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Elizabeth Carlson
University of Minnesota
Children raised in institutions are at dramatically increased risk for a variety of social and behavioral
problems, including disturbances of attachment (Zeanah, 2000). In fact, disturbances of attachment have
been central to the literature on the effects of institutionalization for more than 50 years. Descriptive
studies of institutionalized children by Spitz (1945),
Goldfarb (1945), Provence and Lipton (1962), and
Wolkind (1974) among others, documented the aberrant behaviors that later came to comprise the clinical
syndrome of Reactive Attachment Disorder (RAD).
Perhaps the most important early study in this
regard was Tizards study of young children placed
The Bucharest Early Intervention Project (BEIP) Core Group
consists of: Charles H. Zeanah, Anna T. Smyke, and Sebastian F.
Koga (Tulane University); Charles A. Nelson (University of Minnesota), Susan W. Parker (Randolph Macon College); Nathan A.
Fox (University of Maryland); Peter J. Marshall (Temple University); and Hermi R. Woodward (University of Pittsburgh/MacArthur Research Networks).
The BEIP was funded by the John D. and Catherine T. MacArthur Foundation Research Network on Early Experience and
Brain Development (Charles A. Nelson, Network Chair). The authors wish to acknowledge the many invaluable contributions of
their Romanian partner institutions, the SERA Romania Foundation, the Institute for Maternal and Child Health (IOMC), and the
Department for Social Welfare (DGAS), Sector 1, Bucharest. They
are also deeply grateful to their Romanian team whose hard work
and dedication have made this study possible. Thanks also to
Donald Guthrie of UCLA and Scott Keith of the University of New
Orleans for assistance with data analysis and to L. Alan Sroufe of
the University of Minnesota for assistance with data coding.
Correspondence concerning this article should be addressed to
Charles H. Zeanah, Department of Psychiatry, Tulane University
Health Sciences Center, Tidewater Building TB-52, 1440 Canal
Street, New Orleans, LA 70112. Electronic mail may be sent to
czeanah@tulane.edu.
in residential nurseries in London in the 1960s (Tizard & Hodges, 1978; Tizard & Rees, 1975). She
identified a group of 65 children placed in these
nurseries at birth or soon thereafter. Between the ages
of 2 and 4 years, 24 of the children were adopted, 15
of the children were returned to their birth families,
and another 26 remained institutionalized. When the
26 still institutionalized children were assessed at age
4 years, eight (30.8%) were emotionally withdrawn
and unresponsive, displaying unusual social
behaviors and no evidence of discriminated attachments. Another 10 (38.4%) children were indiscriminate, approaching and seeking attention from
relative strangers as readily as from familiar caregivers. The remaining eight (30.8%) children had
managed to develop a preferred attachment to a
caregiver at the nursery (Tizard & Rees, 1975). The
first two clusters of children comprised an important
basis for the criteria later used to define two clinical
types of RAD, the emotionally withdrawn/inhibited
type and the indiscriminately social/disinhibited
type, which are described in both the Diagnostic and
Statistical Manual of Mental Disorders (4th ed., text rev.
[DSM IV TR]; American Psychiatric Association,
2000) and The ICD-10 classification of mental and behavioral disorders: Clinical descriptions and diagnostic
guidelines (World Health Organization, 1992).
This clinical approach to disturbed attachment in
children raised in institutions has continued in contemporary studies. Smyke, Dumitrescu, and Zeanah
(2002), for example, studied signs of RAD in young
children raised in a single, large institution in
r 2005 by the Society for Research in Child Development, Inc.
All rights reserved. 0009-3920/2005/7605-0006
1016
1017
Method
Participants
Two groups of children participated in this study.
Each was drawn from children participating in the
BEIP (Zeanah et al., 2003), an investigation of foster
1018
Table 1
Demographics of Study Sample
Child
characteristics
Age in months
(SD)
Ethnicity
Romanian
Rroma (Gypsy)
Unknown/Other
Gender
Female
Male
Never
Institution Institutionalized
Group
Group
(n 5 95)
(n 5 50)
Significance
ns
23.85 (4.85)
22.25 (5.01)
53.5%
32.3%
14.1%
90.0%
6.0%
4.0%
w2(3) 5 24.56
po.001, w 5.41
47.5%
52.5%
50.0%
50.0%
ns
Solomon, 1990). Interrater reliability for classifications was adequate (k 5 .78). Differences were resolved by conferencing.
