RAD

Attachment & Human Development,
March 2006; 8(1): 63 86
Reactive attachment disorder in maltreated twins

follow-up: From 18 months to 8 years
SHERRYL SCOTT HELLER1, NEIL W. BORIS1,2,

SARAH-HINSHAW FUSELIER3, TIMOTHY PAGE4,
NINA KOREN-KARIE5, & DEVI MIRON6
1
Tulane University Health Sciences Center, New Orleans, LA, USA, 2Tulane University School of
Public Health & Tropical Medicine, New Orleans, LA, USA, 3University of Texas at Austin, USA,
4
Louisiana State University, USA, 5University of Haifa, Israel, and 6Tulane University, New Orleans,
LA, USA
Abstract
The best means for the diagnosis and treatment of reactive attachment disorder of infancy and early
childhood have not been established. Though some longitudinal data on institutionalized children is
available, reports of maltreated young children who are followed over time and assessed with measures
of attachment are lacking. This paper presents the clinical course of a set of maltreated fraternal twins
who were assessed and treated from 19 months to 30 months of age and then seen in follow-up at 3 and
8 years of age. A summary of the early assessment and course is provided and findings from follow-up
assessments of the cognitive, behavioral, and interpersonal functioning of each child is analysed.
Follow-up measures, chosen to capture social-cognitive processing of these children from an
attachment perspective, are highlighted. Finally, findings from the case are discussed from nosological
and theoretical perspectives.
Keywords: Maltreatment, attachment, reactive attachment disorder, case study, child abuse, adoption
Introduction
Appropriate assessment, diagnosis, and treatment of reactive attachment disorder (RAD)
have recently been debated in the literature (Zeanah & Boris, 2000; Zeanah & OConnor,
2003). Recent special issues of Attachment & Human Development (2003) and the Infant
Mental Health Journal (2004) have focused on the clinical and diagnostic controversies of
research on attachment disorders. One unresolved issue concerns the developmental course
of young children diagnosed with RAD. Though recent longitudinal data on children raised
in institutions are informative, there are no case studies in the peer-reviewed literature that
have followed maltreated children, raised in families and diagnosed in early childhood with
RAD. In this paper, an update of a case report first published in 1999 is presented
(Hinshaw-Fuselier, Boris, & Zeanah, 1999). The focus of this case report is on the cognitive,
socio-emotional, and behavioral development of fraternal twin siblings who were victims of
maltreatment and were placed in foster care before age 2 years. This paper begins with an
overview of the existing diagnostic nosology and controversies about its application in
Correspondence: Sherryl Scott Heller, PhD, Tulane University Health Sciences Center, New Orleans, LA, USA.
E-mail: drsherrylheller@yahoo.com
ISSN 1461-6734 print/ISSN 1469-2988 online 2006 Taylor & Francis
DOI: 10.1080/14616730600585177
64
S. S. Heller et al.
middle childhood. Included in this section is a review of available data on institutionalized

children and how this data may or may not inform our understanding of maltreated but not
institutionalized children. The case report follows beginning with a review of the childrens
history, their initial assessment, and the treatment course when they were aged 19
30 months (more details of the twins early history are available in the previous manuscript;
Hinshaw-Fuselier et al., 1999). A summary of an interim assessment when they were age 3
years precedes a more detailed description of newly standardized measures administered to
the children at 8 years of age. The findings from these measures, coded by research scientists
unaware of details of these childrens clinical history, rounds out the case material. The
paper concludes with a discussion of the twins symptoms from both a diagnostic and social
information processing perspective.
The diagnosis of reactive attachment disorder
Both DSM-IV (American Psychiatric Association, 1994) and ICD-10 (World Health
Organization, 1992) require that the onset of RAD occur before the age of 5 years. In DSMIV, it is specified that pathogenic care precede the onset of symptoms. Both nosologies
also describe two types of RAD, inhibited and disinhibited. The major feature of the
inhibited subtype of RAD involves the child either failing to approach the caregiver or
approaching the caregiver in an abnormal manner (e.g., fearful approach) when clearly
distressed. Children diagnosed as RAD-inhibited also exhibit difficulties in emotional
regulation and a lack of social reciprocity. The disinhibited attachment pattern involves the
child approaching unfamiliar adults or exhibiting a lack of wariness of strangers. These
children may willingly wander off with a stranger, or seek physical contact with unfamiliar
adults.
The difficulty applying DSM-IV criteria clinically has been cited as one reason for the
paucity of peer-reviewed research on RAD (Zeanah, 1996). One proposal, argued for in a
series of papers, has been that there may be more than the two distinct subtypes of RAD
outlined in DSM criteria. An expanded set of alternate criteria for a series of attachment
disorders have been proposed and refined based on clinical case studies (see Zeanah, 1996;
Zeanah, Boris, Bakshi, & Leiberman, 2000). Detailed reviews of the difficulties applying
available diagnostic criteria have also been published (OConnor, 2002; Zeanah, Boris, &
Leiberman, 2000). Attempts to reliably diagnose classic RAD and the proposed alternate
forms of attachment disorders in high-risk samples have been limited; early results clearly
underscore the need for both continued revision of proposed diagnostic criteria and for
further research in this area (Boris, Hinshaw-Fuselier, Smyke, Scheeringa, Heller, &
Zeanah, 2004; Boris, Zeanah, Scheeringa, Larrieu, & Heller, 1998). Especially lacking is
data on the predictive validity of attachment disorders. In fact, the only available
longitudinal data are from follow-up studies of institutionalized children.
Both types of RAD have been described in institutionalized or formerly institutionalized
children, but the disinhibited type is by far the most prevalent (Chrisholm, 1998; Chrisholm,
Carter, Ames, & Morrison, 1995; OConnor, Bredenkamp, Rutter, & The English and
Romanian Adoptees (ERA) Study Team, 1999; OConnor, Rutter, & The English and
Romanian Adoptees (ERA) Study Team 2000; Smyke, Dumitrescu, & Zeanah, 2002). On
the other hand, only a small minority of children adopted from institutions continues to
manifest symptoms of either subtype of RAD over time. Those who remain symptomatic are
generally described as superficially sociable. These children often seek physical contact with
strangers. They may, for instance, climb uninvited into a strange adults lap and caress his or
her hair. On the other hand, caregivers often perceive affected childrens social connections
RAD in Maltreated Twins
65
to be shallow. Some exhibit hyperactivity and attention problems as well as difficulties in

peer relationships (OConnor et al., 1999).
An unforeseen trend, perhaps related to the lack of data on the course of RAD, has been a
fundamental reconceptualization of RAD by clinicians who publish outside the mainstream
scientific literature resulting in the application of revised diagnostic criteria to children older
than 5 years. Published claims that these revised criteria, which overlap with oppositional
defiant disorder and conduct disorder, yield population prevalence for RAD of 3 6% have
followed (Levy & Orlans, 1998). There is now a cottage industry in the USA of selfdesignated centers where attachment disorders are diagnosed and treated. Furthermore,
therapists of varying backgrounds are trained to recognize and treat affected children in their
communities, sometimes using unorthodox forms of treatment. Unfortunately, the use of
treatments involving physical restraint (i.e., holding therapy, re-birthing experiences)
have been documented to directly result in the death of at least six children during
therapy (Boris, 2003; Mercer, Sarner, & Rosa, 2003; Zeanah & OConnor, 2003). This
egregious misapplication of attachment theory underlying attempts to forcefully re-attach
children to their caregivers is of great concern and further demonstrates the need for
research on RAD and its sequelae.
The experiences of children who have been reared in institutions are not the same as those
children who have been maltreated within the context of one or more consistent caregiving
relationships. Children who present with RAD symptoms following maltreatment may have
a different clinical course than institutionalized children. Concerns about long-term effects
of maltreatment and attachment disruption date back to Bowlbys two papers on juvenile
thieves (Bowlby, 1944a, 1944b), however, to date there are no case reports or studies of
maltreated non-institutionalized children diagnosed with RAD who have been followed
longitudinally.
Case report of maltreated twins
Fraternal twins, Claire and Bobby, were placed in foster care when they were 18 months old
following allegations of neglect, including parental lack of adequate supervision of the
children and an inability to maintain adequate housing. The studio apartment was found to
be filthy (dirty diapers scattered about the home, human waste in the bathtub and on the
bathroom floor, trash lying about the apartment) and overcrowded (as many as nine people
were living in the apartment at once). The twins 3-year-old sister was reported to have been
left to play unattended on a second floor ledge and seen climbing on the balcony railing.
A brief placement with relatives had failed just prior to their coming into care. They were
first assessed by an Infant Mental Health (IMH) intervention team providing intensive
services to foster children less than 4 years of age (see Zeanah & Larrieu, 1998, for a
program description). Within a 21-month period, between 6 and 27 months of age, the
twins were moved 11 times, placed in a total of five different foster homes, and eventually
adopted by relative (see Table I for a timeline of placements, assessments, and key events).
Evaluation and treatment recommendations
The IMH team evaluated the twins 6 weeks after placement in foster care; during this time
the children had weekly 1 hour visits with their biological parents. The team observed the
twins in both structured and unstructured evaluation paradigms, in both home and clinic
settings, with both foster and biological parents. The twins exhibited many concerning
behaviors initially (see Table II; see also Hinshaw-Fuselier et al., 1999) and throughout their
. In-home intervention unsuccessful

