Journal of Child & Adolescent Trauma, 4:274–290, 2011

Copyright © Taylor & Francis Group, LLC

ISSN: 1936-1521 print / 1936-153X online
DOI: 10.1080/19361521.2011.609155

Child Exposure and Developmental Variables

Attachment and Trauma in Early Childhood:

A Review

ANGELA S. BREIDENSTINE, LETIA O. BAILEY,

CHARLES H. ZEANAH, AND JULIE A. LARRIEU
Tulane University School of Medicine

Attachment relationships are critical to a young child’s optimal development. Both

the presence and quality of attachment matter. Experiences of trauma can affect
caregiver/child attachment relationships in a variety of ways. This article explores
possible associations among trauma and the presence and quality of attachment rela-
tionships between young children and their caregivers. The nature of attachment,
phases in the development of attachment relationships, and classifications of the qual-
ity of attachment are presented. Possible linkages among past traumatic experiences,
parental states of mind, parental interactive behaviors, and infant attachment rela-
tionships are postulated. The most severe attachment disturbance, reactive attachment
disorder, is discussed, including evidence that suggests modification of the current for-
mulation of reactive attachment disorder subtypes; namely, that the indiscriminate
subtype of reactive attachment disorder may not qualify as an attachment disorder.
More research is needed to better understand reactive attachment disorder and the
reciprocal relationships between attachment and trauma experienced by both parents
and children.

Keywords attachment, trauma, early childhood, RAD, parent-child relationship

Attachment describes an emotional bond that serves to promote and preserve closeness
between a young child and a small number of adult caregivers who are responsible for com-
forting, supporting, nurturing, and protecting the child. Under typical rearing conditions,
human infants form attachments to caregivers whom they have learned through experience
are available and dependable. Attachment theory and research findings regarding attach-
ment styles, disturbances, and disorders have created a foundation for understanding this
important relational context for child well-being and development. Variations in the qual-
ity of attachments, particularly whether or not they form, have important implications for
development in the young child. Children who have adverse attachment experiences, such
as disorganized attachment relationships, or absent attachments as in reactive attachment

Submitted April 7, 2010; revised July 23, 2010; accepted July 29, 2010.
Address correspondence to Angela S. Breidenstine, Department of Psychiatry and Behavioral
Sciences, Tulane University School of Medicine, 1440 Canal St., TB52, New Orleans, LA 70112.
E-mail: abreiden@tulane.edu

274
 Attachment and Trauma 275

disorder, are seen as being at the greatest risk for concurrent and future psychopathology.
It is clear that traumatic experiences can compromise attachment relationships, can occur
within attachment relationships or can influence the attachment patterns of infants/children
when the parent has been previously traumatized. Despite thoughtful syntheses about
attachment, trauma, and brain development (e.g., Schore, 2001), there is still much to
be learned about how traumatic experiences affect attachment relationships, both directly
or indirectly, and how attachment relationships may moderate the effects of trauma on
children.
In this review, we briefly summarize attachment theory and attachment classifications
in children and adults. We then discuss relationships between trauma and attachment,
including what we currently understand about how past parental trauma and attachment
styles may confer risk to present parent-child attachment relationships. Many questions
about the complex interrelationships between attachment and trauma remain unresearched
and unanswered at this time. Finally, we provide an overview of reactive attachment dis-
order (RAD). This diagnosis is frequently misunderstood and is sometimes applied to
children with a variety of traumatic experiences and/or externalizing behavior problems.
Thus, for the interested reader, we include both a review of the current conceptualization
of RAD as well as the basic principles of assessment for this disorder.

Summary of Attachment Theory and Related Findings

Development of Attachment
John Bowlby (1969/1982), a British child psychiatrist and psychoanalyst, developed
attachment theory to explain young children’s behaviors in ethological terms. He char-
acterized the attachment system as a behavioral or motivational system with an external
goal of maintaining an infant’s physical proximity to the caregiver and an internal goal
of achieving “felt security” (Bischof, 1975; Sroufe & Waters, 1977, p. 1186). Central to
this conceptualization of attachment are observable, biologically driven behaviors, which
Bowlby referred to as attachment behaviors. These are any behaviors of the infant or
young child that serve to promote physical proximity to the caregiver, such as crying, smil-
ing, crawling toward, or clinging to the caregiver. Infants are not born with any obvious
attachment preference. Instead, attachment develops gradually over the first 3 years of life.
Table 1 summarizes various distinct phases in the development of infant attachment,
which coincide with predictable biobehavioral shifts of early childhood (Boris, Aoki, &
Zeanah, 1999). These shifts describe points in time after which qualitative changes occur
rapidly and new capacities emerge in the infant that had not been present previously.
As Table 1 illustrates, focused or preferred attachment emerges as a new phenomenon
sometime between 7 and 9 months of age, at least under typical childrearing condi-
tions. Separation protest from attachment figures and initial wariness with strangers are
behavioral indicators that focused attachments have formed.
By 1 year of age, it is possible to observe a balance in the toddler’s motivation to
explore the environment and motivation to seek proximity to the adult caregiver. That
is, the toddler, equipped with newfound capabilities for independent locomotion, is moti-
vated to venture away from the caregiver and explore. Counterbalancing this desire is the
motivation to seek proximity in times of fear, stress, or distress. Thus, when a toddler
is in the presence of an attachment figure and feeling secure, the attachment system is
relatively deactivated, and the child is motivated to explore the environment. If the tod-
dler becomes frightened, threatened, or hurt, the attachment system is activated, and the
276 A. S. Breidenstine et al.

