The term attachment disorder is most often used to describe emotional and behavioral problems of young children.

Attachment disorder is a broad term intended to describe disorders of mood, behavior, and social relationships arising from a failure to form normal attachments to primary care giving figures in early childhood, resulting in problematic social expectations and behaviors. Behavior or behaviour (see spelling differences) refers to the actions or Reactions of an object or Organism, usually Social relation can refer to a multitude of Social interactions regulated by Social norms between two or more people with each having a Social position Attachment theory, originating in the work of John Bowlby, is a Psychological, evolutionary and ethological theory that provides a descriptive Attachment in children is a theory of attachment between children and their caregivers specifically addressing the behaviors and emotions that children direct toward familiar adults Such a failure would result from unusual early experiences of neglect, abuse, abrupt separation from caregivers after about six months but before about three years, frequent change of caregivers or excessive numbers of caregivers, or lack of caregiver responsiveness to child communicative efforts. Child abuse is the physical, psychological or sexual maltreatment of children A problematic history of social relationships occurring after about age three may be distressing to a child, but does not result in attachment disorder.

The term attachment disorder is most often used to describe emotional and behavioral problems of young children, but is sometimes applied to school-age children or even to adults. An emotion is a mental and physiological state associated with a wide variety of feelings thoughts and behaviours Behavior or behaviour (see spelling differences) refers to the actions or Reactions of an object or Organism, usually The specific difficulties implied depend on the age of the individual being assessed and a child's attachment-related behaviors may be very different with one familiar adult than with another, suggesting that the disorder is within the relationship and interactions of the two people rather than an aspect of one or the other personality. ^[1] No list of symptoms can legitimately be presented but generally the term attachment disorder refers to the absence or distortion of age-appropriate social behaviors with adults. A symptom' (from Greek σύμπτωμα, "accident misfortune that which befalls" from συμπίπτω, "I befall" from For example, in a toddler, attachment-disordered behavior could include a failure to stay near familiar adults in a strange environment or to be comforted by contact with a familiar person, whereas in a six-year-old attachment-disordered behavior might involve excessive friendliness and inappropriate approaches to strangers.

There are currently two main areas of theory and practice relating to the definition and diagnosis of attachment disorder, and considerable discussion about a broader definition altogether. The word theory has many distinct meanings in different fields of Knowledge, depending on their methodologies and the context of discussion. Diagnosis is the identification by Process of elimination, of the nature of anything The first main area is based on scientific enquiry, is found in academic journals and books and pays close attention to attachment theory. Attachment theory, originating in the work of John Bowlby, is a Psychological, evolutionary and ethological theory that provides a descriptive It is described in ICD-10 as reactive attachment disorder, or "RAD" for the inhibited form, and disinhibited attachment disorder, or "DAD" for the disinhibited form. The International Statistical Classification of Diseases and Related Health Problems 10th Revision ( ICD -10) is a coding of diseases and signs symptoms abnormal findings Reactive attachment disorder ( RAD) is described in clinical literature as a severe and relatively uncommon Attachment disorder that can affect children Disinhibited attachment disorder of childhood (DAD according to the International Classification of Diseases ( ICD-10) is defined as "A particular In DSM-IV-TR both comparable inhibited and disinhibited types are called reactive attachment disorder or "RAD". The Diagnostic and Statistical Manual of Mental Disorders' ( DSM) is published by the American Psychiatric Association The second area is controversial and is found in clinical practice, on websites and in books and publications, has little or no evidence base and makes controversial claims relating to a basis in attachment theory. Evidence-based medicine (EBM aims to apply Evidence gained from the Scientific method to certain parts of medical practice ^[2] The use of these controversial diagnoses of attachment disorder is linked to the use of controversial attachment therapies to treat them. Diagnosis is the identification by Process of elimination, of the nature of anything ^[3]

Thirdly, some authors have suggested that attachment, as an aspect of emotional development, is better assessed along a spectrum than considered to fall into two non-overlapping categories. Child development refers to the biological and psychological changes that occur in human beings between birth and the end of Adolescence, as the individual This spectrum would have at one end the characteristics called secure attachment; midway along the range of disturbance would be insecure or other undesirable attachment styles; at the other extreme would be non-attachment. ^[4] Agreement has not yet been reached with respect to diagnostic criteria. ^[5]

Finally, the term is also sometimes used to cover difficulties arising in relation to various attachment styles which may not be disorders in the clinical sense.