A 5-point rating scale (see Appendix A) was developed in order to document the range of child
behavior exhibited in the assessment that did not
fit the traditional classification scheme, but appeared
to reflect the degree of, or stages in, attachment
formation (Ainsworth, 1967) (see Appendix A).
Ratings of 5 indicated attachment behavioral
organization consistent with traditional A, B, C, and
D classifications. Ratings of 4 indicated evidence
of attachment behavioral organization and the presence of extreme or pervasive behavioral anomalies
(beyond the scope of traditional disorganization
coding). Ratings of 3, 2, and 1 were assigned
for behavioral displays ranging from fragmented
or incomplete sequences of attachment behavior
differentially directed toward the caregiver, to isolated attachment signals and responses, to no evidence of attachment behavior. Because the
attachment formation rating was developed for
use with the current sample, external measures
of validity were not available. Intraclass correlation coefficient for interrater reliability was .96
(n 5 45).
In summary, all participants were assigned traditional attachment classifications and attachment
formation ratings. Categorical attachment distinctions (ABCD), however, were meaningful (interpretable in relation to attachment literature) only
within subsamples of children receiving ratings of
4 or 5. Categorical distinctions associated with
lower ratings represented forced classifications
assigned to minimal displays of behavior.
Attachment disorder. The Disturbances of Attachment Interview (Smyke & Zeanah, 1999), a semistructured interview, was used to assess signs of
clinical disturbances of attachment. The interview
has been shown to distinguish between institutionalized and never institutionalized children in
Romania (Smyke et al., 2002; Zeanah, Smyke, &
Dumitrescu, 2002) and to identify signs of RAD reliably in young, maltreated children (Zeanah et al.,
2004). In previous research (Smyke et al., 2002; Zeanah et al., 2002), it has been shown to converge with
similar measures used in other studies of signs of
RAD (Chisholm, 1998; OConnor & Rutter, 2000), and
it diverged from measures of aggression, stereotypies, and language development. It includes 12
items, each of which is explored through a series of
probes. Trained interviewers probed sufficiently to
be able to rate each item as 0 5 none or never,
1 5 somewhat or sometimes, and 2 5 considerable or frequently. Each interview was coded
by two native Romanian coders, and discrepancies
were resolved by conferencing, leading to a consensus code for each item.
The first five items of the interview assess signs of
emotionally withdrawn/inhibited RAD, with scores
ranging from 0 to 10. The next three items assess
signs of indiscriminately social/disinhibited RAD,
with scores ranging from 0 to 6. There are four additional items, assessing self-endangering behavior,
clinging/inhibited behavior, vigilant/hypercompliant behavior, and role-reversed behavior, that were
not included in this study.
Caregiving environment. The Observational Record
of the Caregiving Environment (ORCE; NICHD
Child Care Research Network, 1996, 1997, 2003) was
adapted and used to assess a specific childs caregiving environment in either the institution or the
home setting.
We adapted the ORCE for our purposes in two key
ways. First, we videotaped subjects in their environment, rather than using the live coding approach used in the NICHD study. Thus, a research
assistant went to the institution or home in which the
child resided and videotaped the target child with
his or her favorite caregiver for 112 hr. In contrast to
the original ORCE procedure, which consisted of live
coding in situ, we felt that having coders blind to the
hypotheses of the study able to code a given episode
was an advantage. Secondly, we added qualitative
items that we thought would be important in helping
us to understand the childs experience in this
particularly at-risk caregiving environment, such as
marked dysregulation, stereotypical behavior, and
communicative gesture.
1019
Training for coding of the Adapted ORCE consisted first of a period of several months during
which a thorough orientation to all items in the
manual was conducted. In all, on the behavior scales,
there were 55 items that assessed caregiver behavior
(e.g., positive physical contact, asks questions of
child) as well as child behavior (e.g., activity with
objects, unoccupied/watching).
