reactive attachment disorder: implications for school readiness and school functioning

REACTIVE ATTACHMENT DISORDER: IMPLICATIONS FOR SCHOOLREADINESS AND SCHOOL FUNCTIONING

ERIC SCHWARTZ

Sarah A. Reed Children’s Center

ANDREW S. DAVIS

Ball State University

School readiness and functioning in children diagnosed with Reactive Attachment Disorder (RAD)are important issues due to the dramatic impact RAD has on multiple areas of development. Thenegative impact of impaired or disrupted early relationships, characterized by extreme neglect,abuse, parental mental illness, domestic violence, and repeated changes in caregivers is exam-ined. A key component of social and emotional development is self-regulation, which is a criticalvariable in school readiness and is often impaired in children with RAD. Highlighted topicsinclude the academic and school areas which may exacerbate attachment disturbances as well asways in which teachers and other school professionals can encourage the development of moreproductive relationships. Interventions are provided which lead to greater success in school forthese children. © 2006 Wiley Periodicals, Inc.

Case Example1

Nancy is a 6-year-old girl entering the first grade in a new school. This is Nancy’s fourth newschool since age 5. Nancy has been in five foster homes since being removed from her biologicalmother’s care at approximately 2 years of age. Prior to being removed from her mother’s care bythe Department of Social Services, Nancy was exposed to sexual activity between her mother andothers, was emotionally and physically abused, and was profoundly neglected. As an infant, Nancywas often left in her crib screaming, unfed, dirty, and unattended. Nancy was found in a closet,eating garbage, covered in urine and feces. Nancy’s mother’s parental rights were terminatedwhen Nancy was 4. She has been removed from previous foster homes due to uncontrollable ragesand destructive behavior. Nancy becomes angry quickly and strikes without warning. She respondsto nurturance with contempt and fear, and tries to control everything in her environment. Shereportedly does not feel badly about her actions. Her foster parents report Nancy can be charmingand sweet, depending upon the situation, yet her behavior and emotions can change instanta-neously. Her fourth foster mother described Nancy as follows:

You can’t really know Nancy . . . . She is . . . so superficial; at times she is wary around strangers, yet atother times she will simply go up to someone she doesn’t know and hug them. She is very careful toobserve her surroundings and seems to take notice of small details. Sometimes after I have been awayfrom her for a few hours . . . she sees me and has no reaction. She doesn’t seem to look at adults aspeople who can help her.

Nancy has been in her fifth foster home for about 2 months and is having a very hard timeadjusting to this placement. She has hurt the other foster children in the home. Nancy’s first day atschool did not go well. She refused to share and bullied several children into giving up playactivities. She hit her teacher once when the teacher tried to set limits. When her teacher attemptedto console Nancy after she started crying, Nancy shuddered and recoiled back from the touch. Sheended up in a fetal position in the corner of the classroom, quietly crying to herself. Nancy has

Correspondence to: Eric Schwartz, Clinical Director, Sarah A. Reed Children’s Center, 2445 West 34th Street, Erie,PA 16506. E-mail: [email protected]

1Details have been taken from real cases. Aspects of this case are composite details from multiple cases. All identi-fying information has been altered to protect the confidentiality of the clients.

Psychology in the Schools, Vol. 43(4), 2006 © 2006 Wiley Periodicals, Inc.Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pits.20161

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been in psychotherapy for over 1 year, and the psychologist diagnosed Nancy with ReactiveAttachment Disorder (RAD). Nancy also sees a psychiatrist and currently takes Seroquel andAdderall.

RAD: Current Knowledge

Children with early relational trauma and disruptions in the primary infant–parent relation-ship, resulting from grossly pathological care and maltreatment, may be diagnosed with attach-ment disorders and, in some cases, RAD; however, RAD, as a psychiatric diagnosis, extends wellbeyond the narrow scope of the infant–parent relationship and reflects broad social abnormalitiesacross multiple contexts (Richters & Volkmar, 1994). In the Diagnostic and Statistical Manual ofMental Disorders, fourth edition, text revision (DSM IV-TR; American Psychiatric Association,2000), the predominant feature of the disorder is the presence of “markedly disturbed and devel-opmentally inappropriate social relatedness in most contexts beginning before age 5 years and isassociated with grossly pathogenic care” (p. 127). Grossly pathogenic care is characterized by (a)a persistent disregard for the child’s emotional needs for comfort, stimulation, and affection; (b)persistent disregard for the child’s physical needs; and (c) repeated changes of primary caregivers(American Psychiatric Association, 2000).