. Twins and older sister placed in kinship care with paternal aunt (1st foster home)
. Kin placement fails (family is evicted from home)

. Twins and older sister placed in non-relative foster care (2nd foster home)
. Therapeutic visitation with
biological parents begins
. Children start at a child care center
. Burns found on twins hands

. Older sister removed after 1 week
. Ms & Mr. 5th foster home requested

removal of children due to maternal
aunt and uncles interest
. Biological mother made allegations of
sexual abuse against uncle (Mr. Z)
. Allegations not substantiated; appeared
biological mother attempting
to sabotage placement
. Moved into 3rd foster home

. This is move number 3 for the children
. Children are transitioned back to

biological home with older sister
. This is move number 4
. Children are returned to 3rd foster home

. Also placed in respite care (4th foster home) on weekends
. These are move numbers 5 & 6
. Moved from 3rd foster home into respite

care home (4th foster home)
. Moved from respite care home to 5th foster home
. These are move numbers 7 & 8
. Children moved to aunt and uncles home (Mr. & Mrs. Z)

. Children returned to 5th foster home
. Twins returned to aunt and uncle

. Custody is legally transferred

to aunt & uncle (Mr. & Mrs. Z)
17 months
18 months
19 months
21 months
22 months
23 months
25 months
26 months
27 months
30 months
Prior to Infant Team involvement

. CPS provide in-home intervention due to lack of supervision, neglect, and inadequate living conditions
6 months
Event
Placement
Age
Table I. Timeline of placement, events, and assessments for the Smith twins.
(continued)
. Occupational evaluation of twins

occurs when twins are 32 months
. Developmental testing of twins

. Neurological evaluation,
included EEGs
. IMH team evaluation includes:

Home visits, WMCI, ParentChild
Interaction Procedure, Psychiatric
assessment with parents
Assessment
66
S. S. Heller et al.
Placement
. Twins remain with Mr. & Mrs. Z
. Twins residing with Mrs. Z

family has re-located.
Age
36 months
8 years
Table I. (Continued)
. Mr. & Mrs. Z report marital discord.

The couple has separated.
Twins still have visits with Mr. Z.
Event
.
.
.
.
.
cognitive screens (PPVT & KBIT)

parent report (CBCL & HBQ)
teacher report (HBQ)
child report (BPI)
attachment assessments (NSST & AEED)
Second research assessment includes:
. First research assessment includes

SSP & Attachment Interview
Assessment

67
68
S. S. Heller et al.
Table II. X twins diagnostic behavior at time of evaluation (18 months).

Behaviors observed in the foster home
Behaviors observed in the clinic
Bobby
.
.
.
Flat affect
Socially indiscriminant
No verbalization or intentional
communication
. No preferred attachment
. Disorganized attachment behaviors during
separation and reunion with both biological
parents
. Developmentally delayed (tested at
12 13 month level, with language at 7 9
month level)
. Normal EEG and neurological exam
Claire
.
.
.
Flat affect
Socially withdrawn
No verbalization or intentional
communication
. No preferred attachment
. Disorganized attachment behaviors during
separation and reunion with both parents
. Developmentally delayed (tested
13 month level)
. Normal EEG and neurological exam
. Freezing episodes at times of mild
to moderate stress
Mrs. X with the

twins
Children were not observed with

biological parents in the home
at this time period as all visits
with biological parents
were supervised and in the clinic.
Mr. X with the