Table 1
Phases in the development of attachment

Phase Characteristics
Limited Discrimination The infant’s ability to discriminate among individuals
(Birth–8 weeks) is limited to olfactory and auditory stimuli.
Discrimination with Limited The infant becomes increasingly social and more
Preference (2–7 months) interactive (e.g., gazing and cooing), and, although
his/her signals are directed at familiar caregivers,
strong preferences are not yet expressed.
Preferred Attachment The infant becomes more discriminating, developing
(7–12 months) a clear preference for a small number of caregivers,
who are hierarchically ranked. Stranger wariness
and separation protest become apparent at this time.
Secure Base and Safe Haven The infant or toddler begins to use the attachment
(12–18 months) figure as a secure base from which to explore and as
a safe haven to return to when frightened or
distressed. The attachment-exploration balance as
described by Ainsworth et al. (1971) becomes
apparent.
Formation of a Young children and their parents learn to jointly
Goal-Corrected Partnership adjust goals; the child begins to purposefully
(18 months and beyond) consider, to anticipate, and/or to infer the
caregiver’s probable actions, and accordingly to
balance autonomous functioning with reliance on
the caregiver.

motivation to explore diminishes or disappears. Instead, the toddler either seeks proximity
to the caregiver or engages in signaling behaviors to alert the caregiver of his/her distress.
This attachment/exploration balance (Ainsworth, Bell, & Stayton, 1971) can be observed
readily whenever young toddlers and their attachment figures are interacting together.

Classifications of Attachment in Infants and Young Children

Ainsworth, Blehar, Waters, and Wall (1978) developed a laboratory paradigm known
as the Strange Situation Procedure (SSP) to look at variations in the balance between
exploratory and attachment behaviors in the context of specific caregiving relationships.
This 20-minute assessment procedure involves a series of separations and reunions with
the young child, an attachment figure, and an adult female stranger. The SSP reveals quali-
tatively different patterns of infant-to-caregiver attachment, including secure attachment
and several forms of insecure attachment, known as avoidant, resistant, and disorga-
nized. These patterns tend to be relationship specific; that is, the same infant may
have a different SSP classification with different caregivers. These patterns have been
described and replicated in studies conducted throughout the world (van IJzendoorn &
Sagi-Schwartz, 2008).
Infants who demonstrate a balance between proximity-seeking and exploration are
described as securely attached. Throughout the procedure, they indicate comfort with their
 Attachment and Trauma 277