RAD is divided into two subtypes: the Inhibited subtype and the Disinhibited subtype. TheInhibited subtype refers to children who persistently and pervasively fail to initiate and to respondto social interactions in a developmentally acceptable way. The Disinhibited subtype describeschildren who are indiscriminately sociable or demonstrate lack of selectivity in their attachments.In differentiating RAD from other developmental disorders, the DSM IV-TR emphasizes that thediagnosis is predicated upon an etiology of documented grossly pathogenic care, and may includethe experience of frequent and repeated changes in caregivers. For RAD to develop, grosslypathogenic care also must include limited opportunities to develop selective attachments. Exam-ples include children brought up in institutions with multiple caregivers or children who have ahistory of being reared in atypical environments characterized by extreme neglect and abuse.Children raised in these types of environments have been shown to manifest abnormal socialbehaviors such as lack of responsiveness, excessive inhibition, hypervigilance, indiscriminatesociability, or pervasively disorganized attachment behaviors (O’Connor & Rutter, 2000). Thesesymptoms suggest a growing link between children with major attachment disruptions and thepresence of a disorganized attachment status. Children classified with a disorganized attachmentor diagnosed with RAD are seen as controlling and punishing, and engage in role-reversal behav-ioral patterns when reunited with the parent (Hughes, 1997; Main & Cassidy, 1988; Solomon &George, 1996). Research also has shown that the disorganized attachment pattern is linked toaggressive externalizing behavior (Lyons-Ruth, Repacholi, McLeod, & Silva, 1991; Shaw, Owens,Vondra, & Keenan, 1996). Hanson and Spratt (2000) suggested that “the purpose of the RADdiagnosis is to provide a clinical description that includes the problems in the child’s ability torelate to people and the context in which this behavior develops” (p. 138).

The diagnosis of RAD is directly tied to and strongly influenced by the presence of maltreat-ment and neglect, with both subtypes found in maltreated children (Zeanah, 1996; Zeanah &Emde, 1994). Research has clearly demonstrated that the presence of maltreatment establishes adevelopmental trajectory linking abuse and neglect with the disruption and potential failure tosuccessfully resolve developmental issues such as attachment and to manage important develop-mental transitions (e.g., Cicchetti, 2004). Cicchetti and Toth (1995) found that maltreated childrenhave a greater likelihood of negative developmental outcomes and psychopathology. Furthermore,Cicchetti (2004) stated that “child maltreatment exemplifies a pathogenic relational environmentthat poses substantial risk for maladaptive functioning across diverse domains of biological and

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psychological development” (p. 734). When compared to groups of nonmaltreated children fromcomparable socioeconomic backgrounds, children who have experienced maltreatment mani-fested significantly greater maladaptive functioning across developmental domains (Cicchetti &Toth, 1995). This finding suggests that the presence of child maltreatment impacts children overand above the effects of poverty (Cicchetti & Lynch, 1995; Cicchetti & Toth, 1995). Of the manycited examples of maladaptive functioning displayed by maltreated children, the most salientinclude physiological and affect dysregulation, the development of insecure attachment relation-ships with a primary caregiver, poor peer relationships, and unsuccessful adaptation to the schoolenvironment (Cicchetti, 1989; Cicchetti & Lynch, 1995; Shonk & Cicchetti, 2001; Trickett &McBride-Chang, 1995).

