental Psychology. 23.406-414.

Aber, J. L., &Cicchetti, D. (1984). The socio-emotional developmentof maltreated children: An empirical and theoretical analysis. InH. Fitzgerald, B. Lester, & M. Yogman (Eds.), Theory and researchin behavioral pediatrics (Vol. 2, pp. 147-205). New York: PlenumPress.

Ainsworth, M. D. S. (1967). Infancy in Uganda: Infant care and thegrowth ofaltachment. Baltimore: Johns Hopkins UniversityPress.

Ainsworth, M. D. S., Blehar, M. C, Waters, E., & Wall, S. (1978). Pat-terns of attachment: A psychological study of the Strange Situation.NewYork:Basic Books.

American Psychiatric Association. (1968). Diagnostic and statisticalmanual of mental disorders (2nded.).Washington, DC: Author.

American Psychiatric Association. (1980). Diagnostic and statisticalmanual of mental disorders (SjAeA.). Washington, DC:Author.American Psychiatric Association. (1987). Diagnostic and statistical

manual of mental disorders (3rd ed., rev.). Washington, DC: Author.American Psychiatric Association. (1994). Diagnostic and statistical

manualofmentaldisorders (4th ed.). Washington, DC: Author.Anders, T. F. (1989). Clinical syndromes, relationship disturbances,

and their assessment. In A. J. Sameroff & R. N. Emde (Eds.),Rela-tionship disturbances in early childhood (pp. 125-144). New York:Basic Books.

Arend, R., Gove, F., &Sroufe, L. A. (1979). Continuity of individualadaptation from infancy to kindergarten: A predictive study of egoresiliency and curiosity in preschoolers. Child Development, 50, 950-959.

Bates, J. E., Maslin, C. A., & Frankel, K. A. (1985). Attachment secu-rity, mother-child interaction, and temperament as predictors of be-havior-problem ratings at age three years. In I. Bretherton & E. Wa-ters (Eds.), Growing points in attachment theory and research.Monographs of the Society for Research in Child Development.50(SerialNo. 209), 167-193.

Bischof, N. A. (1975). A systems approach toward the functionalcon-nections of fear and attachment. Child Development, 46, 801-817.

Bowlby, J. (1951). Maternal care and mental health. Geneva, Switzer-land: World Health Organization.

Bowlby, J. (Kb1)). Attachment and loss: Attachment. New York: BasicBooks.

Bowlby, J. (1973). Attachment and loss: Separation. New York: BasicBooks.

Bowlby,J. (1980).Attachment and loss: Loss. NewYork: Basic Books.


9/11

50 ZEANAHBowlby,J. (1988).A securebase. NewYork: Basic Books.Bretherton, I., & Waters, E. (Eds.). (1985). Growing points of attach-

ment theoryand research. Monographs of the Societyfor ResearchinChild Development, 50( Serial No. 209).

Call, J. D. (1980). Attachment disorders of infancy. In H. 1. Kaplan,A. M. Freedman, & B. J. Sadock (Eds.), Comprehensive textbook ofpsychiatry(pp. 2586-2597). Baltimore:WilliamsAWilkins.

Call, J. D. (1983). Toward a nosology for psychiatric disorders in in-fancy. In J. Call, E. Galenson, & R. L. Tyson (Eds.), Frontiers of in-fant psychiatry (pp. 117-128). New \fork: Basic Books.

Carlson, V.,Cicchetti, D., Baraett, D., &Braunwald, K. (1989). Find-ing order in disorganization: Lessons for research from maltreatedinfants attachments to their caregivers. In D. Cicchetti & V. Carlson(Eds.), Child maltreatment: Theory and research on the causesandconsequences of child abuseand neglect (pp. 494-528). Cambridge,MA: Cambridge University Press.

Cassidy, J. (1988). Child-mother attachment and the self at age six.Child Development, 57, 331-337.

Chapin, H. D. (1915). Are institutions for infants necessary? Journalof theAmericanMedical Association, 64, 1-3.

Cicchetti,D. (1991). Denning psychological maltreatment: Reflectionsand future directions. Development and Psychopathology, 3, 1-2.Curtiss, S. (1977). Genie: A psycholinguistic study of a modern-day"wildchild." London: AcademicPress.

DeMulder, E. K., & Radke-Yarrow, M. (1991). Attachment in affec-tively ill and well mothers: Concurrent behavioral correlates. Devel-opment andPsychopathology, 3.227-242.

Easterbrooks, A., & Goldberg, W. (1990). Security of toddler-parentattachment: Relation tochildren's sociopersonality functioning dur-ing kindergarten. In M. T. Greenburg, D. Cicchetti, & E. M. Cum-mings (Eds.),Attachment in thepreschool years (pp. 221-244).Chi-cago: University of ChicagoPress.

Emde, R. N., & Sameroff, A. J. (1989). Understanding early relation-ship disturbances. In A. J. Sameroff & R. N. Emde (Eds.),Relation-ship disturbances in early childhood. New\brk:Basic Books.