twins
. Alternates between dismissing childrens

attachment needs and angry preoccupation
. Difficulty reading cues and responding
contingently
. Unable to take responsibility for plight
of children
. Repeatedly missed appointments to see kids
. Dismissing of attachment needs of children
. Low level of interaction; minimal
shared affect
time in foster care. One of the teams recommendations was to increase supervised visitation
to twice a week; unfortunately, Mr. and Mrs. Xs attendance remained inconsistent
throughout their treatment. The parents had difficulty viewing the world from their childs
perspective. For example, Ms. X reported that her 19-month-old twins were easy to care for
as she just had to give them a few toys and they would entertain themselves all day long in
the playpen. Additionally both parents reported that they felt the twins were too young to
know what was going on in regards to the separation from their parents.
At the teams first home visit with foster family two, Bobby and Claire exhibited flat affect
and blank facial expressions and they appeared to be delayed in their development (e.g., few
verbalizations, no intentional communication). While Claire was emotionally withdrawn,
Bobby was socially indiscriminant (e.g., reached out to be held by the clinicians when he
first met them and cried inconsolably when they left). Neither twin demonstrated preferred
attachment behaviors with either their biological parents or their foster parents. Moreover,
when the twins were separated from their parents during evaluation procedures, both
showed strong indices of disorganized attachment upon reunion (Main & Solomon, 1990;
our observations of key reunion behaviors have been confirmed by coders masked to the
clinical history of the twins). At reunion, both twins exhibited heightened distress with
aborted approaches (e.g., approach mixed with avoidance). Claire also had stereotypies,
anxious or fearful facial expressions and prolonged freezing on reunion. The discrete
freezing episodes, during which she was unresponsive to auditory, visual, and tactile
stimulation, were evident in multiple contexts and were noted to increase following visits
69
with the biological parents or a move to a new foster home. Once stabilized in a new home
setting the freezing episodes would decrease.
In addition to the host of social emotional disturbances, developmental testing confirmed
that the twins were significantly developmentally delayed. Neurological evaluation included
negative sleep-deprived EEGs and, beyond global developmental delay, no evidence of
neurological abnormalities.
The IMH team conducted a thorough evaluation with the twins biological parents, Mr. &
Mrs. X. Both parents were administered the Working Model of the Child Interview (Benoit,
Parker, & Zeanah, 1997; Zeanah & Benoit, 1995). This is a semi-structured interview that is
designed to assess caregivers internal representations, or working models, of their
relationship with a particular child. Separate interviews are administered to each caregiver
regarding each child. Mr. & Ms. X were also observed in a semi-structured interactional
procedure with each child (Heller et al., 1998). This interaction included periods of free play
as well as episodes where the parent is instructed to help the child complete developmental
tasks of increasing difficulty (e.g., stacking blocks or putting shapes in a shape sorter).
Ms. Xs assessment. Ms. Xs interview about her relationship with Claire was marked by
inconsistency. She tended to use generic terms to describe both Claires personality and her
relationship with Claire and had a very limited ability to recall specific stories to support her
descriptions. For instance, she used the same Christmas morning story on numerous
occasions. As evidenced in the following excerpt from her Working Model of the Child
Interview, Ms. X was eager to talk about her daughter, but seemed unable to present a clear
picture of her relationship with Claire:
Interviewer: What do you feel is unique or different about Claire compared to what you
know about other children?
Ms. X: She does a lot more than other children do that are her age.
Interviewer: What do you . . .
Ms. X: Umm, she is very playful and hyper. Like I see the difference between Bobby and
Bobby umm Claire. He is mellow, he likes being by himself . . . he likes watching his TV
and just being alone. Claire likes being around everybody. She plays better by herself at
times. Umm she likes just being with everybody. A lot of kids are shy and stuff like that
around new people but she is not.
As with Claire, Ms. Xs descriptions of Bobby and her relationship with Bobby were
inconsistent. For example, she reported that Bobby had a bad temper, yet later in the
interview she stated that Bobby did not get emotionally upset. When she was pushed for
detailed episodic memories, her responses became generic. She described Bobby as being
like other children his age and was unable to provide specific stories to support her
descriptions of Bobbys personality or of her relationship with Bobby.
Ms. X had very little insight about the effects of her experiences on herself or her children.
She described harrowing details of extreme family violence, including her stepmother
stabbing her father. Her reports of her chaotic and frightening childhood were detailed
and delivered in a tone that vacillated between matter-of-fact and overbright. However, when asked about how her childhood experiences affected her, Ms. Xs face became
expressionlessshe stopped speaking and she lost track of the interview. After a moment
Ms. X appeared to return to the present, asking the interviewer to repeat the question.
She then responded, in a very flat tone, that her childhood experiences did not affect her
at all.
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S. S. Heller et al.
In the parent child interaction procedure, Claire rarely initiated any interaction with
her mother and avoided eye-contact throughout the 40 minute procedure. When Claire
struggled on any of the tasks she did not turn to her mother for help. Throughout the
procedure Ms. X offered vague instructions in an overbright tone and provided very
little praise. Claire, for the most part, was unresponsive to any of Ms. Xs overtures.
Ms. X was observed to vacillate between overbright and detached affect in her interactions
with Bobby. His general affective tone fluctuated between being flat and irritable. When
upset, Bobby gave mixed cues as to whether he wanted or did not want his mother, for
example he signaled for contact and then immediately rejected it. Ms. Xs response to
Bobbys fussing would be to infantilize Bobby (e.g., holding him like a newborn) and to get
increasingly intrusive with teasing and at times sexualized behavior (e.g., tickling Bobby or
holding him to her breast).
Mr. Xs assessment. Mr. X was withdrawn and anxious in the presence of the clinicians and
his children. His childhood was characterized by loss and rejection: his mother abandoned
him when he was 2 years old, his father was critical and cold, and his stepmother was
physically abusive. Mr. X had a history of learning disability and difficulty maintaining a job.
He was diagnosed with major depression, chronic early onset dysthymia, and developmental
learning disorder.
Like Mrs. X, Mr. X demonstrated a very poor understanding of his children and the way
in which his experiences affected himself and his children. Mr. X provided a very
impoverished and ambiguous picture of his daughter and their relationship, despite the fact
that both parents referred to Claire as daddys girl. Mr. X stated that he did not have
much influence on Claire or her development.
Similar to his interview regarding Claire, Mr. X provided a sketchy and generic picture of
his son, Bobby, and his relationship with Bobby. His descriptions of Bobby were repetitive
and he had great difficulty coming up with five distinct adjectives that captured his
relationship with his son. When asked to provide specific examples to support the adjectives
chosen, his examples were limited and he became increasingly frustrated with the interview.
In the following excerpt, Mr. X is describing why he chose the word happy to characterize
his relationship with Bobby:
Mr. X: Well aaa hes always happy because aaaa he keeps himself happy . . . he keeps
himself occupied or whatever. Or he does something that makes him happy about himself,
if he does the right thing or whatever.
Interviewer: Do you remember a specific time?
Mr. X: He was playing with lego blocks one time and he, like he had trouble putting the
blocks together and he finally got them together and he was happy about it (shrugsflat).
And he come running up to me and Im like there you gostart putting more on. And
hell go back and start putting more on. Hes happy for himself. Hes proud that he finally
figured out how to do it. He does something right he gets himself happy.
The overall tone of the interview was one of detachment; for example, Mr. X reported that
Bobby was just like any other child and was unable to present his child as unique in any
way. His relationship with Bobby, therefore, appeared shallow. His interview about Claire
was similar.
Mr. X was observed to have little emotional connection with his children; the dyads
demonstrated low levels of interaction and shared affect. Claire was self-directive and
focused on the tasks in the parent child interaction procedure. She exhibited minimal
71
interest in interacting with her father and was typically unresponsive to her fathers rigid and
repetitive attempts at encouragement or assistance; she spent long periods of time engaged
in tasks and ignoring Mr. Xs bids.
In contrast, Mr. X diligently attempted to engage Bobby throughout the parent child
interaction procedure. As with his daughter, however, Mr. Xs attempts to support his son
were rigid, repetitive, and unsuccessful. Bobby, in response, appeared unfocused, dazed,
frustrated, and was unable to use his father for emotional or instrumental support.
Mr. and Mrs. Xs marital relationship was historically volatile (the two were separated at
the time of referral) and admitted to past bi-directional aggression. The dyad also had a
history of chronic and severe financial problems.
Following the evaluation, the IMH team determined that a stable placement with
consistent and sensitive care was the most important treatment goal for the children, in
order to facilitate developmental progress and social-emotional health. As the plan with
Child Protective Service (CPS) was to work toward reunion with the biological parents,
many of the initial treatment recommendations focused on Mr. & Mrs. X individually,
together, and with their children.
Post evaluative course
Though a stable and sensitive caregiving environment was considered imperative for the
twins, a series of unforeseen circumstances led the twins to experience five different foster
placements and 11 moves between the ages 6 and 27 months. When the twins were in a
stable and sensitive caregiving environment they exhibited less behavioral symptomatology
(e.g., food stuffing and aggression), rapid developmental gains, and shifts in attachment
behavior (e.g., increased comfort seeking and decreased freezing). For a more detailed
history of the X familys treatment and the twins placement history see Hinshaw-Fuselier,
Boris, & Zeanah (1999).
When the children were 30 months old, Mr. & Mrs. X surrendered their parental rights
and legal custody of the twins was transferred to the maternal great uncle and aunt (Mr. &
Mrs. Z), who adopted them. Two months later, the twins were evaluated by an occupational
therapist who placed Claires developmental functioning at the level of a 23 month old and
Bobby slightly behind Claire. At that time, Mrs. Z reported behaviors in Bobby and Claire
that were characteristic of preferred attachment (e.g., seeking comfort in times of distress,
preferring comfort from the aunt over others, etc.). Additionally, their freezing episodes had
reportedly stopped occurring.
The IMH team maintains involvement with a family until the children are surrendered,
returned to their biological family, or freed for adoption and in a stable placement. In the X
familys case, once the parents surrendered their rights, the IMH team began working
toward treatment termination. Fortunately, the team received research funding that enabled
them to follow-up on the twins progress and development at two different time points, aged
3 and 8 years.
Follow-up at 36 months
At 36 months of age, the twins and Mrs. Z (the adoptive mother) consented to participate in
a clinical assessment as part of a research project. Although the children clearly used Mrs. Z
as their primary attachment figure, each child demonstrated concerning behaviors. The
authors, as well as an independent coder blind to the twins maltreatment status, noted the
disordered attachment behaviors. Claire strived to control the interaction with her caregiver
72
S. S. Heller et al.
in either a punitive or caregiving manner. The shift, observed in Claire, from disorganized
attachment behaviors in infancy to controlling attachment behaviors in the preschool period
have been documented in other dyads in the attachment literature (Main & Cassidy, 1988;
Wartner, Grossmann, Fremmer-Bombik, & Suess, 1994). Main & Hesse (1990) have
proposed that this developmental shift, from disorganized to controlling, occurs out of the
childs need to take a parental role in the relationship. This need is believed to occur when
the parents own caregiving strategy is disorganized due to the parents history of loss or
trauma. Claires behavior with her adoptive mother suggests an internalized expectation that
her caregiver requires emotional support.
Bobby was repeatedly observed to engage in self-endangering behaviors and often laughed
when he performed dangerous feats (e.g., empty laughter after jumping several feet off a
platform into a tire tunnel and landing hard on the ground). Although self-endangering
behavior has not been documented in the research literature on attachment disorders it has
been documented in the clinical literature (Boris et al., 2004). The same questions regarding
Claires continued disorganized/disordered behavior with her adoptive mother apply to
Bobby.
Although the twins had some age-typical dysarthria they were not notably cognitively
delayed. At the time of this evaluation, however, neither twin was formally tested.
Standardized measures used at the 8-year follow-up
When the children were 8 years old they participated in a comprehensive evaluation. The
twins and their adoptive mother had two 2 3 hour home visits at which time several
measures were administered. Typical cognitive screens (the K-BIT and the PPVT) were
employed, as were standardized assessments of child behavior using parent and teacher
report (the Health Behavior Questionnaire and the Child Behavior Checklist). Some more
specialized measures were also used and an expanded description of these measures and the
purpose and analysis of each follows.
Capturing child self-report
A childs self-perceptions shape his or her behavior in school, at home, and in relation to
others. Research has demonstrated that attachment history (Green & Goldwyn, 2002;
Verschueren & Marcoen, 1999) and maltreatment history (Bolger, Patterson, &
Kupersmidt, 1998; Kim & Cicchetti, 2004; Vondra, Barnett, & Cicchetti, 1989) influence
childrens perceptions of their social competence, peer relationships, school functioning,
self-esteem, and psychological adjustment.
In recent years, the measurement of attachment has progressed beyond its original
emphasis on behavioral observations to include assessments of attachment security at the
level of representation (Main, Kaplan, & Cassidy, 1985). Based on Bowlbys conceptualization of the internal working model (Bowlby, 1973), researchers have devised methods
that provide access to the mental organization of attachment experiences. Internal working
models are organized memories of the way in which attachment needs have been responded
to by attachment figures. They function in the way that cognitive schemas do, to provide an
efficient means of prediction and interpretation of experience. The terminology Bowlby
chose for his concept, however, was intended to emphasize the potential for revision and
updating of memory in the face of new experience in attachment relationships.
Representational assessments of attachment are designed to provide the respondent with
an opportunity to reveal expectations of attachment relationships, typically stored in
73
unconscious memory. Attachment security assessed through representational measures in