The development of insecure attachment relationships and dysregulated emotional states inmaltreated children highlights the importance of attachment as a theoretical connection betweenabuse and neglect and RAD. Attachment theory provides a useful lens through which to view thedevelopment of early relationships and the potential trajectory for later interpersonal functioning.Bowlby (1982) defined attachment from a bioevolutionary perspective, concluding that attach-ment is a fundamental human need based in biology and intimately related to the survival of thespecies. More specifically, attachment is the organization of a set of specific behaviors designed toachieve four primary goals: proximity, security, safety, and regulation of a child’s affective states(Bowlby, 1982; Schore, 2001). Recently, Schore (2001) reiterated Bowlby’s hypothesis, notingthat an infant’s adaptive and coping capacities play a prominent and central role in their mentalhealth and that these domains of functioning cannot be separated or understood apart from thechild’s attachment and relationship with his or her caregiver.

In the development of a secure attachment, the infant is able to draw upon the mother forresponsive, nurturing, and reliable care for regulating distress (Stern, 1985). Schore (2001), in anattempt to link emotion regulation and attachment, reframed basic attachment theory as a regula-tory theory. He posited that the caregiver’s secure attuned interactions with the infant continuouslyhelp regulate the infant’s shifting levels of arousal and emotional states, enabling the infant tobegin to form coherent responses to cope with levels of arousal in response to stress. Sroufe (1996)also linked emotion and regulation to define attachment. He described attachment as a primarilydyadic emotion-regulation system of interactions between infant and parent that foster emotionalregulation and create transactional patterns, which lead to a secure attachment. Essentially, thepresence of a responsive, nurturing caregiver helps regulate the infant’s arousal state and emo-tions, resulting in the infant’s expanding and growing capacity to learn the skills necessary forself-regulation, ability to cope with stress, and the development of a secure attachment. In thecontext of a secure attachment, children are thus likely to be better equipped to regulate their ownaffect. In turn, children who can better regulate their emotions and behavior are more likely to beready to enter school and function effectively once in school. On the other hand, children withearly relational trauma, histories of maltreatment, and disruptions in their earliest relationshipshave been shown to be at significant risk for both internalizing and externalizing behavior prob-lems (Kennedy & Kennedy, 2004). Van der Kolk and Fisler (1994) highlighted the fact that losingthe ability to effectively regulate and modulate the intensity of feelings and impulses is one of themost serious and problematic consequences of early relational trauma (p. 145).

Similar to the behaviors associated with maltreatment, the descriptive symptomatology ofRAD suggests maladaptive patterns of interpersonal functioning and emotional regulation thathave far-reaching consequences for children (American Psychiatric Association, 2000). For exam-ple, it has been found that children with RAD demonstrate maladaptive attachment behaviorsspecifically with regard to how they cope with exploration, fear, and wariness (O’Connor, Bren-denkamp, & Rutter, 1999). Aber, Allen, Carlson, and Cicchetti (1989) found that children who are

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maltreated exhibit poor self-esteem and self-regulation, poor peer relations, and developmentaland cognitive delays. They concluded that the predominant issue for these maltreated children wasa concern for security and reflected an expectation of adults as unresponsive, unavailable, andrejecting (Aber et al., 1989). Children diagnosed with RAD have similar difficulties self-regulating and modulating their emotions and behaviors (Kay-Hall & Geher, 2003). In anotherstudy, O’Connor and Rutter (2000) compared a group of orphans who had experienced severedeprivation with a group who received adequate institutional care. The authors discovered attach-ment disorders occurred regardless of the level of deprivation, but the likelihood of disorders ofattachment occurred more frequently with the duration of early deprivation. Ritchie (1996) foundthat children placed in foster care, or those with multiple caregivers, presented with serious inter-personal deficits leading to more severe problems relating to others including teachers and peers ina therapeutic preschool setting. Children with attachment disorders such as RAD struggle to formtypical, reciprocal relationships with others (Reber, 1996). According to a number of researchers,children with RAD display a wide variety of maladaptive behaviors including property destruc-tion, aggression, hoarding food, stealing, lying, bullying, and cruelty to animals and people (Parker& Forrest, 1993; Reber, 1996). Additionally, children diagnosed with RAD may seek out strangersat inappropriate times, and experience difficulties both giving and receiving affection (Reber,1996). Kirschner (1992) found these children tend to seek out other children with similar emo-tional and behavioral disturbances. Other behaviors reportedly seen in children diagnosed withRAD include poor impulse control, poor self-regulation, hyperactivity, low frustration tolerance,and seeking out and associating with other children with behavioral problems and superficiality(Kirschner, 1992; Reber, 1996). Kay-Hall and Geher (2003) found that children diagnosed withRAD evidenced significantly more violent behaviors, were less empathic, and had more person-ality difficulties than did children who were not diagnosed with RAD. The problems typically seenin children with RAD are typically intense and pervasive; children with problems related to attach-ment struggle to find joy, mutuality, and reciprocity in their interactions with others (Hughes,1997). These children have not experienced the necessary sense of reciprocity and security of aresponsive, attuned parent. They have grown up in a world that is often chaotic, neglectful, andfrightening. These experiences are reflected in their inability to regulate and modulate their emo-tions and behaviors, often appearing out of control.