attachment figures in comparison to relative reticence with the stranger. During separa-
tion, these infants typically decrease exploration and often show distress. On reunion with
their attachment figures, securely attached infants directly express their distress and seek
proximity to and comfort from the adult caregiver (Ainsworth et al., 1978). In preschool
children, who are less likely than younger children to express overt distress during sep-
arations, the reconnection during reunion may be more verbal than behavioral (Cassidy,
Marvin, & the MacArthur Working Group, 1992).
Infants who show little evidence of distress upon separation from their caregivers,
instead turning their attention to toys or other objects, are classified as having avoidant
attachments. During reunion, they ignore or actively avoid physical closeness with their
caregivers (Ainsworth et al., 1978). In preschool children, the avoidance includes avoiding
conversation, gaze that is minimal or fleeting, and neutral affect throughout the interaction.
There is usually clear evidence of the child’s actively inhibiting affect (Cassidy, Marvin, &
the MacArthur Working Group, 1992).
Infants whose attachments are classified as resistant or ambivalent typically protest
strongly at being separated from their caregivers. On reunion, however, they are unable to
use the caregiver to obtain comfort for their distress. They seem alternately to seek comfort
and to resist being comforted (Ainsworth et al., 1978). In the preschool years, this classifi-
cation is called dependent to emphasize the passive, helpless, or immature behaviors these
children display; although this style also includes angry and petulant behaviors directed
toward the caregiver (Cassidy, Marvin, & the MacArthur Working Group, 1992).
Infants who demonstrate incomplete, confused, or contradictory behavioral strategies
for using the caregiver as a source of comfort have attachments classified as disorganized.
They may display disordered sequences of behavior (e.g., approach for comfort followed
by avoidance of the caregiver), simultaneous contradictory behaviors (e.g., approach for
comfort with marked gaze aversion), or repetitive, stereotyped behaviors, freezing or
stilling in the presence of the caregiver, fear of the caregiver, and/or directing attach-
ment behaviors to a stranger in the presence of the caregiver (Main & Solomon, 1990).
In preschool children, behaviors may be similar to those evident in infants, or the child
may show solicitous or punitive efforts to control the behavior of the caregiver (Cassidy
et al., 1992).
Those infants who do not meet criteria for any other classifications are designated
cannot classify (Hesse, 2008). They may demonstrate avoidant behavior in one reunion and
resistant behavior in the other, but without disorganized behaviors as described above. This
designation also may be used to describe infants who are assessed in the Strange Situation
Procedure with caregivers to whom they have no attachments (see Zeanah, Smyke, Koga,
Carlson, & BEIP Core Group, 2005). Cannot classify is used to describe either very dis-
turbed or nonexistent attachment relationships; although, to date, this has not been well
studied as a category.
There are also some preschool children who display behaviors not seen in other
classifications, and they are classified insecure other. This classification includes chil-
dren who display a combination of avoidant and dependent behaviors in sequential
transitions or simultaneous display of both, children who display depressed or dissociative-
like disengagement, children who appear engaged but fearful of the caregiver (includes
compulsive-compliance with the caregiver’s instructions or demands), and affectively dys-
regulated behaviors that may involve silly, hyperactive, or other poorly organized behaviors
(Marvin & Brittner, 1995).
These classifications or patterns of attachment should not be confused with diagnoses
or psychopathology. Rather, they are risk and protective factors that predict subsequent
278 A. S. Breidenstine et al.

or concurrent psychopathology (DeKlyen & Greenberg, 2008). Secure attachment is a

protective factor and insecure attachment is a risk factor for psychopathology; although
these differences are most evident within the context of high-risk conditions. More
recently, even stronger links have been demonstrated between disorganized attachment
and psychopathology, particularly disturbances in interpersonal relatedness. Disorganized
attachment has been demonstrated to predict both externalizing and internalizing problems
concurrently and in later childhood and adolescence (Green & Goldwyn, 2002; Lyons-
Ruth & Jacobvitz, 2008; Zeanah, Keyes, & Settles, 2003).

Classifications of Attachment in Adults

Drawing on Bowlby’s (1969/1982) assertion that attachment is a lifespan construct, Main,
Kaplan, and Cassidy (1985) developed a method of assessing patterns of attachment in
adults: the Adult Attachment Interview (AAI). The AAI inquires about early relation-
ship experiences and the adult’s current perspective on early childhood relationships.
Classifications of attachment are assigned on the basis of qualitative differences in narra-
tive discourse and expressed attitudes about attachment. Theoretically, AAI classifications
are presumed to reflect differences in internal working models of attachment, that is, those
processes involved in attending to and perceiving social and emotional information and
regulating responses to that information. The qualitative narrative characteristics of inter-
view responses are believed to reflect important differences in the organization of the
individual’s internal experience, including defensive processes.
Adults who describe their own childhood attachment relationships in a clear and
straightforward manner, who convey that relationship experiences matter and have
effects, and who demonstrate emotionally well-integrated responses are deemed to have
autonomous classifications. Adults with this classification are expected to have children
who are securely attached to them because they have an attachment style that directly
conveys positive and negative affects, acknowledges needs directly and is emotionally well
regulated. According to a meta-analysis of 854 parent/infant dyads (van IJzendoorn, 1995),
the effect size for concordance between adult autonomous and infant secure attachments
was large (d = 1.00).
In contrast, adults who dismiss the importance of attachment relationship experiences
or who assert that they had no effect or do not matter are classified as dismissing in the
AAI (Hesse, 2008). Their style consistently minimizes any negative aspects of relationship
experiences, much as infants with avoidant attachments turn their attention away from
separation distress and their own need for comfort during the Strange Situation Procedure.
The meta-analytic effect size of dismissing attachments in adults and avoidant attachment
in infants was medium to large (d = 0.70; van IJzendoorn, 1995).
Adults who describe relationships incoherently, conveying intense involvement with
poor emotional regulation and difficulty maintaining focus on the topic have attach-
ments classified as preoccupied (Hesse, 2008). These interviews may display oscillations
between contradictory appraisals as well as current internal entanglements with par-
ent figures, often conveying a sense that the adult is angrily preoccupied or passively
overwhelmed. The effect size of preoccupied adult classifications and child resistant attach-
ment classifications was significant but small (d = 0.30) in the van IJzendoorn (1995)
meta-analysis.
Adults who have significant lapses in coherence and monitoring when describing
childhood experiences of loss or trauma, often in the form of confusion, disorientation,
or affectively unregulated fear or guilt, are classified as having unresolved attachments
 Attachment and Trauma 279