childhood has been correlated with a variety of measures of childrens social behavior with
peers and adults, as well as behavioral measures of attachment security to parents (see Page,
2001, for a review). The relatively recent emphasis in attachment research on the
representational level has provided new avenues for understanding the developmental
implications of attachment security. Despite the fact that Bowlby originally relied on diverse
fields of knowledge to formulate attachment theory, including the construct of the internal
working model, attachment research has only relatively recently begun to explore
intersections among previously divergent fields of inquiry. One such intersection has been
attachment research and social information processing. Within the attachment relationship,
through the expression of attachment needs and the accommodation of those needs by
attachment figures, children learn seminal lessons in basic social skills such as how to
accurately appraise the intentions and wishes of others, how to express ones desires to
others, and how to negotiate differences in relational goals (Ainsworth, 1992). These more
sophisticated negotiation and expressive skills are reflective of the later stage of childhood
attachment relationships referred to by Bowlby as the goal-corrected partnership.
Representational assessments of attachment, thus, can provide researchers with a wide view
of an array of social information processing skills, first learned in attachment relationships.
The Berkeley Puppet Interview (BPI). The Berkeley Puppet Interview (BPI; Ablow &
Measelle, 1993) was developed in response to concerns regarding the validity of
measurement tools capturing preschool and early school-age childrens self-perception
(Measelle, Ablow, Cowan, & Cowan, 1998). The BPI employs puppets to create a peer-like
exchange that holds the young childs attention. The interview has been formatted so that
for each item each puppet admits to one side of a two-sided contingency (e.g., one will say
I take things that dont belong to me while the other will say I dont take things that
dont belong to me and the first will ask the subject How about you?). The format of the
interview decreases the likelihood of response biases (e.g., social desirability or overcompliance). The puppets are gender neutral and with each question they alternately
endorse or deny a given symptom. Most children quickly follow the flow of the interview and
each child is given a chance at the end of a section to talk to or play with the puppets. The
examiner hides his or her face behind the puppets, using a playful voice and moving each
puppets mouth in relaying the queries. Videotaping of the interview allows for verbal or
non-verbal responses (some children point to one or the other puppet) accommodating for
the variability in young childrens expressive vocabulary.
The authors of the BPI created several modules to assess various aspects of a young childs
life. The twins were interviewed using modules focused on family life, school adjustment,
peer relationships, and psychological adjustment or symptomatology. To date there are no
published norms for the BPI, thus for the purposes of this paper Bobby and Claires scores
were compared to those of a group of maltreated peers, all of whom were placed in foster
care before age 4 years.
The authors of the BPI also developed a questionnaire, the Health Behavior
Questionnaire (HBQ), to be administered to parents and teachers. This questionnaire is
scored on four domains: emotional and behavioral symptomatology, impairment, adaptive
social functioning, and physical health. Items are rated on a 3-point scale and match BPI
scales (Essex, Boyce, Goldstein, Armstrong, Kraemer, & Kupfer, 2002).
The Narrative Story-Stem Technique (NSST). The NSST is a representational attachment
method originally devised by Bretherton and colleagues (Bretherton, Ridgeway, & Cassidy,
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S. S. Heller et al.
1990) and was used in this study. Various forms of this measure have been referred to as the
Attachment Story Completion Task and MacArthur Story-Stem Battery, depending on the
selection of narratives.
In the NSST method, children are presented with up to 10 brief story-stems, each of
which depicts some familiar, mildly stressful situation (see Table III for a list of story-stems
used). The story-stems are enacted with the aid of props, to facilitate the childrens
comprehension of the story-stem. In this study, the props used were as reported in Page &
Bretherton (2001) consisting of a bear family (mother, father, two siblings the same gender
as the subject child, grandmother, and childrens friend) and several play furniture items
corresponding to the elements of the story-stem. After the presentation of the story-stem,
the child is asked to show and tell what happens next in the story. The childs response is
Table III. List of story-stems used with twins.

Story 1
Spilled Juice
The family is sitting at the table and the little child (Jane, Robert) reaches for
some juice and spills the pitcher on the floor.1
Story 2
Hurt Knee
The family is taking a walk in the park. Little (Jane, Robert) tries to climb a
high, high rock and falls off it, crying, Ive hurt my knee, Im bleeding!2
Story 3
Monster in Bedroom Its bedtime and the mother tells little (Jane, Robert) to go to bed. S/he goes
into the bedroom and cries out, Theres something scary in my room!
Theres something scary in my room!2
Story 4
Departure
The mother and dad are going to go on a trip for 3 days, and say
to the children, See you in 3 days, Grandma will stay with you.2
Story 5
Reunion
The mother and dad return from their trip.1
Story 6
Headache
The mother and little (Jane, Robert) are sitting on the couch watching TV.
Mom says she has a headache and she turns the TV off, and asks little
(Jane, Robert) for some quiet. The doorbell rings and its little
(Janes, Roberts) friend who asks to come in and watch TV because
there is a really neat show on.3
Story 7
The Bathroom Shelf
Part I: The two children are playing in their toybox and the mother comes in
and says she has to go to the neighbors, and the children are not to touch
anything on the bathroom shelf while she is away. The children resume playing
in the toybox. Little Jane/Robert cries, Ouch! I cut my finger, quick, get me a
Band-Aid! The older sibling replies, But mom told us not to touch anything
on the bathroom shelf. Jane/Robert replies, But my finger is bleeding!
Part II: the mother returns.3
Story 8
Threes a Crowd
The older child and friend are playing in the wagon. The younger child asks to
join them. The friend replies, If you let your brother/sister play, I wont be
your friend any more.3
Story 9
Broken Cup
The mom sits on the couch, crying. Robert comes in and the mom says, Im
so sad because I just broke the cup that you gave me.
Story 10 Play with Ball
Jane/Robert is playing with her/his ball with her/his friend, Mary/Pete.

Suddenly, the friend grabs the ball. Jane/Robert cries, Ouch! That hurt
my hand!4
From the Attachment Story Completion Task (Bretherton, Ridgeway, & Cassidy, 1990).
From the Attachment Story Completion Task (Bretherton et al., 1990), with revisions by Granot & Mayseless
(2001).
3
From the MacArthur Story-Stem Battery (Bretherton, Oppenheim, Buchsbaum, Emde, and the MacArthur
Narrative Group, 1990).
4
From Warren, Emde, & Sroufe (2000).
2
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then coded for themes of interest. Initial coding of the childrens stories was based on
established methods reported in previous studies with the NSST (Page, 2001). For the
purposes of this paper, the content of the two childrens narrative responses were evaluated
on the presence of various positive or negative interactions between story characters,
autonomous or negative depictions of individuals, enactment of attachment behavior in
children, parenting nurturance and discipline, and the presence of highly distorted or bizarre
elements. In addition, overall story coherence and the degree to which the child avoided the
story-stems were rated. Quantitative variables based on frequencies of response codes were
not analysed, as they normally are for larger samples, because comparisons between only
two children would be unlikely to be meaningful. The codes were used to provide a rough
guide in tracking the responses, and to facilitate qualitative analyses of the significant themes
the two children presented in their stories. The fourth author, who was blind to the twins
history and had previously demonstrated inter-rater reliability with Inge Bretherton, an
originator of the NSST, performed this analysis.
The Autobiographical Emotional Events Dialogue (AEED). Another approach to understanding childrens internal representations is to analyse co-construction of narratives with
their caregivers (Fivush, 1991). Through repeated experiences of narrative co-construction,
the child internalizes his parents communication style over time so that the parent is eventually able to structure the conversations with questions but allow the child to develop the
story (Snow, 1990). It is through this process that the child learns, and eventually internalizes,
a style or range of emotional expression. Parents who express a wide range of emotions
typically have children who develop an open style of emotional communication and,
conversely, parents who have a restricted range of emotional expression tend to have children
who have a limited range of emotional expression (Dunn, Bretherton, & Munn, 1987).
Securely attached children have been described as holding richer emotional dialogue with
their parent compared to non-securely attached children (Laible & Thompson, 1998). Male
preschoolers, who have disorganized attachment classifications, are significantly more likely
to exhibit non-open communication styles with their mothers than their male peers classified
as secure (Etzion-Carasso & Oppenheim, 2000). An emotionally open communication style
in a parent child dyad allows the child to process both positive and negative emotions and
experiences safely and without fear of rejection (Settles, 2003).
The Autobiographical Emotional Events Dialogue procedure (AEED) is a narrative coconstruction measure developed to assess attachment security in childhood. The authors
(Koren-Karie, Oppenheim, Chaimovich, & Etzion-Carasso, 2003) argue that, in a dyad
exhibiting an open style of communication, the parent helps the child to contain
negative emotion, provides structure and organization, encourages the childs involvement,
and ensures that the child completes the task feeling successful and confident. Dyads
classified as securely attached in infancy have been found to exhibit an emotionally matched
or open style of communication (Koren-Karie, Oppenheim, Chaimovich, & EtzionCarrasso, 2001).
In the AEED, mothers and children are presented with four cards, on each of which a
name of a feeling is written: happy, mad, sad, and scared (Fivush, 1991). Dyads are asked to
remember an event in which the child felt each feeling and to jointly construct a story about
each of the events. Conversations can be classified into one of four groups, one reflecting
Emotionally Matched dyads presumably showing a psychological secure base and
three reflecting Emotionally Unmatched dyads (labeled Exaggerating, Flat, and
Inconsistent) presumably showing a lack of a psychological secure base.
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S. S. Heller et al.
Findings at 8-year follow-up