The present article will consider ways of looking at attachment-related problems ranging from mild to serious.

Attachment and attachment disorder

Main article: Attachment theory

Main article: Attachment in children

Attachment theory is primarily an evolutionary and ethological theory. Attachment theory, originating in the work of John Bowlby, is a Psychological, evolutionary and ethological theory that provides a descriptive Attachment in children is a theory of attachment between children and their caregivers specifically addressing the behaviors and emotions that children direct toward familiar adults Attachment theory, originating in the work of John Bowlby, is a Psychological, evolutionary and ethological theory that provides a descriptive An adaptation is a characteristic of an Organism that has been favored by Natural selection and Ethology ( from Greek ἦθος ethos, "character" and λόγος logos, "knowledge") is the scientific study of Animal In relation to infants, it primarily consists of proximity seeking to an attachment figure in the face of threat, for the purpose of survival. ^[6] Although an attachment is a "tie" it is not synonymous with love and affection although they often go together and a healthy attachment is considered to be an important foundation of all subsequent relationships. Infants become attached to adults who are sensitive and responsive in social interactions with the infant, and who remain as consistent caregivers for some time. Social interaction is a dynamic changing sequence of Social actions between individuals (or groups who modify their actions and reactions according to the actions by their Parental responses lead to the development of patterns of attachment which in turn lead to 'internal working models' which will guide the individual's feelings, thoughts and expectations in later relationships. ^[7]

In the clinical sense, a disorder is a condition requiring treatment as opposed to risk factors for subsequent disorders. Clinical psychology includes the scientific study and application of Psychology for the purpose of understanding preventing A disease is an abnormal condition of an organism that impairs bodily functions and can be deadly ^[8] There is a lack of consensus about the precise meaning of the term 'attachment disorder' although there is general agreement that such disorders only arise following early adverse caregiving experiences. Reactive attachment disorder indicates the absence of either or both the main aspects of proximity seeking to an identified attachment figure. Reactive attachment disorder ( RAD) is described in clinical literature as a severe and relatively uncommon Attachment disorder that can affect children This can occur either in institutions, or with repeated changes of caregiver, or from extremely neglectful primary caregivers who show persistent disregard for the child's basic attachment needs after the age of 6 months. Current official classifications of RAD under DSM-IV-TR and ICD-10 are largely based on this understanding of the nature of attachment. The Diagnostic and Statistical Manual of Mental Disorders' ( DSM) is published by the American Psychiatric Association The International Statistical Classification of Diseases and Related Health Problems 10th Revision ( ICD -10) is a coding of diseases and signs symptoms abnormal findings

The words attachment style refer to the various types of attachment arising from early care experiences, called secure, anxious-ambivalent, anxious-avoidant, (all organized), and disorganized. Attachment in children is a theory of attachment between children and their caregivers specifically addressing the behaviors and emotions that children direct toward familiar adults Some of these styles are more problematical than others, and, although they are not disorders in the clinical sense, are sometimes discussed under the term 'attachment disorder'.

Discussion of 'disorganized attachment' style sometimes includes this style under the rubric of attachment disorders because disorganized attachment is seen as the beginning of a developmental trajectory that will take the individual ever further from the normal range, culminating in actual disorders of thought, behavior, or mood. ^[9] Early intervention for disorganized attachment, or other problematic styles, is directed toward changing the trajectory of development to provide a better outcome later in the person's life.