Reactive Attachment Disorder: Implications for SchoolReadiness and Functioning

When children have experienced major disruptions in attachment caused by profound neglect,abuse, or repeated changes in caregivers, they are likely to experience significant emotional andbehavioral problems in a variety of contexts, including school. Given that the teacher–studentrelationship is an important variable in student achievement, the impact of these early disruptionscannot be underestimated. Children will enter relationships with others based on these early expe-riences, and if these attachment relationships have been characterized by abuse and neglect, thesefuture relationships will often reflect the problematic nature of their early attachments (Pianta &Steinberg, 1992). Kennedy and Kennedy (2004) suggested that the teacher–student relationship,and by extension other relationships both in school (e.g., peers, school psychologists, counselors)and outside school (e.g., peers, neighbors), are inextricably tied to a child’s internal workingmodel of the parent–child relationship.

Let us return to Nancy. It would be hard to imagine, given her history, that Nancy is ready toenter school. Nancy history of maltreatment, her movement from foster home to foster home, herexperience with separation and loss, and her inability to regulate her emotions and behaviors placeher at great risk for experiencing a wide range of behavioral and emotional problems as she enters



school. For Nancy, as with many children, the first day of school is one of life’s major transitions.It is ordinarily filled with the hopes, dreams, fears, anxieties, and expectations of children, parents,teachers, and other school personnel. It is a time when a child’s capacity to engage the wider worldis tested for the very first time. This process of adjustment and accommodation to their expandinghorizons hinges upon a child’s capacity to effectively regulate their emotions and behaviors asthey begin to establish complex interpersonal relationships.

The ability to regulate emotions and behaviors in the context of developing relationships is animportant prerequisite skill required for school readiness and academic success (Webster-Stratton& Reid, 2004). Raver and Zigler (1997) indicated that the emotional, social, and behavioral adjust-ment to school is just as important as cognitive and academic preparation. Children who cannotpay attention, follow teacher directions, get along with others, or control negative emotions dorelatively poorly in school (Ladd, Kochenderfer, & Coleman, 1997). Shores and Wehby (1999)found that children with these characteristics tend to be more highly rejected by peers and receiveless positive feedback from teachers. Lewit and Baker (1995) found that teachers tended to ratesocial-emotional characteristics as more important while parents tended to focus on pre-academicskills (e.g., pencil grip) as critical for school readiness. The National Center for Early Development’ssurvey of a sample of teachers found that 46% of teachers believed that over half the children intheir class lacked the kinds of abilities and experiences that would enable them to function pro-ductively in kindergarten (as cited in Rimm-Kaufman, Pianta, & Cox, 2000).

Clearly, school readiness is a multidimensional concept involving family, peers, school, andcommunity (Blair, 2002). Blair (2002) also noted that when addressing self-regulation as a factorin school readiness, it is critical to attend to and focus on multiple developmental and transactionalpatterns and processes. Furthermore, high motivation and self-regulation are clearly associatedwith academic achievement independent of measured intellectual functioning (Blair, 2002). Chil-dren who are ready for school are confident, friendly, and attentive. They are able to developrelationships with peers and teachers, concentrate and persist with tasks, communicate their emo-tions, and respond to instructions (Peth-Pierce, 2000). Social and emotional school readiness iscritical to a smooth transition to kindergarten and early school success (Blair, 2002).