(Hesse, 2008). These interviews may have underlying features of autonomous, dismissing,
or preoccupied attachments, but the significant incoherence regarding loss or trauma leads
to the unresolved classification. In the van IJzendoorn (1995) meta-analysis, there was a
medium effect size (d = 0.65) of unresolved attachment in parents predicting disorganized
attachment in infants.
These AAI classifications, like infant SSP classifications, are believed to reflect dif-
ferences in how internal representations are organized, and they relate to caregiving
interactional behavior as well as infant and preschool attachment classifications (Hesse,
2008). Table 2 describes these associations as understood currently. As with attachment
classifications, AAI classifications are not designations of psychopathology but rather
represent risk and protective factors for psychopathology.

Trauma and Attachment

The reciprocal relationships between trauma and parent-child attachment relationships are
incompletely understood. Any attachment relationship will likely be affected by a child
and/or parent’s traumatic experience. For example, experiencing violence and trauma can

Table 2
Infant and adult attachment patterns, caregiving behaviors, and associated risks

Infant Adult Links to child

attachment attachment Associated adult psychopathology and
patterns patterns caregiving behavior social maladaptation
Secure Autonomous Sensitive/responsive Protective factor in
high-risk samples
Avoidant Dismissing Emotionally distant; Modest risk factor in
encouraging high-risk samples
independence and
discouraging neediness
Resistant/ Preoccupied Inconsistent Modest risk factor in
Dependent responsiveness high-risk samples
Disorganized Unresolved Frightening or frightened Risk factor for
behavior or disrupted externalizing disorders,
affective communication dissociative disorders,
(affective internalizing disorders,
communication errors, social incompetence
role confusion,
negative-intrusive
behavior, disorientation,
withdrawal)
Cannot Unknown Unknown but substantially Overlaps with emotionally
Classify increased in institutions withdrawn/inhibited
RAD
Insecure Other Unknown Unknown but substantially Risk factor for
increased in institutions internalizing and
externalizing disorders
280 A. S. Breidenstine et al.

stress and compromise a previously secure and organized attachment relationship or pre-
clude the development of a secure attachment relationship (Lieberman, 2004; Schechter &
Willheim, 2009). Lieberman (2004) has noted that young children’s ability to recover from
the damaging effect of traumatic events is deeply influenced by the quality of the child’s
attachments and by the parent’s ability to respond sensitively to the child’s traumatic
responses. Although a causal mechanism is not yet clear, it has also been observed that
following trauma, young children with more trauma-related symptoms have parents with
more trauma-related symptoms (Scheeringa & Zeanah, 2001).
As noted previously, disorganized attachment is the pattern that carries the greatest
risk for concurrent and future psychopathology. A disorganized attachment relationship
may leave a child more vulnerable to the effects of new traumatic experiences and may also
come about, in part, because of the influence of various past and current traumas on the
parent and child. There is very little longitudinal research specifically looking at whether
attachment styles affect later adjustment following traumatic experiences. A recent study
examined whether disorganized attachment relationships at 12 months of age predicted
level and type of posttraumatic stress disorder (PTSD) symptoms or other anxiety dis-
orders when children were 81/2 years old (MacDonald et al., 2008). In this low-income
sample, early disorganized attachment status was associated with a higher rate of PTSD
total symptoms, a higher rate of avoidance cluster PTSD symptoms, and a higher rate
of re-experiencing cluster PTSD symptoms at 81/2 but was not associated with symptoms
of other anxiety disorders. The results lent support to the hypothesis that early disorga-
nized attachment status may relate to a child’s greater difficulty coping with traumatic and
stressful experiences in later childhood.

Parental Characteristics, Trauma, and Attachment

There is now considerable evidence that various parental characteristics are associated with
disorganized attachment in both low- and middle-income families. There is evidence that
mothers with substance-use disorders, severe mood disorders, and borderline personality
disorders all have children at increased risk for disorganized attachment (see Lyons-Ruth &
Jacobvitz, 2008, for review). These distal risk factors for disorganized attachment often
co-occur with trauma, but the relationship between trauma and attachment frequently has
not been studied. Somewhat more proximal risks relevant to the question of trauma and
caregiving that have been studied include parental states of mind with respect to attachment
as well as parental interactional behaviors, as are outlined below.