Cognitive screens and behavioral reports
Claire scored in the average range on both cognitive screens, although her adoptive mother
reported that Claire had learning difficulties. Bobby scored average in math abilities and
below average in verbal abilities. Mrs. Z reported that Bobby had been diagnosed with
Attention Deficit Hyperactivity Disorder (ADHD) for which he was receiving medication.
He had also been diagnosed with dyslexia and was currently receiving speech therapy.
Mrs. Z completed a Child Behavior Checklist (CBCL) on both children. Claire scored in
the borderline range on the externalizing scale and in the clinical range on the delinquent
subscale. Some of the items Mrs. Z endorsed as occurring often with Claire were: lies and
cheats, steals outside the home, argues a lot, destroys things belonging to others, has temper
tantrums. Her mother also reported having found Claire smoking cigarettes on two separate
occasions. Claires teacher reported, Claire desperately wants friends. She is unable to
interact appropriately, denying her that privilege. She sometime borrows personal items
from potential friends but then takes the items home. She is constantly trying to create
friendships.
Based on her report, Bobby scored in the normative range on all behavioral scales.
Bobbys score on the attention problems subscale was considerably higher than his scores on
the other subscales although it remained slightly below the borderline range. Both Mrs. Z
and Bobbys teacher indicated that he had problems with fidgeting, being easily distracted,
and being impulsive.
Childrens reports using the Berkeley Puppet Interview
Claires Berkeley Puppet Interview. Claire had a tendency to endorse contradictory items
throughout her interview. She endorsed items in the ADHD spectrum (e.g., difficulty
paying attention, difficulty sitting still). In regards to her school performance she endorsed
negative items (e.g., I think I am stupid, other kids learn faster than me, other kids know
more than me) as well as positive items (e.g., I think I am smart, I am smarter than other
kids). This contradictory pattern was repeated in regards to her peer relationships. Claire
endorsed items reflecting difficulties with her peers (e.g., I do not have a lot of friends, kids
do mean things to me, I am a lonely kid) as well as positive peer behaviors (e.g., kids like to
sit next to me, I do not tease other kids, other kids ask me to play with them). Claire
reported separation anxiety symptoms (e.g., scared to go to sleep without parent by bed, not
like going places without parents, worry parents will go away and not come back) although
she also reported that she does not worry about her parents when she is at school and that
she does not get scared if her parents go someplace without her.
Claires scale scores tended to be similar to those of her maltreated peers. She differed on
only two of the symptomatology scales, depression and anxiety; on both of these scales she
endorsed less anxiety and sadness than her maltreated peers.
Bobbys Berkeley Puppet Interview. Bobby endorsed items that reflected his AHDD diagnosis
(e.g., difficulty sitting still, difficulty paying attention) yet he also reported that he liked
school and was happy there. He reported a number of worries (e.g., I worry a lot and I
worry that bad things will happen). Many of the anxiety items that he endorsed reflected
separation concerns (e.g., worry parents will leave and never come back or scared to go
places without his parents). Bobby reported some difficulty with his peer relationships (e.g.,
feels lonely, other kids dont ask him to play, is left out of games, and he fights a lot), as well
77
as positive peer experiences (e.g., he has a lot of friends, kids like him a lot, and he helps
other kids).
Bobbys scores across the BPI domains, in comparison to the scores of maltreated children
who had completed the same intervention program, were similar, though he reported somewhat lower levels of depression, impulsivity, aggression, and school engagement than the
average scores endorsed by his maltreated peers.
Both children reported that their parents fight a lot and when their parents fight both
worried that their parents were mad at them. Marital conflict was, however, also widely
reported by their maltreated peers. Claire was less likely than her peers to perceive parental
resolution to those conflicts while Bobby was less likely than his peers to blame himself for
the conflict. Indeed, the Zs were in the midst of a contentious separation at the time of the
8-year-old evaluation; the childrens responses speak to the validity of the measure in that
they were comfortable with reporting information that is not socially desirable.
Childrens report using the Narrative Story-Stem Technique
Claires Narrative Story-Stem Technique. Claire presents several stories with unusually
frightening images, deceit, contradictory representations of parents, and incoherent story
structures. Despite the incoherent story structure and negative themes in her stories, Claire
does exhibit some positive elements, especially several representations of the mother as
authoritative disciplinarian and nurturer.
Injuries to children are enacted beginning with the Departure story. In the first scene that
Claire enacts in that story, the children go with the grandmother to the park where they
immediately fall and bloody their noses. There is no clear reparation for this injury. Soon
after this, the children deceive the grandmother by running away and then going to a store
and stealing candy. The grandmother then pursues and finds them, but the children are not
safe at this point because the stolen candy, which they ate, contained nails that get caught in
their throats. The grandmother then takes them to the hospital, providing at least some
sense of protection. Vulnerability suddenly returns in the Reunion story, where out of
nowhere a robber appears who almost kills the younger child. The police arrive and, after
some uncertainty, catch the robber.
The most dramatic enactment of vulnerability occurs in the Bathroom Shelf story where,
very abruptly, Claire re-introduces the deception theme with an enactment of the older child
smoking.
Examiner: And mom asks Jane, Jane, how did you get a Band-Aid on your finger?
Claire: (younger sister replies) Dad went to the store and bought me one, cause I cut my
finger.
Then (taking the older sister in hand) the sister was smoking, and she left the cigarette on the
ground and the house burned down (moves all off to the side)
(mother appears to ask) What happened, yall?!
(younger sister appears to reply) Oh, I dont know, but sister was smoking.
(mother) Daughter, what have you been doing (unintell.)?
(younger sister complains to mother) Now mommy, she made my toys get on fire. Mommy,
could you buy me a new toy?
(mother) Yes, sweetie, at the toy store. (moves all on table) She, um, fireman (unintell.)
Examiner: What did the firemen do?
Claire: Came and put the fire out . . . She went to buy her a toy (moves all across the table), a
Barbie, and she (refers to older sister) didnt get nothing . . .
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S. S. Heller et al.
And for smoking, she died (lays older sister down) . . . And theyre at the funeral (holds
father, mother, and younger sister in front of older sister, then moves them across table) And they
got a new house . . . And they had another daughter (stands older sister up with the rest, now
apparently as new daughter).
So she died (takes younger sister and sets her apart from the others) but she wasnt smoking.
Then they had another daughter (now sets younger sister back with the rest, apparently as
another new daughter) and that would be her.
Examiner: But she (pointing to little sister) died too?
Claire: (nods and smiles) She had another daughter, she had two more daughters . . . Now
they have a happy family (holds all in hand) . . . happy ever after.
Abrupt plot shifts are especially evident in six stories, where seemingly unrelated plot
elements suddenly appear, typically characterized by highly emotionally charged themes
(four of these are very frightening, one is an enactment of stealing, and one is of the parents
wedding). The Departure and Bathroom Shelf stories (described above) provide perhaps the
most dramatic examples of this. In two other stories, a noticeable sense of detachment is
communicated at the end, when the children are placed lying down, looking at the sky.
Deception and/or stealing are prominent themes in the narrative representations in five
stories. In three of these stories, children deceive parents or grandmother (running away,
stealing candy, sneaking a cigarette, stealing money from the mothers purse). In Monster in
the Bedroom story, in contrast, the children apparently overhear the parents fighting and ask
for an explanation. The parents response to the children, however, is to deny that they were
fighting. Stealing is enacted in two other scenes by outsiders. In the Reunion story, a
robber threatens the family, and in the Wagon story, someone steals the childrens wagon,
which is later recovered.
Despite the presence of several unusually disturbing narrative representations, positive
family interactions are also enacted. The mother is particularly authoritative in the first three
stories (Spilled Juice, Hurt Knee, and Monster in Bedroom), taking charge of situations to
effectively manage childrens behavior. There are also unambiguously positive representations of family interactions in the Broken Cup and Ball Play stories. Empathic responding of
children to the mother is enacted prominently in the two stories (Headache and Broken
Cup) designed to elicit this response. Childrens attachment behavior toward the mother
(and to a lesser extent the father) is enacted most clearly in two stories only (Wagon and
Ball Play) however, in both instances, the children seek assistance to resolve disputes
with peers.
In several stories, in contrast, the father is represented as selfish, incompetent, and
infantile. In the second story (Hurt Knee), he appears as a rival of the children, climbing the
rock and, once on top, looking down and laughing at them, which makes the younger
daughter cry. In the Bathroom Shelf story, he uses the toilet (the only character who ever
does so), and it overflows.
In summary, Claire creates several positive images in her stories, notably of the mother in
authoritative roles and of children responding empathically to her. In contrast, however,
there are few representations of childrens attachment behavior, and there are several very
unusual enactments of very frightening images and of deceit, as well as very abrupt plot
changes which are typically accompanied by highly emotionally charged themes.
Bobbys Narrative Story-Stem Technique. Bobbys narrative responses were characterized
most notably by repeating representations of detached independent behavior, especially by
the younger child. In the first story, for example, the sequence of drinking juice, spilling it,
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and cleaning up is enacted in turn by each of the four family members, independently. Injury
is frequently associated with independence. In the second story (Hurt Knee), Bobby first
enacts the parents taking the child to the doctor. He then repeats the theme of injury to the
child twice and resolves these by having the child go to the doctors by himself. The theme of
injury and reparation enacted in the Hurt Knee story is repeated in the Headache, Bathroom
Shelf, Wagon, and Ball Play stories. The representations of injury in the last story (Ball
Play) are particularly noteworthy for their apparent incongruity with the story-stem.
Here, each family member becomes injured by breaking bones, and the mother is injured
worst of all.
Bobby: (Younger child and friend approaching parents) I hurt my . . . We hurt our hands.
And they went to sleep, cause they had a cast on their hands. (subject lies younger child and
friend down together)
Examiner: They had a cast on their hands?
Bobby: And then he goes, plays with the ball, basketball (enacts the older child bouncing the
ball) He plays basketball. And then, Owww. I broke my leg. And then he went, he broke
his leg, and got a cast (subject lies older child down with younger child and friend). And then
dad went, and played basketball (subject enacts the father kicking the ball)
Examiner: What is he playing?
Bobby: Kickball. And he broke his leg (father walks away). And he laid down and got a
cast (subject lies father down with others). Then the mom went to bounce the ball. Bonk
Bonk (The ball hits the mother on the head.) Ahhh, I got a headache. I broke (subject lies
mother down with the others) . . . and now . . . and they all broke the . . . everything on their
body. The end.
Unlike the other stories in which there are enactments of injury and reparation, this story
ends with the entire family injured and no reparation provided.
Representations of family members sleeping, as seen in the above example, are common.
In addition to the Monster story, in which family members do not appear to be able to
wake up, seven of the 10 stories end with family members sleeping. Solomon, George, &
DeJong (1995) reported that such representations of sleep were indicators of avoidant
attachment.
Despite the multiple injuries to family members and some chaotic representations of
family relationships (e.g., punitive role-reversals in the Wagon story), positive themes such
as reparation, parent nurturing, and childrens attachment behavior toward parents are also
common throughout Bobbys stories. In the Broken Cup story, a structure similar to the
repetition of injury and reparation seen in several of the earlier stories is enacted. In this
story, however, the repetition is of breaking a prized object, and each family member
responds to this in turn, expressing empathy and replacement of the object. Childrens
appropriate empathic responding to the mother is also prominent in the Headache story.
The Departure Reunion story sequence (which was the basis, alone, for an analysis by
Solomon, George, & DeJong, 1995) is characterized by initial withdrawal by the children,
followed by the grandmother providing nurturance and, when the parents arrive home,
exuberant proximity seeking and affection.
In summary, in Bobbys stories there is often a sense of disconnection in family
relationships, and repeated injuries occur in several stories. Almost always, injuries are
responded to in some way with reparation, attachment behavior is frequently shown toward
parents (especially the mother), parents are represented in nurturing roles, and the story
structures are, for the most part, fairly coherent.
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The childrens Autobiographical Emotional Events Dialogue