Children entering school with histories of maltreatment or of disrupted attachments, and/orthose diagnosed with RAD (like Nancy), may present to schools with a variety of behavioral,academic, and social-emotional challenges and problems. Kobak, Little, Race, and Acosta (2001)suggested that the child’s use of the teacher relationship might be strongly linked and influencedby the child’s early attachment history. It was found that children who suffered major disruptionsin attachment evidenced a greater degree of dependency on the teacher. This pattern grew morepronounced over the course of the school year. Lynch and Cicchetti (1992) found that childrenwho had been maltreated were significantly more likely to engage in proximity-seeking behaviorswith their teachers and to evidence significantly more emotional involvement with their teachersas compared to nonabused children. Kobak et al. reported that the presence of maltreatment and itsassociation with attachment problems in children may lead them to experience less confidence inthe availability of attachment figures, thus seeking help from teachers in less appropriate ways.Given the reciprocal nature of relationships, Kobak et al. noted that as a result of these atypicalbehaviors, it is reasonable to assume that the teacher’s level of stress may increase. This may leadthe teacher to respond in a way that escalates the child’s behaviors, such as being punitive. Kobaket al. found that children with Serious Emotional Disturbances (SED) being served in specialeducation classrooms were quite different from other high-risk children in general-education class-rooms. The authors found that children who were labeled SED experienced major disruptions intheir relationships with their primary caregivers compared to high-risk regular-education children.Kobak et al. highlighted the fact that it was the presence of major unplanned disruptions, or a

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complete loss of the parent, that were highly prevalent in the group of seriously emotionallydisturbed children. These types of disruptions may leave these children at an increased risk formore disorganized types of coping. Kobak et al. (2001) found that children who had experiencedmajor unplanned disruptions or losses in their lives experienced higher levels of dissociativesymptoms than other high-risk children. The significant risk associated with these types of earlyexperiences has been found to be associated with the disorganized attachment pattern and disor-ders of attachment such as RAD (Cicchetti, 2004; Richters & Volkmar, 1994). Schools themselvespresent unique challenges for children diagnosed with RAD. While the mission is to educatestudents, children with RAD are primarily concerned with internal issues of safety, security, andtrust. The need for survival, given their history of maltreatment, can be overwhelming, leavingthem unable to profit from the learning environment. The child’s preoccupation with survival andacute hypervigilence works against the organizational skills necessary for school functioning.Schools are places where success is often the result of working, collaborative relationships; how-ever, children diagnosed with RAD, who have core deficits in relational functioning, may expe-rience many challenges in their effort to succeed. For example, they may struggle with the conflictingdemands between the delay of gratification and their inability to regulate emotions and behaviorswhen gratification is not immediate. This can trigger feelings of rejection leading to a heightenedstate of anxiety in the child.

Interventions

Specific therapeutic interventions for children diagnosed with RAD have not been well val-idated in peer-reviewed journals; however, if RAD is linked to maltreatment (by fulfilling thecriteria for grossly pathogenic care), then interventions that have been used with children whohave been maltreated may offer guidelines for interventions with children with RAD (Hanson &Spratt, 2000). Perry (2001) outlined the following interventions for maltreated children: (a) Nur-ture the child; (b) understand behaviors before punishing; (c) interact with these children based onemotional age; (d) be consistent, predictable, and repetitive; (e) model and teach appropriatesocial behaviors; (f ) listen, talk, and play with these children; (g) maintain realistic expectations;(h) be patient with the child and yourself; (i) take care of yourself; and ( j) use other resources.Considering the four basic goals of attachment, (proximity, security, safety, and self-regulation), itis important to provide children with a sense of stability. Environmental and relational stabilityprovides children with an opportunity to feel safe and secure, and must include caregivers who aresensitive to the child’s need for proximity while maintaining awareness that closeness in the pasthas meant danger. The school psychologist, knowing the crucial role of stability, can take a prom-inent role in guiding and directing teachers and other school staff in ways to enhance the child’ssense of security. For example, educating school personnel on the role of attachment and inter-personal styles of relating can be helpful in sensitizing these individuals to the plight of the child.Consultation, as a means of providing guidance on managing the behavioral manifestations ofRAD, is another critical role for school psychologists (Mattison & Forness, 1995). By supportingthe teacher, the school psychologist can enhance the teacher’s willingness and capacity to supportthe student and the process (Kobak et al., 2001). Furthermore, the school psychologist can helpreframe the child’s behaviors, highlighting the child’s need to compensate for unmet attachmentneeds (Kobak et al., 2001). Teachers and school personnel, such as counselors and school psy-chologists, must help children learn how to regulate and modulate their affect and behavior, andhave the unique opportunity to act as a secure base for the child (Kobak et al., 2001). In attemptingto aid children who are unable to effectively regulate emotions and behaviors, it is critical forthose who intervene to be cognizant of their own capacity to modulate and regulate their ownemotions and behaviors.