Parental States of Mind and Infant Disorganized Attachment

Traumatic events experienced by a caregiver, even years before a child is born, may affect
the child/caregiver attachment relationship. Research findings regarding narratives on the
AAI indicate that parents who are classified as unresolved on the AAI have increased risk
for disorganized attachment relationships with their infants. This means that when parents’
childhood traumatic experiences (abuse, loss, etc.) are not successfully resolved, as evi-
denced by nonintegrated emotional reactions, disorientation, or dissociative-like responses,
they have children whose attachments to them are more likely to be disorganized. In the
van IJzendoorn (1995) meta-analysis, 53% of infants with disorganized attachment had
mothers whose attachment classifications were unresolved, and 53% of mothers who were
unresolved had infants whose attachments to them were disorganized.
 Attachment and Trauma 281

Other aspects of parental states of mind besides being unresolved with respect to loss
or trauma are also associated with disorganized attachment in infants. For example, Lyons-
Ruth, Yellin, Melnick, and Atwood (2005) coded hostile helpless states of mind based
on AAI narratives that combined positive identification and devaluing of the same per-
son, a clinical phenomenon known as splitting. This splitting defense is characteristic of
individuals diagnosed with borderline personality disorder, which is often associated with
childhood trauma, particularly sexual abuse (Widiger & Mullins-Sweatt, 2008). The hostile
subtype of this state of mind includes devaluing a caregiver as hostile or threatening while
also identifying positively with the individual without awareness of the discrepancy. In the
helpless subtype of this state of mind, the individual devalues but also positively identifies
with an abdicating (role-reversing) parental figure.

Parental Interactive Behaviors and Disorganized Attachments

It is clear that parental behaviors affect the quality of attachment relationships. Maltreated
infants, for example, had high rates of disorganized attachment in studies involving the
maltreating parent (Carlson, Cicchetti, Barnett, & Braunwald, 1989; Cicchetti, Rogosch, &
Toth, 2006). The original putative mechanism proposed to explain the association between
a caregiver’s unresolved trauma and infant disorganized attachment was offered by Main
and Hesse (1990). They argued that the parent who has not resolved a trauma demonstrates
lapses in monitoring of discourse, perhaps related to dissociative, quasi-dissociative, or
other defensive processes. For the traumatized parent, the infant serves as a traumatic
trigger, leading the parent to reenact frightening behavior that he or she had experi-
enced in other relationships toward the child (see also Schechter et al., 2005, 2008).
Because the parent’s behavior derives from experiences that could not be known by the
infant, it is experienced by the infant as inexplicable and unpredictable. Further, when
the infant’s attachment needs are activated, particularly when the parent is frightening,
the infant’s source of comfort is also simultaneously a source of fear (Main & Hesse,
1990). This circumstance leads to conflicted impulses within the infant about approach-
ing or withdrawing, which corresponds with the observed infant behaviors that define
disorganized attachment.
To explain the link between unresolved attachment in the AAI and infant disorganized
attachment, one study demonstrated that parental frightening/frightened/dissociative
behavior partially mediated the effect of unresolved adult attachment on infant disorga-
nized attachment (Madigan et al., 2006). In addition, Lyons-Ruth, Bronfman, and Parsons
(1999) expanded the focus from frightened/frightening/dissociative behavior to disrupted
affective communication between parents and infants. These patterns included negative
intrusive behavior, role confusion, affective communication errors (e.g., contradictory sig-
nals), and disorientation (Lyons-Ruth et al., 1999). Several studies have demonstrated an
association between disrupted affective communication and infant disorganized attachment
(see Lyons Ruth & Jacobvitz, 2008, for review).
The states of mind and interactive behaviors in parents that are associated with infant
disorganized attachment may plausibly be linked to parental experiences of trauma. These
data underscore the importance of traumatic experiences of parents on their young children.

Attachment Disorders
Although children are biologically predisposed to develop preferred attachment rela-
tionships with caregivers, there are times when developmentally expected attachment
282 A. S. Breidenstine et al.

relationships do not form. Next, we review current conceptualizations of attachment

disorders as recognized by existing diagnostic systems.