Claire and Bobby were both coded as participating in Unmatched-Flat dialogues. Flat dyads
are characterized by the lack of development of the stories and by their lack of involvement
and interest in the task. Mother and child may mention names of emotions, but there is
almost no development of the meaning of the emotion. The stories tend to be very short and
often mother and child cannot provide four stories and consequently cannot completing the
task. Mother and child do not seem to be bothered by their lack of ability to provide four
different stories, and the mothers do not try to refresh their childrens memory or to
encourage them to develop a story.
Claires Autobiographical Emotional Events Dialogue. A pattern of impoverished narratives was
evident between Mrs. Z and Claire. When Claire and Mrs. Z are talking about the happy
card, we get four different labels for happiness but none of them developed into a full story:
Mrs. Z: Happy
Claire: Im happy when I go to school.
Mrs. Z: When you go to school you are happy?
Claire nods
Mrs. Z: What else makes you happy?
Claire: Um, my friends.
Mrs. Z: And how about when you see your favorite person?
Claire: Ya!
Mrs. Z: Were gonna go see all your little friends soon. What else makes you happy?
Claire: When I go shopping.
Mrs. Z: When you go shopping? That makes me happy too. OK. Wanna go to the next
card?
In this short example it can be seen that the dialogue between Claire and Mrs. Z is very
limited and shallow. They did not come up with an episodic story concerning a happy event,
but rather mention titles for different events. The mother did not try to coax the child to tell
more details, and as a result it is not really known why, for example, she is happy in school.
There were no answers in the text, and neither mother nor child seemed to be bothered by
that. It seems as if naming an event as happy is the most they could do. Such an emotional
climate may convey to the child the message that she should not look deeper for reasons for
her feelings and that talking about emotions only means labeling events with the right
names.
Bobbys Autobiographical Emotional Events Dialogue. When Mrs. Z was talking with Bobby,
she did not help him construct full stories but rather appeared satisfied with adequate labels.
This is very obvious in their talking about the Scared card.
Mrs. Z: Scared.
Bobby: I am, I was, I am scared.
Mrs. Z: What are you scared of?
Bobby: Of the dark.
Mrs. Z: Of the dark?
Bobby: Yeah.
Mrs. Z: Do you know why?
81
Bobby: Yeah.
Mrs. Z: Why?
Bobby: Cause I hate the dark!
Mrs. Z: You hate the dark? What else are you scared of?
In this short example it can be seen that Mrs. Z repeats Bobbys word and does not help him
to elaborate on the dark story or ask him to give more details relating to his feelings. She
accepts his statement that he hates the dark as a sufficient elaboration and continues to
another example without resolving the negative feelings of being scared of the dark.
Discussion
The long-term sequelae of RAD diagnosed in early childhood are unknown. The little
existing data on institutionalized children, most of who show little coherent attachment
behavior while institutionalized (Zeanah, Smyke, & Dumitrescu, 2002), suggest varied
outcomes once institutionalized children are adopted into families. While the twins followed
in this case experienced gross disturbances in early care, they were never institutionalized.
This is the first longitudinal case report of children diagnosed with RAD in early childhood
and seen in follow-up.
The twins early experiences were extreme, though not inconsistent with those
experienced by many young children placed in early foster care. The predictive validity of
a diagnosis of RAD, and of these associated behaviors, is unknown. This is partly because
measures for assessing attachment in middle childhood, by tapping into what Dodge and
Rabiner (2004) have called latent mental structures, have only recently been developed.
Both age-appropriate and validated measures of cognitive and behavioral functioning were
used as well as narrative measures of attachment to capture each childs internal experiences
and expectations for relationships.
One way to make sense of the data gathered on the twins at follow-up is to consider the
findings from a psychiatric diagnostic perspective and from a relational or social information
processing perspective (Dodge & Rabiner, 2004). From a diagnostic perspective, the twins
symptoms at age 8 years were indicative of differing trajectories, most likely because their
symptom complexes had always been different. For each, symptoms were evident by both
parent and self-report.
Claire was reported by her mother to be evidencing delinquent behavior, a concern also
raised by her teacher. Her self-report on the Berkeley Puppet Interview was inconsistent
across most domains of functioning, but the themes of her story-stem responses included
delinquent acts and deceit and she even portrayed a young child smoking, a specific act her
mother had been concerned about. She endorsed lower levels of anxiety and depression than
a group of maltreated peers who were also placed in foster care before age 4 years and
followed as part of a larger study. Whether this represents the kind of affective disengagement
typical of children with early conduct disorder is unclear. What anxiety she did endorse, like
her brother, concerned separation.
Bobby endorsed symptoms of ADHD and Developmental Reading Disorder through the
Berkeley Puppet Interview; his mother endorsed attentional deficits and impulsivity on the
CBCL as well and his cognitive screen documented below average verbal abilities.
Social information processing (or social cognitive processing) refers to the engagement of
mental representations in social situations (Dodge & Rabiner, 2004). Discerning
how mental representations then influence social behavior is an important goal of research
in the social information processing area. Both the Narrative Story-Stems Technique and
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S. S. Heller et al.
the Autobiographical Emotional Events Dialogue, as described above, require narrative