Lieberman (1992) suggested that to help students with attachment problems, strategies usedin her work with infants and parents could function as a model for student–teacher relationships.Teachers who are aware of their own capacity to modulate their affect as well as understand thechild’s internal working model will recognize that the child’s difficulties symbolize a history ofdisrupted attachment. Teachers who are capable of this type of thinking can be prompted to engagewith attachment-disordered children in an empathic and attuned manner. On the other hand, ateacher who is unaware of his or her own schemas of relationships or is prone to scolding orpunitive discipline has more difficulty empathizing with children with attachment problems. AsKennedy and Kennedy (2004) noted, above all else, the quality of the child–teacher relationshipmay be the most critical variable for adaptation to the school environment. Teachers and otherschool personnel who are knowledgeable about and value the importance of relationships withchildren, especially children who are diagnosed with RAD, will be best able to foster and enhancea child’s functioning at school. Over time, providing a sense of safety and security and enhancingself-regulation may enable children to develop the sense of trust needed to explore the environ-ment, regulate emotions and behaviors, and join others in the process of learning. Lieberman andZeanah (1999) summarized the basic ideas behind interventions for children with attachmentdisorders. They pointed to the need for interventions to be child specific, to be developmentallyappropriate, and to minimize the use of negative practices such as scolding, embarrassment, andcondemning. Interventions which rely on emotional pressure invariably lead to empathic failureswhich reinforce the child’s existing impaired internal working models and increase the likelihoodof escalating behaviors.

Summary

The presence of maltreatment as a precursor for a variety of emotional and behavioral prob-lems, including attachment difficulties, has been well documented in the literature. Although theconnection between maltreatment and RAD is less well articulated, children diagnosed with RADmust have a documented history of parenting characterized by grossly pathogenic care. Childrendiagnosed with RAD present unique challenges when entering school. Their readiness for school,particularly their ability to regulate their emotions and behaviors, is often compromised. Whenself-regulation is inadequate, the resulting sequelae present serious problems for the school. A keycomponent of intervention in the school with children who have been diagnosed with RAD relatesto improving a child’s ability to regulate his or her feelings and actions. By providing an atmo-sphere of stability with adults who are aware of their own emotional and behavioral limits andtheir capacity for interpersonal relations, the school can enhance the environment’s potential forsupporting a sense of trust and security in the child. Finally, as additional research becomesavailable regarding RAD, it will be important to those working with children with RAD to beknowledgeable about the types of interventions that enhance school functioning as well as thosethat are detrimental to the child.

References

Aber, J.L., Allen, J.P., Carlson, V., & Cicchetti, D. (1989). The effects of maltreatment on development during earlychildhood: Recent studies and their theoretical, clinical, and policy implications. In V. Carlson & D. Cicchetti (Eds.),Child maltreatment: Theory and research on the causes and consequences of child abuse and neglect (pp. 579– 619).New York: Cambridge University Press.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text Rev.).Washington, DC: Author.

Blair, C. (2002). School readiness: Integrating cognition and emotion in a neurobiological conceptualization of children’sfunctioning at school entry. American Psychologist, 57, 111–127.

Bowlby, J. (1982). Attachment and loss (2nd ed.). New York: Basic Books.