First, coders watched the tape for 10 min and then
began to code items at the first even time (e.g.,
12 : 20 : 00) that occurred after the initial observation.
This rule was established to ensure that double
coding would be feasible. Coders then watched for
a 30 s observation period and proceeded to mark
behavioral items as present or not present during
the subsequent 30 s coding period. The observation/
coding cycle was conducted for 10 min, followed
by a 2 min observation/no coding episode, and
then followed by two more observation/coding cycles, separated by another 2 min observation/no
coding episode. At the end of these observation/
coding cycles, another 10 min observation period
took place.
Qualitative items were then rated on a scale
ranging from 1 (not at all characteristic) to 4 (highly
characteristic). Examples of qualitative items included
caregiver detachment and sensitivity to child distress. Caregiver detachment was characterized by
lack of emotional involvement and failure to respond
contingently to the childs cues. Among other behaviors, coders looked for caregivers who did not
make eye contact with the child and caregivers who
provided instrumental care to the child in a mechanical way without talking or interacting with the
child. Sensitivity to child distress was assessed by
noting how long it took caregivers to respond when
children exhibited distress, noting the number of
times during which distress elicited a response, and
finally, whether the caregiver used appropriate means
to soothe the child.
After orientation and coding of practice tapes,
coders completed 10 reliability tapes, which consisted of observations of children and caregivers
from the New Orleans community and observations
collected in institutional settings during the pilot/
feasibility phase of the BEIP. Having established
reliability, coders discussed differences in particular
ratings. For the current sample, 40% of tapes
were randomly selected for double coding to
ensure the ongoing fidelity of the process (reliability 5 95%).
Cognitive abilities. The Bayley Scales of Infant Development II (BSID-II; Bayley, 1993), a well-known
measure of cognitive development, were used to assess
1020
Percent of Children
90%
1021
Table 2
Distribution of Strange Situation Procedure Classifications
80%
Institution
70%
Community
60%
Strange Situation
Procedure
Classification
Secure
Avoidant
Resistant
Disorganized
Unclassifiable
50%
40%
30%
Institution
Group (%)
(n 5 95)
18.9
3.2
0.0
65.3
12.6
Never Institutionalized
Group (%)
(n 5 50)
(18)
(3)
(0)
(62)
(12)
74.0
4.0
0.0
22.0
0.0
(37)
(2)
(0)
(11)
(0)
20%
10%
0%
0
1-2
3+
RAD Emotionally Withdrawn / Inhibited Score
Figure 1. Distribution of scores on the Reactive Attachment Disorder (RAD) emotionally withdrawn/inhibited scale (possible
range: 0 10).
60%
50%
40%
30%
20%
10%
0%
0
1-2
3+
RAD Indiscriminately Social/ Disinhibited Score
Figure 2. Distribution of scores on the Reactive Attachment Disorder (RAD) indiscriminately social/disinhibited scale (possible
range: 0 6).
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Table 3
Distribution of Continuous Ratings of Attachment
Attachment rating
Never Institutionalized
Group (%)
Institution
group (%)
0
0
9.5
25.3
0
0
100
30.5
31.6
3.2
1 5 No attachment behavior
2 5 Some differentiation
3 5 Preference but passive expression
4 5 Attachment with anomalies
5 5 Clear ABCD attachment patterns
Strange Situation
Procedure Classifications
Institution Group
Unclassifiable: 9
Secure: 7 Avoidant: 3
Disorganized: 11 Unclassifiable: 3
Secure: 7 Disorganized: 22
Secure: 3 Disorganized: 27
Secure: 1 Disorganized: 2
Table 4
Regression on Strange Situation Procedure Attachment Continuous Ratings in Institutionalized Children
Cognitive development
Competence score
Quantitative aspects of caregiver child interaction
Quality of caregiving
Constant
Model R2
po.01.