Reactive Attachment Disorder

It is clear that attachment relationships fail to develop in only the most maladaptive
and extreme caregiving environments (Zeanah & Smyke, 2009). Beginning in the 1940s,
children living in institutions were described as showing abnormal attachment behaviors or
even a lack of attachment behaviors (O’Connor & Zeanah, 2003; Zeanah & Smyke, 2009).
Tizard and Rees (1975) reported that a majority of children in United Kingdom residential
nurseries exhibited atypical attachment behaviors at the age of 4 years, including children
who were withdrawn and unresponsive, as well as children who were indiscriminately
social and attention seeking. Descriptions such as these created the foundation for current
conceptualizations of reactive attachment disorder (RAD).
The revised fourth edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV-TR; American Psychiatric Association, 2000) and the tenth revi-
sion of the International Statistical Classification of Diseases and Related Health
Problems (ICD-10; World Health Organization, 1992) provide similar criteria for the
diagnosis of RAD, with both describing an emotionally withdrawn/inhibited type and a
socially indiscriminate/disinhibited type. Both nosologies indicate that extremely adverse
caregiving experiences or pathogenic care is presumed to be an etiological factor. Children
with the emotionally withdrawn/inhibited type of RAD exhibit few or no attachment
behaviors even in situations that should elicit such behaviors. The disorder is character-
ized by the absence of organized attachment behaviors, low levels of social engagement
and reciprocity, difficulties with emotional regulation, little or no comfort seeking even
when distressed, and limited response to soothing by others (Zeanah & Smyke, 2009). The
indiscriminately social/disinhibited type of RAD is characterized by a failure to display
developmentally appropriate reticence with unfamiliar adults and a tendency to violate
social boundaries. Although stranger wariness typically emerges in the second half of the
first year of life, children with this type of RAD exhibit little to no wariness. This lack
of reticence can be seen in children’s willingness to approach and engage socially with
strange adults, their tendency to wander off and to fail to check back with caregivers when
in unfamiliar settings, and their willingness to go off with strangers.
There are few longitudinal studies of the signs and symptoms of RAD. Findings have
indicated that there is some stability of signs in the emotionally withdrawn type of RAD
during the first four to five years of life when caregiving environments remain the same.
However, when children are placed in more favorable caregiving environments, such as fos-
ter care or adoptive families, signs of the disorder lessen substantially (Smyke et al., 2010;
see Zeanah & Smyke, 2009). In contrast, signs of the indiscriminate type have been found
to persist despite placement in more positive and appropriate caregiving environments
(Chisholm, 1998; Rutter et al., 2007; Smyke et al., 2010). There has been limited research
on signs or symptoms of attachment disorders in middle childhood and adolescence
(Zeanah & Gleason, 2010). Tables 3 and 4 outline what we understand currently about the
signs of both types of RAD in different age groups. The emotionally withdrawn/inhibited
type of RAD has not been described in children older than 8 years, and it is not yet known
whether the symptoms seen in earlier years persist in the same form if caregiving environ-
ments do not improve or if caregiving environments only improve when children are older.
We know more about the persistence and evolution of indiscriminately social/disinhibited
signs across ages, as outlined in Table 4.
 Table 3
Reactive Attachment Disorder (emotionally withdrawn/inhibited) from infancy to adolescence

9–24 months 2–4.5 years 4.5–8 years 8–11 years 11–16 years
Emotionally 1. No preferred 1. No preferred 1. No preferred Not described Not described
Withdrawn/ attachment figure attachment figure attachment figure
Inhibited RAD 2. Fails to seek or 2. Fails to seek or 2. Fails to seek or
respond to comfort respond to comfort respond to comfort
when distressed when distressed when distressed
3. Reduced or absent 3. Reduced or absent 3. Reduced or absent

283
positive affect positive affect positive affect
4. Reduced social 4. Reduced social 4. Reduced social
responsiveness responsiveness responsiveness
5. Unprovoked and 5. Unprovoked and 5. Unprovoked and
poorly regulated poorly regulated poorly regulated
irritability, fear, or irritability, fear, or irritability, fear, or
sadness sadness sadness
6. Limited 6. Limited 6. Limited exploration
exploration exploration
 Table 4
Reactive Attachment Disorder (socially indiscriminate/disinhibited) from infancy to adolescence

9–24 months 2–4.5 years 4.5–8 years 8–11 years 11–16 years
Socially 1. Actively 1. Actively 1. Actively approaches and 1. Actively approaches and 1. No best friend
Indiscriminate/ approaches and approaches and interacts with strangers interacts with strangers
Disinhibited interacts with interacts with
RAD strangers without strangers
reticence
2. Fails to check 2. Fails to check 2. Fails to check back with 2. Fails to check back with 2. Superficial peer
back with back with adult in adult in unfamiliar adult in unfamiliar relationships in
caregiver in unfamiliar settings settings settings which mere
unfamiliar settings acquaintances are
described as close
friends