responses, which are then recorded and coded. Claires narratives were compelling in light
of the reports of her adoptive mother and teacher about her behavior. Her mother reported
behaviors above the clinical cutoff for delinquent behavior on the Child Behavior Checklist
and her teacher viewed Claire as desperately want[ing] friendships, though her
interactions with peers were conflictual. The themes of half of her narratives centered
around deception and/or stealing. Her stories were marked by abrupt and confusing plot
shifts with calamitous events suddenly befalling the children. The children in her stories
were portrayed as being very vulnerable yet they were also deceitful and ended up
experiencing much unpredictable calamity. Interestingly, her self-report from the Berkeley
Puppet Interview was quite contradictory regarding her relationships with peers and her
fears about separation from her caregivers. She both endorsed and denied difficulty with
friendships and fear of separation from her caregivers. The co-constructed narrative with her
mother was marked by considerable emotional disengagement. It is likely this disengagement characterizes their relationship (e.g., narrative measures have been shown to have
moderate to high stability), though it is unclear how this pattern has been shaped by previous
history of interactions (e.g., Claires controlling behavior at age 3 years) or current events
likely to be distressing to both partners (e.g., the marital discord and separation).
Nevertheless, the combination of Claires externalizing symptoms, contradictory report of
current functioning, chaotic personal narratives, struggles with friendships, and emotional
disengagement with the caregiver she portrays in her narratives as most nurturing, result in a
clinical picture that is quite concerning.
Bobbys response patterns are interesting in several ways. First, despite his difficulties with
attention and verbal processing, his stories were reasonably coherent and highly developed.
His observed impulsive and self-endangering behavior at age 3 years is evident still at age 8
years even in the content of many of his stories which involve repeated injuries and
reparation of injures. Though he depicts nurturing of children by caregivers in his stories,
there is also a good deal of avoidance, with children acting autonomously to care for
themselves and family members sleeping rather than interacting. As the case with his sister,
the tendency toward avoiding emotional expression is also evident in Bobby and his adoptive
mothers shared narratives in which emotions were labeled with little elaboration such that
the experience of having an emotion remained undeveloped. His self-report of separation
anxiety symptoms is interesting in light of the relatively strong avoidance depicted in his
stories. Separation anxiety is certainly not unexpected, given his early history of multiple
placements and the contemporaneous separation of his adoptive parents; nevertheless, the
avoidant aspects of his narratives suggest that it might be difficult for him to directly express
this anxiety.
Each twin exhibited different patterns of behavior across time. For Claire, the sequence
consisted of extreme inhibition as an infant, controlling behavior as a preschooler, and
conduct symptoms with affective disengagement and peer relationship problems as a schoolaged child. Bobby was socially indiscriminate as an infant, self-endangering as a preschooler,
and had impulsivity and attention difficulties at 8 years of age. What seems clear is that life
stressors, from early neglect to later family discord, may have impacted each child
differently, perhaps due to underlying differences in temperament. The narrative measures
are helpful in tracking how early attachment disruption is associated with later expectations
about relationships.
It had been hoped to re-engage this family in treatment following the 8-year assessment of
the twins. Unfortunately, though the twins adoptive mother received feedback about our
research teams concerns, particularly about Claire, and agreed to individual and/or family
83
therapy, she did not bring the children in for treatment (despite repeated calls). Our plan
was to begin with family assessment, especially given our sense, as reviewed by Byng-Hall
(1995), that attachment-based family work might be useful in targeting child behavior (see
also Safier, 2003). Of course, the separation of the adoptive parents is a clinical wildcard in
this case; without a comprehensive family assessment the options for clinical intervention are
very limited.
If Claires symptoms were not to improve with family-based intervention, one option
would be to adapt the work of Moretti, Holland, and Peterson (1994) who have shown
promising results using an attachment-based treatment for adolescents with conduct
disorder. One clinical quandary in attachment-based narrative work with children who
experienced early disruptions in care concerns the degree to which the therapist joins with
the child to create a new relationship. It has been argued that working through the caregiver
is most appropriate under these circumstances since the creation and eventual dissolution of
even a therapeutic relationship may be difficult for the child (American Psychiatric
Association, 1994). Given the relatively disengaged narratives co-constructed by each twin
with their adoptive mother, it is hard to know how reflective and open to change the adoptive
mother might be. Assessing reflective function through the use of further narrative
interviews with the adoptive mother would likely be useful in charting a course for
intervention (Oppenheim & Koren-Karie, 2002).
Strengths and limitations
The utility of the case study methodology in psychological research has been debated.
Critics of the case study consider the methodology to be unscientific because of its
dependence upon anecdotal and retrospective information, lack of control of extraneous
variables, and an inability to generalize findings. Conversely, others argue that the ability to
facilitate the discovery of aspects of a phenomenon in question represent a considerable
strength of case studies (Gilgun, 1991; Trepper, 1990). A considerable strength of this case
study is its longitudinal nature and the selection of subjects (e.g., maltreated siblings
diagnosed before age 3 years with RAD) of clinical interest. Remarkable associations were
found between measures at each age even when standardized follow-up measures coded by
reviewers masked to the childrens early history were used. Nevertheless, the findings
regarding the clinical course of these children only begin to shed light on the possible
outcomes of other maltreated young children with attachment disruptions before age 4
years. As OConnor (2003) suggests, more research on how early attachment relates to
patterns of development of high-risk children over time is necessary. This case suggests that
the use of standardized tools, including narrative measures, will help inform both research
and practice. The course of institutionalized children with early attachment disruptions has
been systematically studied recently. Comprehensive assessment of non-institutionalized
maltreated children in infancy and early childhood using observational and narrative
measures derived from attachment research is now possible. In the future, the use of school
age measures capturing both eventual psychiatric symptomatology and social cognitive
processing will enrich our understanding of how maltreated children develop.
Acknowledgements
The authors would like to thank the twins and their families for sharing their lives with us.
We would also like to express our gratitude to Charles H. Zeanah, MD, and all of his staff
and clinicians on the Tulane University Infant Team for their commitment to this family
84
S. S. Heller et al.
and other families exposed to maltreatment. And finally, we would like to acknowledge the
hard work and dedication of all the Childhood Behavior Study research assistants for
collecting the assessments discussed in this paper.
References
Ablow, J. C., & Measelle, J. R. (1993). Berkeley Puppet Interview: Administration and scoring system manuals.
Unpublished manuscript, University of California at Berkeley.
Ainsworth, M. D. S. (1992). A consideration of social referencing in the context of attachment theory and research.
In S. Feinman (Ed.), Social referencing and the social construction of reality in infancy (pp. 349 367). New York:
Plenum Press.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington,
DC: Author.
Benoit, D., Parker, K., & Zeanah, C. H. (1997). Mothers representations of their infants assessed prenatally:
Stability and association with infants attachment classifications. Journal of Child Psychology and Psychiatry, 38,
307 313.
Bolger, K. E., Patterson, C. J., & Kupersmidt, J. B. (1998). Peer relationships and self-esteem among children who
have been maltreated. Child Development, 69, 1171 1197.
Boris, N. (2003). Attachment, aggression, and holding: A cautionary tale. Attachment and Human Development, 5,
245 247.
Boris, N. W., Hinshaw-Fuselier, S. S., Smyke, A. T., Scheeringa, M. S., Heller, S. S., & Zeanah, C. H. (2004).
Comparing criteria for attachment disorders: Establishing reliability and validity in high-risk samples. Journal of
the American Academy of Child & Adolescent Psychiatry, 43, 568 577.
Boris, N. W., Zeanah, C. H., Scheeringa, M. S., Larrieu, J. L., & Heller, S. S. (1998). Attachment disorders in
infancy and early childhood: A preliminary investigation of diagnostic criteria. American Journal of Psychiatry,
155, 295 297.
Bowlby, J. (1944a). Forty-four juvenile thieves: Their characters and home-life. International Journal of PsychoAnalysis, 25, 19 53.
Bowlby, J. (1944b). Forty-four juvenile thieves: Their characters and home-life (II). International Journal of PsychoAnalysis, 25, 107 128.
Bowlby, J. (1973). Attachment and loss. Vol. 2: Separation: Anxiety and anger. New York: Basic Books.
Bretherton, I., Oppenheim, D., Buchsbaum, H., Emde, R., and the MacArthur Narrative Group. (1990). The
MacArthur story-stem battery. Unpublished manual, University of Wisconsin-Madison.
Bretherton, I., Ridgeway, D., & Cassidy, J. (1990). Assessing the internal working models of the attachment
relationship: An attachment story completion task for 3-year-olds. In M. T. Greenberg, D. Cicchetti, & E. M.
Cummings (Eds.), Attachment in the preschool years: Theory, research, and intervention (pp. 273 308). Chicago:
University of Chicago Press.
Byng-Hall, J. (1995). Creating a secure family base: some implications of attachment theory for family therapy.
Family Process, 34, 45 58.
Chrisholm, K. (1998). A three year follow-up of attachment and indiscriminate friendliness in children adopted
from Romanian orphanages. Child Development, 69, 1092 1106.
Chrisholm, K., Carter, M. C., Ames, E. W., & Morrison S. J. (1995). Attachment security and indiscriminate
friendly behavior in children adopted from Romanian orphanages. Developmental Psychopathology, 7, 283 294.
Dodge, K., & Rabiner, D. L. (2004). Returning to roots: On social information processing and moral development.
Child Development, 75, 1003 1008.
Dunn, J., Bretherton, I., & Munn, P. (1987). Conversations about feeling states between mothers and their young
children. Developmental Psychology, 23, 132 139.
Essex, M. J., Boyce, W., Goldstein, L. H., Armstrong, J. M., Kraemer, H. C., & Kupfer, D. J. (2002). The
confluence of mental, physical, social, and academic difficulties in middle childhood II: Developing the
MacArthur Health and Behavior Questionnaire. Journal of the American Academy of Child and Adolescent
Psychiatry, 41, 588 603.
Etzion-Carasso, A., & Oppenheim, D. (2000). Open mother preschooler communication: Relations with early
secure attachment. Attachment & Human Development, 2, 347 370.
Fivush, R. (1991). The social construction of personal narratives. Merrill-Palmer Quarterly, 37, 59 82.
Gilgun, J. F. (1991). Discovery oriented, qualitative methods relevant to longitudinal research on child abuse and
neglect. In R. H. Starr & D. A. Wolfe (Eds.), The effects of child abuse and neglect: Issues and research (pp. 144
163). New York: Guilford Press.
85
Granot, D., & Mayseless, O. (2001). Attachment security and adjustment to school in middle childhood.
International Journal of Behavioural Development, 25, 530 541.
Green, J. M., & Goldwyn, R. (2002). Annotation: Attachment disorganization and psychopathology: New findings
in attachment research and their potential implications for developmental psychopathology in childhood.
Journal of Child Psychology and Psychiatry, 43, 835 846.
Heller, S., Aoki, Y., Crowell, J., Chase-Lansdale, P. L., Brooks-Gunn, J., Schoffner, K., & Zamsky, E. S. (1998).
Parent child interaction procedure: Coding manual. Unpublished manuscript.
Hinshaw-Fuselier, S., Boris, N. W., & Zeanah, C. Z. (1999). Reactive attachment disorder in maltreated twins.
Infant Mental Health Journal, 20, 42 59.
Kim, J., & Cicchetti, D. (2004). A longitudinal study of child maltreatment, mother child relationship quality
and maladjustment: The role of self-esteem and social competence. Journal of Abnormal Child Psychology, 32,
341 354.
Koren-Karie, N., Oppenheim, D., Chaimovich, Z., & Etzion-Carasso, A. (2001, April). Mother-child communication
about emotions: Relation with early attachment. Paper presented at the biennial meeting of the Society for Research
in Child Development, Minneapolis, MN.
Koren-Karie, N., Oppenheim, D., Chaimovich, Z., & Etzion-Carasso, A. (2003). Dialogues of seven-year-olds with
their mothers about emotional events: Development of typology. In R. Emde, D. P. Wolf, & D. Oppenheim
(Eds.), Affective meaning making in narratives: Studies with young children (pp. 338 354). New York: Oxford
Press.
Laible, D. J., & Thompson, R. A. (1998). Attachment and emotional understanding in preschool children.
Developmental Psychology, 34, 1038 1045.
Levy, T. M., & Orlans, M. (1998). Attachment, trauma, and healing: Understanding and treating attachment disorders in
children and families. Washington, DC: Child Welfare League of America.
Main, M., & Cassidy, J. (1988). Categories of response to reunion with the parent at age 6: Predictable from infant
attachment classifications and stable over a 1-month period. Developmental Psychology, 24, 415 426.
Main, M., & Hesse, E. (1990) Parents unresolved traumatic experiences are related to infant disorganized
attachment status: Is frightening and/or frightened behavior the linking mechanism? In M. T. Greenberg,
D. Cicchetti, & E. M. Cummings (Eds.), Attachment in the preschool years: Theory, research and intervention
(pp. 161 182). Chicago: University of Chicago Press.
Main, M., Kaplan, N., & Cassidy, J. (1985). Security in infancy, childhood, and adulthood: A move to the level of
representation. In I. Bretherton & E. Waters (Eds.), Growing points of attachment theory and research.
Monographs of the Society for Research in Child Development, 50. (1 2, Serial No. 209).
Main, M., & Solomon, J. (1990). Procedures for identifying infants as disorganized/disoriented during the strange
situation. In M. T. Greenberg, D. Cicchetti, & E. M. Cummings (Eds.), Attachment in the preschool years:
Theory, research and intervention (pp. 134 146). Chicago: University of Chicago Press.
Measelle, J. G., Ablow, J. C., Cowan, P. A., & Cowan, C. P. (1998). Assessing young childrens views of their
academic, social, and emotional lives: An evaluation of the self-perception scales of the Berkeley Puppet
Interview. Child Development, 69, 1556 1576.
Mercer, J., Sarner, L., & Rosa, L. (2003). Attachment therapy on trial: The torture and death of Candace Newmaker.
Westport, CT: Praeger Publishers/Greenwood Publishing Group, Inc.
Moretti, M. M., Holland, R., & Peterson, S. (1994). Long-term outcome of an attachment-based program for
conduct disorder. Canadian Journal of Psychiatry, 39, 360 369.
OConnor, T. (2003). Early experience and psychological development: Conceptual questions, empirical
illustrations, and implications for intervention. Development and Psychopathology, 15, 671 690.
OConnor, T. G. (2002). Attachment disorders in infancy and childhood. In M. Rutter & E. Taylors (Eds.),
Child and adolescent psychiatry: Modern approaches (4th ed., pp. 776 792). Boston: Blackwell Scientific
Publications.
OConnor, T. G., Bredenkamp, D., Rutter, M., & The English and Romanian Adoptees (ERA) Study Team.
(1999). Attachment disturbances and disorders in children exposed to early severe deprivation. Infant Mental
Health Journal, 20, 10 29.
OConnor, T. G., Rutter, M., & The English and Romanian Adoptees (ERA) Study Team. (2000). Attachment
disordered behavior following early severe deprivation: Extension and longitudinal follow-up. Journal of the
American Academy of Child and Adolescent Psychiatry, 39, 703 712.
Oppenheim, D., & Koren-Karie, N. (2002). Mothers insightfulness regarding their infants internal
experience: Relations with maternal sensitivity and infant attachment. Developmental Psychology, 38, 534
542.
Page, T. (2001). The social meaning of childrens narratives: A review of the attachment-based narrative story-stem
technique. Child and Adolescent Social Work Journal, 18, 171 187.
86
S. S. Heller et al.
Page, T., & Bretherton, I. (2001). Mother and father child attachment themes in the story completions of
preschoolers from postdivorce families: Do they predict relationships with peers and teachers? Attachment and
Human Development, 3, 1 29.
Safier, E. J. (2003). Seven ways that the concepts of attachment, mentalization and theory of mind transform family
treatment. Bulletin of the Menninger Clinic, 67, 260 270.
Settles, L. D. (2003). Narrative representation in a sample of maltreated children. Unpublished doctoral dissertation,
University of Indianapolis, IN.
Smyke, A. T., Dumitrescu, A., & Zeanah, C. H. (2002). Attachment disturbances in young children I: The
continuum of caretaking casualty. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 972
982.
Snow, C. E. (1990). Building memories: The ontogeny of autobiography. In D. Cicchetti and M. Beeghly (Eds.),
The self in transition (pp. 213 242). Chicago: The University of Chicago Press.
Solomon, J., George, C., & DeJong, A. (1995). Children classified as controlling at age six: Evidence of
disorganized representational strategies and aggression at home and at school. Development and Psychopathology,
7, 447 463.
Trepper, T. (1990). In celebration of the case study. Journal of Family Psychotherapy, 1, 5 13.
Verschueren, K., & Marcoen, A. (1999). Representations of self and social emotional competence in
kindergarteners: Differential and combined effects of attachment to mother and to father. Child Development,
70, 183 201.
Vondra, J., Barnett, D., & Cicchetti, D. (1989). Perceived and actual competence among maltreated and
comparison school children. Development and Psychopathology, 1, 237 255.
Warren, S. L., Emde, R. N., & Sroufe, L. A. (2000). Internal representations: Predicting anxiety from childrens
play narratives. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 100 107.
Wartner, U., Grossmann, K., Fremmer-Bombik, E., & Suess, G. (1994). Attachment patterns at age six in South
Germany: Predictability from infancy and implications for preschool behavior. Child Development, 65, 1014
1027.
World Health Organization. (1992). The ICD-10 classifications of mental and behavioral disorders: Clinical descriptions
and diagnostic guidelines. Geneva: Author.
Zeanah, C. H. (1996). Beyond insecurity: A reconceptionalization of attachment disorders of infancy. Journal of
Consulting and Clinical Psychology, 64, 42 57.
Zeanah, C. H., & Benoit, D., (1995). Clinical applications of a parent perception interview in infant mental health.
Child and Adolescent Psychiatric Clinics of North America, 43, 539 554.
Zeanah, C. H., & Boris, N. (2000). Disturbances and disorders of attachment in early childhood. In C. H. Zeanah
(Ed.), Handbook of Infant Mental Health (pp. 353 368). New York: Guilford Press.
Zeanah, C. H., Boris, N., Bashki, S., & Leiberman, A. (2000). Disorders of attachment. In J. Osofsky &
H. Fitzgerald (Eds.), WAIMH Handbook of Infant Mental Health (pp. 92 122). New York: Wiley.
Zeanah, C. H., Boris, N., & Leiberman, A. (2000). Attachment disorders of infancy. In A. Sameroff & M. Lewis
(Eds.), Handbook of developmental psychopathology (2nd ed., pp. 293 307). Dordrecht: Kluwer Academic
Publishers.
Zeanah, C. H., & Larrieu, J. (1998). Intensive intervention for maltreated infants and toddlers in foster care. Child
and Adolescent Psychiatric Clinics of North America, 7, 357 371.
Zeanah, C. H., & OConnor, T. G. (2003). Attachment disorders: Assessment strategies and treatment approaches.
Attachment & Human Development, 5, 223 244.
Zeanah, C. H., Smyke, A. T., & Dumitrescu, A. (2002). Attachment disturbances in young children. II:
Indiscriminate behavior and institutional care. American Academy of Child & Adolescent Psychiatry, 41, 983 989.