SEB
.26
.25
.10
.34
.01
.01
.09
.12
.37
.01
.01
.06
.05
.77
.17
b
.13
.10
.20
.39
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Table 5
Logistic Regression on Organized vs. Not Organized Attachment in Institutionalized Children
Attachment rating
Cognitive development
Competence score
Quantitative aspects of caregiver child interaction
Quality of caregiving
Constant
Model w2 (df)
OR
95% CI
p value
0.379
1.041
0.961
0.861
1.292
0.076
74.608 (5)
0.183 0.786
0.979 1.106
0.911 1.014
0.627 1.182
1.004 1.663
.009
.204
.145
.353
.047
.248
Note. Nagelkerke Pseudo R2 5 .213; OR, odds ratio; CI, confidence interval.
po.05; po.01; po.001.
Discussion
This is the largest and most comprehensive study of
attachment conducted to date in institutionalized
children, and it replicated and extended findings of
previous studies in a number of ways. As predicted
by attachment theory, serious disturbances of
attachment are the rule rather than the exception
in children raised in the relatively socially deprived
context of contemporary institutions for young children in Romania. We studied disturbances of
attachment using three different approaches, and in
each case, differences between children raised
in institutions and children raised in families were
substantial.
From the clinical perspective of RAD, institutionalized children clearly demonstrated more signs
of both emotionally withdrawn/inhibited RAD and
indiscriminately social/disinhibited RAD than never
institutionalized children from the community. This
replicates the findings of Smyke et al. (2002) but with
a larger and more representative sample of children,
who were drawn, in fact, from all of the institutions
for young children in Bucharest. Interestingly, within
the ages studied, 11 31 months of age, there was no
relationship between length of institutionalization
and signs of RAD emotionally withdrawn/inhibited
and RAD indiscriminately social/disinhibited. Findings relating length of institutionalization to signs
of RAD have come from adoption studies (e.g.,
OConnor & Rutter, 2000), that is, studies in which
a presumed dramatic improvement in the environment has occurred. In this sample, the lack of relationship likely results from the fact that the children
are still in the adverse caregiving environment.
Findings about signs of RAD in this sample were
amplified by assessments of attachment from the
developmental perspective using the Strange Situation Procedure. Assessed with their favorite care-
Table 6
Logistic Regression on Organized vs. Not Organized Attachment in Institutionalized Children (includes Unclassified)
Attachment rating
Cognitive development
Competence score
Quantitative aspects of caregiver child interaction
Quality of caregiving
Constant
Model w2 (df)
OR
95% CI
p value
0.69
1.024
0.98
0.86
1.295
0.013
79.68 (5)
0.39 1.22
0.97 1.08
0.93 1.03
0.63 1.19
1.02 1.65
.199
.405
.453
.366
.036
.035
Note. Nagelkerke Pseudo R2 5 .12; OR, odds ratio; CI, confidence interval.
po.05; po0.001.
1024
behavior. A study of young, maltreated and homeless children in the US also failed to demonstrate a
clear association between RAD and Strange Situation
Procedure classifications (Boris et al., 2004). Differences between these findings and those of OConnor
and colleagues may be because of the different ages
of the children, the fact that Strange Situation Procedures in the OConnor sample were conducted in
the home rather than in the lab, problems with the
interview itself, or differences in children living in
institutions rather than with families.
Another important contribution of this study was
the demonstration that the quality of the caregiving
that the child received in the institutional setting was
significantly related both to the continuous rating of
attachment and to the childs organization of attachment. Impressively, these results held even when
other variables, such as cognitive level, perceived
competence, and quantitative interaction ratings,
were controlled for. In contrast, there was no relationship between caregiving quality and attachment
in the community setting. Previous studies suggest a
consistent if modest effect of sensitive caregiving and
secure attachment (DeWolff & van IJzendoorn, 1997;
NICHD Early Child Care Research Network, 1997).
The difference between institutionalized and community children observed here suggest that individual differences in caregiving may matter more in
an environment of severe deprivation. Variability in
caregiving quality within the community sample
may have been too limited to capture differences that
related to attachment (particularly given that the
sample is so skewed toward secure).