RAD 477


Cicchetti, D. (1989). How research on child maltreatment has informed the study of child development: Perspectives fromdevelopmental psychopathology. In V. Carlson & D. Cicchetti (Eds.), Child maltreatment: Theory and research on thecauses and consequences of child abuse and neglect (pp. 377– 431). New York: Cambridge University Press.

Cicchetti, D. (2004). An odyssey of discovery: Lessons learned through three decades of research on child maltreatment.American Psychologist, 59, 731–741.

Cicchetti, D., & Lynch, M. (1995). Failures in the expectable environment and their impact on individual development:The case of child maltreatment. In D.J. Cohen & D. Cicchetti (Eds.), Developmental psychopathology: Vol. 2. Risk,disorder, and adaptation (pp. 32–71). Oxford, England: Wiley.

Cicchetti, D., & Toth, S.L. (1995). A developmental psychopathology perspective on child abuse and neglect. Journal ofthe American Academy of Child and Adolescent Psychiatry, 34, 541–565.

Hanson, R.F., & Spratt, E.G. (2000). Reactive attachment disorder: What we know about the disorder and implications fortreatment. Child Maltreatment, 5, 137–145.

Hughes, D.A. (1997). Facilitating developmental attachment: The road to emotional recovery and behavioral change infoster and adopted children. Northvale, NJ: Aronson.

Kay-Hall, S.E., & Geher, G. (2003). Behavioral and personality characteristics of children with reactive attachment dis-order. Journal of Psychology, 137, 145–162.

Kennedy, J.H., & Kennedy, C.E. (2004). Attachment theory: Implications for school psychologists. Psychology in theSchools, 41, 247–259.

Kirschner, D. (1992). Understanding adoptees who kill: Dissociation, patricide, and the psychodynamics of adoption.International Journal of Offender Therapy and Comparative Criminology, 36, 323–333.

Kobak, R., Little, M., Race, E., & Acosta, M.C. (2001). Attachment disruptions in seriously emotionally disturbed chil-dren: Implications for treatment. Attachment and Human Development, 3, 243–258.

Ladd, G.W., Kochenderfer, B.J., & Coleman, C.C. (1997). Classroom peer acceptance, friendship, and victimization:Distinct relational systems that contribute uniquely to children’s school adjustment? Child Development, 68, 1181–1197.

Lewit, E.M., & Baker, L.S. (1995). School readiness. Future of Children, 5, 128–139.

Lieberman, A.F. (1992). Infant–parent psychotherapy with toddlers. Development and Psychopathology, 4, 559–574.

Lieberman, A.F., & Zeanah, C.H. (1999). Contributions of attachment theory to infant–parent psychotherapy and otherinterventions with infants and young children. In P.R. Shaver & J. Cassidy (Eds.), Handbook of attachment: Theory,research, and clinical applications (pp. 555–574). New York: Guilford Press.

Lynch, M., & Cicchetti, D. (1992). Maltreated children’s reports of relatedness to their teachers. In R. Pianta (Ed.), Beyondthe parent: The role of other adults in children’s lives (pp. 81–107). San Francisco: Jossey-Bass.

Lyons-Ruth, K., Repacholi, B., McLeod, S., & Silva, E. (1991). Disorganized attachment behavior in infancy: Short-termstability, maternal and infant correlates, and risk-related subtypes. Development and Psychopathology, 3, 377–396.

Main, M., & Cassidy, J. (1988). Categories of response to reunion with the parent at age six: Predictable from infantattachment classifications and stable over a 1-month period. Developmental Psychology, 24, 415– 426.

Mattison, R.E., & Forness, S.R. (1995). Mental health system involvement in SED placement decisions. In J.W. Lloyd &J.M. Kauffman (Eds.), Issues in educational placement: Students with emotional and behavioral disorders (pp. 197–211). Hillsdale, NJ: Erlbaum.

O’Connor, T.G., Brendenkamp, D., & Rutter, M. (1999). Attachment disturbances disorders in children exposed to earlysevere deprivation. Infant Mental Health Journal, 20, 10–29.