284
3. Willing to “go 3. Willing to “go 3. No hesitation in going 3. No hesitation in going 3. Possibly
off” with strangers off” with strangers off with strangers off with strangers indiscriminate
sexual relations
4. Clingy and 4. Approaches unfamiliar 4. Approaches unfamiliar
attention seeking adults in an aggressive adults in an aggressive
with everyone and intrusive way and intrusive way
5. Takes unusual 5. Takes unusual
(nonaggressive) liberties (nonaggressive) liberties
with unfamiliar adults, with unfamiliar adults,
such as getting too close such as getting too close
physically or asking physically or asking
overly personal overly personal
questions questions
 Attachment and Trauma 285

RAD is very rare, particularly in the absence of extreme rearing conditions. There
were no reported cases in a quasi-community sample of 2- to 5-year-old children recruited
from pediatric clinics in North Carolina (Egger et al., 2006). In one study, few cases were
identified in high-risk groups, such as impoverished or homeless young children (Boris
et al., 2004). Although signs of both types of RAD have been identified in maltreated chil-
dren in foster care (Oosterman & Schuengel, 2008; Zeanah et al., 2004), we have limited
data on actual prevalence rates at this time. Even among young children being raised in
institutions, only a minority meet categorical criteria for RAD (Gleason et al., 2011).
Current research and clinical findings support the conceptualization of the emotion-
ally withdrawn/inhibited type of RAD as analogous to the absence or near absence of
preferred attachments (Zeanah & Smyke, 2008). This type of RAD is related to the qual-
ity of the caregiving environment, and children diagnosed with this type tend to recover
with appropriate caregiving (Rutter, Kreppner, & Sonuga-Barke, 2009; Zeanah & Smyke,
2009). The indiscriminate type of RAD has been identified in children with and without
preferred attachment relationships, but the risk for more persistent indiscriminate behavior
appears to increase the longer a child is raised in an institutional setting (Rutter et al., 2007;
Zeanah & Smyke, 2009). Signs of the indiscriminate type tend to persist and are not related
to the quality of the current caregiving environment. Overall, evidence suggests that these
two types may not in fact reflect the same construct, and that the indiscriminate type of
RAD is something other than an attachment disorder (Zeanah & Gleason, 2010; Zeanah &
Smyke, 2009).
Trauma is implicit in the construct of pathogenic care, but since RAD may arise
primarily in response to social neglect (Zeanah & Smyke, 2009), it is unclear how to
disentangle the effects of the presence of traumatic experiences rather than the absence
of normative caregiving experiences in the etiology of these disorders. An important
question is whether trauma provides the correct model for the caregiving environment
of children with RAD. That is, they may be suffering from an absence of normative
caregiving behavior (neglect) rather than the presence of harmful behaviors. In cases in
which both abuse and neglect are evident, young children may exhibit PTSD and RAD
comorbidly (Hinshaw-Fusilier, Boris, & Zeanah, 1999). Much work on the delineation of
what comprises pathogenic care is needed.

Assessment of Reactive Attachment Disorder

Adequate assessment of RAD requires a multimethod evaluation approach. The American
Academy of Child and Adolescent Psychiatry released practice parameters for RAD in
2005. Their recommendations for assessment included the following: (a) observing the
child individually with each important caregiver and with an unfamiliar adult, (b) gathering
a complete history of early caregiving experiences from collateral sources, and (c) using
a relatively structured observational procedure to acquire analogous sets of observations
across different relationships. Boris and colleagues (2004) also recommended combining
a structured observational procedure with a structured interview to assess for symptoms
of RAD.
Although the assessment of RAD continues to be complicated by questions about
the diagnostic criteria (see Chaffin et al., 2006), it is clear that any diagnostic decisions
related to RAD need to be based on a thorough understanding of a child’s history of
caregiving experiences in conjunction with an understanding of their attachment behav-
iors in the context of current caregiving relationships. In practice, a thorough assessment
for attachment disorders should thus include a combination of clinical interview with the
286 A. S. Breidenstine et al.

child’s caregiver(s) and relational observation methods. Through interview, it is impor-