This study does have some limitations that are
important to acknowledge. First, Romanian institutions, which are characterized for the most part with
particularly poor caregiver to child ratios, may not
be representative of some institutions in other
countries. Both in Greece (Vorria et al., 2003) and
in older studies from the UK (Tizard & Hodges,
1978; Tizard & Rees, 1975), DQs in institutionalized
children were within the normal range, whereas in
this sample the average Bayley MDI score was
65 (see Zeanah, Smyke, & Koga, 2003). Nevertheless,
the fact that the distributions of Strange Situation
Procedure classifications in this sample were
almost identical to those of Vorria et al. (2003) despite
the large differences in cognitive performance
suggests that attachment in toddlers is particularly
vulnerable to disturbance in residential group care
settings.
Second, these data are cross sectional, and a
number of important questions await longitudinal
follow-up. For example, the direction of effects of
1025
1026
Taken together with previous research on attachment and institutionalization, it is clear that attachment is a severely compromised developmental
domain in young, institutionalized children. The
importance of quality caregiving for young children
in extreme conditions of social deprivation is clear. In
the stark environments of institutions, a positive relationship with a caregiver is possible, although
unlikely. Caregivers sensitive responsiveness to
childrens distress and active engagement with the
children enhances the probability of formation of a
more developed and more organized attachment.
Essential questions about the potential for recovery of attachment, how timing of intervention relates
to recovery, and which factors enhance or impede
recovery, remain to be addressed in future research.
Having a sample of children whose attachment behaviors in the institution were systematically and
thoroughly characterized, means that follow-up of
these children over time may provide a unique opportunity to address these questions in a way that
has not been possible previously in studies of children adopted out of institutions.
References
Ainsworth, M. D. S. (1967). Infancy in Uganda: Infant care
and the growth of love. Baltimore, MD: Johns Hopkins
University Press.
Ainsworth, M. D. S. (1990). Some considerations regarding
theory and assessment relevant to attachments beyond
infancy. In M. T. Greenberg, D. Cicchetti & E. M. Cummings (Eds.), Attachment in the preschool years: Theory,
research and intervention (pp. 463 488). Chicago: University of Chicago Press.
Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S.
(1978). Patterns of attachment. Hillsdale, NJ: Erlbaum.
American Psychiatric Association. (2000). Diagnostic and
Statistical Manual of Mental Disorders, 4th editionFText
revision (DSM-IV-TR). Washington, DC: American Psychiatric Association.
Bayley, N. (1993). Bayley Scales of Infant Development (2nd
ed.). New York: Psychological Corporation.
Boris, N. W., Hinshaw-Fuselier, S. S., Smyke, A. T.,
Scheeringa, M., Heller, S. S., & Zeanah, C. H. (2004).
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Carlson, V., Cicchetti, D., Barnett, D., & Braunwald, K.
(1989). Disorganized/disoriented attachment relationships in maltreated infants. Developmental Psychology, 25,
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Appendix
Attachment Formation Rating (Carlson, 2002)
5FChild exhibits behavior consistent with one of four
traditional attachment classification patterns (secure, anxious avoidant, anxious resistant, disorganized/disoriented) (Ainsworth et al., 1978; Main & Solomon, 1990). The
child demonstrates a clearly recognizable pattern of attachment and exploratory behavior in relation to the
caregiver.
4FA traditional attachment pattern is discernible, but
attachment behaviors are associated with unusual behavioral anomalies. Attachment exploratory behavioral
patterns are evident (e.g., child searched or showed caregiver-related distress on separation and initiated a response to the caregiver on reunion). Anomalous behaviors
(distinct from those characteristic of disorganization) are
pronounced, including vigorous or prolonged rocking
when distressed, and extreme arousal/excitability in relation to the caregiver.
3FChild demonstrates a clear preference for the familiar caregiver over the stranger, but expresses this
preference passively. The child may exhibit some caregiver-related distress (e.g., crying, rocking) during separation,
and rarely, some search behavior. Caregiver child interaction is still largely orchestrated by the caregiver; the
1028
child may respond to caregiver initiatives with weak initiatives and/or limited change in affect.
2FChild demonstrates a discernible discrimination of
familiar and unfamiliar adults, with a slight preference
for the familiar caregiver. The child exhibits little change
in behavior or affect in relation to caregiver presence
or initiative. Activity is largely orchestrated by the
caregiver.