O’Connor, T.G., & Rutter, M. (2000). Attachment disorder behavior following early severe deprivation: Extension andlongitudinal follow-up. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 703–712.

Parker, K.C., & Forrest, D. (1993). Attachment disorder: An emerging concern for school counselors. Elementary SchoolGuidance & Counseling, 27, 209–215.

Perry, B.D. (2001). Bonding and attachment in maltreated children: Consequences of emotional neglect in childhood.Houston, TX: Child Trauma Academy Press.

Peth-Pierce, R. (2000). A good beginning: Sending America’s children to school with the social and emotional competencethey need to succeed. The Child Mental Health Foundations and Agencies Network (FAN) Monograph. Bethesda,MD.

Pianta, R.C., & Steinberg, M. (1992). Teacher–child relationships and the process adjusting to school. In R.C. Pianta (Ed.),Beyond the parent: The role of other adults in children’s lives (pp. 61–80). San Francisco: Jossey-Bass.

Raver, C.C., & Zigler, E.F. (1997). Social competence: An untapped dimension in evaluating Head Start’s success. EarlyChildhood Research Quarterly, 12, 363–385.

Reber, K. (1996). Children at risk for reactive attachment disorder: Assessment, diagnosis, and treatment. Progress: FamilySystems Research and Theory, 5, 83–98.

Richters, M.M., & Volkmar, F.R. (1994). Reactive attachment disorder of infancy or early childhood. Journal of theAmerican Academy of Child and Adolescent Psychiatry, 33, 328–332.



Rimm-Kaufman, S.E., Pianta, R.C., & Cox, M.J. (2000). Teachers’ judgments of problems in the transition to kindergarten.Early Childhood Research Quarterly, 15, 147–166.

Ritchie, S.A. (1996). Attachment relationships of substance-exposed children with their caregivers and their teachers.Dissertation Abstracts International, 56, 3892A.

Schore, A.N. (2001). Effects of a secure attachment relationship on right brain development, affect regulation, and infantmental health. Infant Mental Health Journal, 22, 7– 66.

Shaw, D.S., Owens, E.B., Vondra, J.I., & Keenan, K. (1996). Early risk factors and pathways in the development of earlydisruptive behavior problems. Development and Psychopathology, 8, 679– 699.

Shonk, S.M., & Cicchetti, D. (2001). Maltreatment, competency deficits, and risk for academic and behavioral maladjust-ment. Developmental Psychology, 37, 3–17.

Shores, R.E., & Wehby, J.H. (1999). Analyzing the classroom social behavior of students with EBD. Journal of Emotionaland Behavioral Disorders, 7, 194–199.

Solomon, J., & George, C. (1996). Defining the caregiving system: Toward a theory of caregiving. Infant Mental HealthJournal, 17, 183–197.

Sroufe, L.A. (1996). Emotional development: The organization of emotional life in the early years. New York: CambridgeUniversity Press.

Stern, D. (1985). The interpersonal world of the infant: A view from psychoanalysis and developmental psychology. NewYork: Basic Books.

Trickett, P.K., & McBride-Chang, C. (1995). The developmental impact of different types of child abuse and neglect.Developmental Review, 15, 311–337.

Van der Kolk, B.A., & Fisler, R.E. (1994). Childhood abuse and neglect and loss of self-regulation. Bulletin of theMenninger Clinic, 58, 145–168.

Webster-Stratton, C., & Reid, M.J. (2004). Strengthening social and emotional competence in young children—The foun-dation for early school readiness and success: Incredible years classroom social skills and problem-solving curricu-lum. Infants and Young Children, 17, 96–114.

Zeanah, C.H. (1996). Beyond insecurity: A reconceptualization of attachment disorders in infancy. Journal of Consultingand Clinical Psychology, 64, 42–52.

Zeanah, C.H., & Emde, R.N. (1994). Attachment disorders in infancy. In M. Rutter, E. Taylor, & L. Hersov (Eds.), Childand adolescent psychiatry: Modern approaches (pp. 490–504). Oxford, England: Blackwell.

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reactive attachment disorder: implications for school readiness and school functioning

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