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Attachment & Human Development,

March 2006; 8(1): 63 86

Reactive attachment disorder in maltreated twins

SHERRYL SCOTT HELLER1, NEIL W. BORIS1,2,

middle childhood. Included in this section is a review of available data on institutionalized

RAD in Maltreated Twins

to be shallow. Some exhibit hyperactivity and attention problems as well as difficulties in

. In-home intervention unsuccessful

. Kin placement fails (family is evicted from home)

. Children start at a child care center

. Burns found on twins hands

. Ms & Mr. 5th foster home requested

. Moved into 3rd foster home

. Children are transitioned back to

. Children are returned to 3rd foster home

. Moved from 3rd foster home into respite

. Children moved to aunt and uncles home (Mr. & Mrs. Z)

. Children returned to 5th foster home

. Twins returned to aunt and uncle

. Custody is legally transferred

Prior to Infant Team involvement

. Occupational evaluation of twins

. Developmental testing of twins

. IMH team evaluation includes:

. Twins remain with Mr. & Mrs. Z

. Twins residing with Mrs. Z

. Mr. & Mrs. Z report marital discord.

cognitive screens (PPVT & KBIT)

Second research assessment includes:

. First research assessment includes

RAD in Maltreated Twins

Table II. X twins diagnostic behavior at time of evaluation (18 months).

Behaviors observed in the clinic

Mrs. X with the

Children were not observed with

Mr. X with the

. Alternates between dismissing childrens

RAD in Maltreated Twins

RAD in Maltreated Twins

RAD in Maltreated Twins

unconscious memory. Attachment security assessed through representational measures in

Table III. List of story-stems used with twins.

The mother and dad return from their trip.1

The Bathroom Shelf

Story 10 Play with Ball

Jane/Robert is playing with her/his ball with her/his friend, Mary/Pete.

RAD in Maltreated Twins

Findings at 8-year follow-up

RAD in Maltreated Twins

RAD in Maltreated Twins

The childrens Autobiographical Emotional Events Dialogue

RAD in Maltreated Twins

the Autobiographical Emotional Events Dialogue, as described above, require narrative

RAD in Maltreated Twins

RAD in Maltreated Twins

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