tant to obtain information about the child’s current and past attachment relationships,
caregiving history, specific attachment behaviors, and experiences/symptoms that would
suggest other or additional diagnostic concerns (for example, pervasive developmental
disorders). As noted by Zeanah and Smyke (2009), clinicians can use a comprehen-
sive structured psychiatric interview, such as the Preschool Age Psychiatric Assessment
(PAPA; Egger et al., 2006), or a semistructured interview specifically created to assess
for signs of RAD, such as the Disturbances of Attachment Interview (DAI; Smyke,
Dumitrescu, & Zeanah, 2002; Zeanah, Smyke, & Dumitrescu, 2002). The DAI contains
questions designed to evaluate the extent to which a child has a focused attachment, and
to determine whether there are symptoms of the emotionally withdrawn/inhibited or the
socially indiscriminate/disinhibited types of RAD.
The observational portion of assessment should provide opportunities to see the child’s
interaction with each caregiver and with unfamiliar adults. Particular attention is paid to
the presence or absence of expected attachment behaviors (e.g., seeking comfort when
distressed or stressed, inhibition of exploration in the absence of the caregiver), as well
as to the presence of characteristic symptoms (e.g., indiscriminate sociability). Although
attachment behaviors can be observed in a variety of contexts, use of a fairly structured
procedure allows the clinician to construct comparable observations of different caregiver-
child dyads and to easily create opportunities to observe the desired behaviors in a clinic
setting. One available structured dyadic procedure, known as the Clinical Observation of
Attachment, was designed as a clinic-based observational measure for use in the diagnostic
assessment of attachment disorders (see Boris et al., 2004, for details). This procedure,
designed to elicit attachment behaviors, involves a series of interactions with the caregiver
and a stranger as well as separation and reunion episodes. Other observational measures
of attachment relationships are available, such as the Crowell Problem-Solving Procedure
(see Miron, Lewis, & Zeanah, 2009).
The aforementioned assessment guidelines for RAD are used with children between
the ages of 9 months and 6 years of age; 9 months is the point at which infants are devel-
opmentally capable of having formed a focused attachment. Thus, diagnosis of RAD prior
to 9 months of age is not possible. Presumably, a similar multimethod diagnostic approach
is needed to assess for RAD in older children. However, assessment for RAD in older
age groups is complicated by the fact that there is still limited research on the signs and
symptoms of attachment disorders in older children. In addition, there is also no gold stan-
dard for assessing attachment security in older children, which complicates the process
of recognizing the presence or absence of expected attachment behaviors and cognitions
(Zeanah & Gleason, 2010).

Conclusions and Directions for Future Research

It is clear that adverse and pathogenic caregiving can lead to significantly disturbed
attachments in infants and young children. At the most extreme end of the caregiving
spectrum, as may be seen with severe maltreatment, severe neglect, or institutional
care, young children can exhibit very aberrant relational behaviors, such as emotionally
withdrawn/inhibited or socially indiscriminate/disinhibited behaviors. Another relational
effect of trauma includes increased risk for less adaptive attachment relationships. As we
have noted, research has begun to elucidate links between parents’ past experiences
of trauma, parental states of mind, interactive behaviors, and the parent-child attach-
ment relationship. If shaped by trauma, attachment relationships may lead to lasting
 Attachment and Trauma 287

effects on the child’s emotional regulation, interpersonal style, and experience of intimate
relationships.
There is much that we still do not know about the complex, reciprocal, direct, and
indirect relationships that exist between trauma and attachment. It is noteworthy that
our conceptualizations of the etiology of reactive attachment disorder and significantly
disturbed attachment patterns such as disorganized attachment presume that the infant
endures markedly atypical and severely distressing relational experiences. For an exceed-
ingly dependent infant or young child who is biologically and psychologically primed for
nurturing caregiving, severe neglect, abuse, or a lack of a reliable caregiver must indeed feel
threatening and may, in many cases, be experienced as traumatic. In our clinical work with
young children in foster care, we have seen children who have not been able to disclose or
truly begin healing from past trauma until they form a secure or at least organized attach-
ment relationship with a new caregiver. Although we certainly would not propose that this
is the only factor in recovery from traumatic experiences, many clinicians have observed
the importance of a consistent attachment relationship for children who are coping with
various forms of trauma.
Increasingly, the effects of adverse early experiences on subsequent development are
recognized as having potentially long-term effects on health and mental health. Specific
studies are needed now to delineate more precisely the mechanisms linking traumatic
experiences of caregivers and their effects on attachment relationships with their children.
For example, a study with a longitudinal design that assesses trauma in caregivers, adult
attachment, and infant attachment independently has not yet been conducted. A study with
this design might confirm whether the initial suppositions described herein are warranted.
Exploring mechanisms through which trauma and disturbed attachment exert their effects
necessarily invites studies of the effects of trauma on the developing brain. Interest in epi-
genetics is one example of recent attempts to understand how trauma and disturbances of
attachment lead to lasting maladaptation (McGowan et al., 2009).
A great deal also remains to be learned about how the quality of attachment pro-
tects or undermines a child’s experience of a potentially traumatic event, a child’s ability
to recover from trauma, and how trauma can affect those same attachment relationships.
Future research should explore the manner in which attachment relationships facili-
tate or complicate a child’s ability to identify, to integrate, and to manage intense and
distressing emotions and behavior arising from exposure to trauma, and how such expe-
riences are incorporated into beliefs and expectations about safety relative to the self and
the caregiving other. Having knowledge about the complex interplay of trauma, cogni-
tions, expectations, emotions, memories, and behaviors can assist clinicians in promoting
healthier functioning in adults and their young children.

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