Erickson, M. F, Sroufe, L. A., & Egeland, B. (1985). The relationshipbetweenqualityof attachment and behavior problems in preschool ina high-risk sample. Monographs of the Society for Researchin ChildDevelopment, 50(Serial No. 209), 147-166.

Fagot, B. L., & Kavanagh, K. (1990). The prediction of antisocial be-havior from avoidant attachment classifications.Child Development,61, 864-873.

Gaensbauer, T. J., & Harmon, R. J. (1982). Attachment in abused/neglected and premature infants. In R. N. Emde & R. J. Harmon(Eds.), The development of attachment and qffiliative systems (pp.263-280). NewYork: Plenum Press.

Gaensbauer, T., & Sands, K. (1979). Distorted affective communica-tions in abused/neglected infants and their potential impact oncare-givers. Journal of the American Academyof Childand Adolescent Psy-chiatry, IS.236-250.

George, C, & Main, M. (1979). Social interactions in young abusedchildren:Approach, avoidance, and aggression. Child Development,50,306-318.

Goldfarb, W. (1945). Effects of psychological deprivation in infancyand subsequent stimulation. American Journal of Psychiatry, 102,18-33.

Greenspan, S. I. (1981). Psychopathology and adaptation in infancy andearly childhood: Principles of clinical diagnosisand preventive inter-vention. (Clinical Infant Reports, 1). New York: International Uni-versities Press.

Greenspan, S. I., & Lieberman, A. (1988). A clinical approach to at-tachment. In J. Belsky & T. Nezworski (Eds.), Clinical implicationsof attachment (pp. 387-424). Hillsdale, NJ: Erlbaum.

Greenspan, S. I., &Lourie, R. (1981). Developmental structuralist ap-

proach to theclassificationofadaptive and pathologicpersonality or-ganization: Application to infancy and early childhood. AmericanJournal of Psychiatry, J3S, 725-735.

Hirshfield, R., &Goodwyn, F.(1988) Mood disorders. In J. A.Talbott,R. E. Hales, & S. Yudofeky (Eds.), The American Psychiatric Presstextbook of psychiatry (pp. 403-442). Washington, DC: AmericanPsychiatricPress.

Hubbs-Tait, L., Eberhart-Wright, A.,Ware,L., Osofsky, J., Yockey, W,& Fusco, J. (1991). Maternal depression and infant attachment:Be-haviorproblemsat 54 months inchildren of adolescent mothers. Paperpresented at theBiennial Meeting oftheSociety for Research inChildDevelopment, Seattle,WA.

Koluchova, J. (1972) . Severe deprivation in twins: A case study.Journal of Child Psychology and Psychiatry, 13, 107-114.

Lamb, M., Thompson, R. A., Gardner, W.P., Charnov, E. L., & Estes,D. (1984). Security of infantile attachment as assessed in the"Strange Situation": Its study and biological interpretation. The Be-havioral and Brain Sciences, 7, 127-171.

Lewis, M., Feiring, C, McGuffog, C., & Jaskir, J. (1984), PredictingPsychopathology in six-year-olds from early social relations. ChildDevelopment, 51,123-136.

Lieberman, A. F., & Pawl, J. (1988). Clinical applications of attach-ment theory. In J. Belsky& T. Nezworski (Eds.), Clinical implica-tions of attachment (pp. 327-351). Hillsdale, NJ: Erlbaum.

Lieberman, A. F., &Paw], J. (1990). Disorders of attachment and se-cure base behavior in the second year of life: Conceptual issues andclinical intervention. In M. T. Greenburg, D. Cicchetti, & E. M.Cummings (Eds.), Attachment in the preschool years (pp. 121-160).Chicago: University of ChicagoPress.

Lieberman,A. F, &Zeanah, C. H. (1995).Disordersof attachment. InK. Minde (Ed.), Infant psychiatry, child and adolescent clinics ofNorth America (pp. 571-588).Philadelphia: Lippincott.

Lyons-Ruth, K., Alpern, L., & Repacholi, B. (1993). Disorganized in-fant attachment classification and maternal psychosocialproblems aspredictors of hostile-aggressivebehavior in the preschool classroom.Child Development. 64,572-585.

Lyons-Ruth,K., Repacholi,B., McLeod, S., & Silva., E. (1991). Disor-ganized attachment behavior in infancy: Short-term stability, mater-nal and infant correlates,and risk-relatedsubtypes. Development andPsychopathology, 3,377-396.

Main, M., & George, C. (1985). Responses of abused and disadvan-taged toddlers to distress in agemates: A study in the day-caresetting.Developmental Psychology, 21,407-412.

Main, M., & Solomon, J. (1986). Discovery of an insecure,disorganized/disoriented attachment pattern: Procedures, findings,and implications for the classification of behavior. In M. Yogman &T. B.Brazelton (Eds.),Affective development in infancy (pp. 95-124).Norwood, NJ:Ablex.

Main, M., & Solomon, J. (1990). Procedures for identifying infants asdisorganized/disorientedduring theAinsworth Strange Situation. InM. T. Greenburg, D. Cicchetti, & E. M. Cummings (Eds.),Attach-ment in the preschool years (pp. 121-160). Chicago: University ofChicagoPress.

Matas, L., Arend,R. A., &Sroufe, L. A. ( 1978). Continuityofadapta-tion in the second year: The relationship between qualityof attach-ment and later competence. Child Development, 49, 547-556.

McGee, R., & Wolfe, D. A. (1991). Psychological maltreatment: To-ward an operational definition. Development and Psychopathology, 3,3-18.

Mueller, E., & Silverman, N. (1989). Peer relations in maltreated chil-dren. In D. Cicchetti & V.Carlson (Eds.), Child maltreatment: The-ory and research on the causes and consequences of child abuse andneglect. Cambridge, MA: Cambridge UniversityPress.

O'Connor, M. J., Sigman, M., & Brill, N. (1987). Disorganization of


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52 ZEANAHAppendix A AppendixB

DSM-IV'Criteria for Reactive AttachmentDisorderReactive Attachment Disorder

Criterion A. Markedly disturbedanddevelopmental inappropriatesocial relatedness inmost contexts, beginning beforeage 5, as evidencedbyeitherA1or A2:1. Persistent failure to initiateor respond in a

developmentallyappropriate fashion tomost socialinteractions, as manifest byexcessively inhibited,hypervigilant, or highlyambivalentandcontradictory responses (e.g., the child may respondtocaregivers with a mixture of approach, avoidance,and resistance tocomfortingor mayexhibit frozenwatchfulness)

2. Diffuse attachments as manifested byindiscriminatesociability withrelativefailure toexhibitappropriate selective attachments (e.g., excessivefamiliaritywith relative strangers or lackofselectivity inchoiceofattachment figures)Criterion B. The disturbance inCriterion A is not accounted for

solely bydevelopmental delays(as in mentalretardation) and is not a symptom of pervasivedevelopmental disorder.

Criterion C. Pathogenic Care as evidencedby at least one of thefollowing:1. Persistent disregard of the child's basic emotional

needs forcomfort, stimulation,and affection2. Persistent disregard of the child's basic physical

needs3. Repeated changesofprimarycaregiver that prevent

formation of stable attachments (e.g., frequentchanges infoster care)

Criterion D. There is a presumption that thecare inCriterion C isresponsible for thedisturbed behavior inCriterion A.(e.g., the disturbances inCriterionAbegan followingthe pathogenic care in Criterion C).

Specify type:Inhibited type: IfcriterionAI predominates in theclinical

presentationDisinhibited type: ]fcriterion A2 predominates in theclinical

presentationNote. From Diagnostic and Statistical Manual of Mental Disorders,Fourth Edition (p. 118), by the American Psychiatric Association,1994, Washington,DC: Author. Copyright 1994 by the American Psy-chiatricAssociation. Adapted with permission.

ICD-10Criteria for Attachment DisordersReactiveAttachment Disorder

A. Onset beforeage of 5 years.B. Strongly contradictory of ambivalent social responsesthat extendacross social situations (but whichmayshowvariabilityfromrelationship-to-relationship).

C. Emotionaldisturbance as shownbymisery, lack of emotionalresponsiveness, withdrawal reactions, aggressive responses toone'sown oranother'sdistress,and/or fearful hypervigilance.

D. Evidence of capacity for social reciprocity and responsiveness asshownbyelements ofnormal social relatedness in interactionswith appropriately responsive, non-deviant adults.

E. Doesnot meet the criteria for pervasive developmental disorders.Disinhibited AttachmentDisorder

A. Diffuse attachmentsas apersistent feature during the first fiveyears oflife (but not necessarily persisting intomiddlechildhood). Diagnosis requires a relative failure to shew selectivesocial attachments manifestedby:i. Anormal tendency toseek comfort from others when

distressed.ii. Anabnormal or relative lack of selectivity in the person from

whom comfort is sought.B. Poorly modulated social interactions with unfamiliar persons.

Diagnosis requires at least one of the following: generally clingingbehaviorin infancy or attentionseekingand indiscriminatelyfriendly behavior inearlyor middle childhood.

C. Lack ofsituation-specificity in the aforementioned features.Diagnosis requires that the first two features are manifest acrossthe rangeof social contexts experienced by thechild.

Note. From the ICD-10 Classification of Mental and BehavioralDis-orders: Clinical Descriptions and Diagnostic Guidelines (pp. 279-282), by the World Health Organization, 1992, Geneva, Switzerland:Author. Copyright 1994 by the World Health Organization. Adaptedwithpermission.

Received August 26,1993Revision received January 14,1995

Accepted July 10, 1995 i

attachment disorders article

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