Zeanah and colleagues proposed an alternative set of criteria (see below) of three categories of attachment disorder, namely "no discriminated attachment figure", "secure base distortions" and "disrupted attachment disorder". Charles H Zeanah Jr MD is a child and adolescent psychiatrist who is a member of the Council (Board of the American Academy of Child and Adolescent Psychiatry In Psychometrics, criterion validity is a measure of how well one Variable or set of variables predicts an outcome based on information from other variables These classifications consider that a disorder is a variation that requires treatment rather than an individual difference within the normal range. ^[10]

Classification

Main article: Reactive attachment disorder

ICD-10 describes Reactive Attachment Disorder of Childhood, known as RAD, and Disinhibited Disorder of Childhood, less well known as DAD. Reactive attachment disorder ( RAD) is described in clinical literature as a severe and relatively uncommon Attachment disorder that can affect children The International Statistical Classification of Diseases and Related Health Problems 10th Revision ( ICD -10) is a coding of diseases and signs symptoms abnormal findings Reactive attachment disorder ( RAD) is described in clinical literature as a severe and relatively uncommon Attachment disorder that can affect children Disinhibited attachment disorder of childhood (DAD according to the International Classification of Diseases ( ICD-10) is defined as "A particular DSM-IV-TR also describes Reactive Attachment Disorder of Infancy or Early Childhood. The Diagnostic and Statistical Manual of Mental Disorders' ( DSM) is published by the American Psychiatric Association Reactive attachment disorder ( RAD) is described in clinical literature as a severe and relatively uncommon Attachment disorder that can affect children They divide this into two subtypes, Inhibited Type and Disinhibited Type, both known as RAD. The two classifications are similar and both include:

• markedly disturbed and developmentally inappropriate social relatedness in most contexts,
• the disturbance is not accounted for solely by developmental delay and does not meet the criteria for Pervasive Developmental Disorder,
• onset before 5 years of age,
• requires a history of significant neglect, and
• implicit lack of identifiable, preferred attachment figure. The diagnostic category pervasive developmental disorders (PDD as opposed to Specific developmental disorders (SDD refers to a group of five disorders characterized

ICD-10 includes in its diagnosis psychological and physical abuse and injury in addition to neglect. Child abuse is the physical, psychological or sexual maltreatment of children This is somewhat controversial, being a commission rather than omission and because abuse of itself does not lead to attachment disorder.

The inhibited form is described as "a failure to initiate or respond. . . to most social interactions, as manifest by excessively inhibited responses" and such infants do not seek and accept comfort at times of threat, alarm or distress, thus failing to maintain 'proximity', an essential element of attachment behavior. The disinhibited form shows "indiscriminate sociability. . . excessive familiarity with relative strangers" (DSM-IV-TR) and therefore a lack of 'specificity', the second basic element of attachment behavior. The ICD-10 descriptions are comparable. 'Disinhibited' and 'inhibited' are not opposites in terms of attachment disorder and can co-exist in the same child. The inhibited form has a greater tendency to ameliorate with an appropriate caregiver whilst the disinhibited form is more enduring. ^[11]

Whilst RAD is likely to occur following neglectful and abusive childcare, there should be no automatic diagnosis on this basis alone as children can form stable attachments and social relationships despite marked abuse and neglect. Abuse can occur alongside the required factors but on its own does not explain attachment disorder. Experiences of abuse are associated with the development of disorganised attachment, in which the child prefers a familiar caregiver, but responds to that person in an unpredictable and somewhat bizarre way. Within official classifications, attachment disorganization is a risk factor but not in itself an attachment disorder. Further although attachment disorders tend to occur in the context of some institutions, repeated changes of primary caregiver or extremely neglectful identifiable primary caregivers who show persistent disregard for the child's basic attachment needs, not all children raised in these conditions develop an attachment disorder. ^[12]

Boris and Zeanah's typology

Many leading attachment theorists, such as Zeanah and Leiberman, have recognized the limitations of the DSM-IV-TR and ICD-10 criteria and proposed broader diagnostic criteria. There is as yet no official consensus on these criteria. The APSAC Taskforce recognised in its recommendations that "attachment problems extending beyond RAD, are a real and appropriate concern for professionals working with children", and set out recommendations for assessment. ^[13]

Boris and Zeanah (1999),^[14] have offered an approach to attachment disorders that considers cases where children have had no opportunity to form an attachment, those where there is a distorted relationship,and those where an existing attachment has been abruptly disrupted. This would significantly extend the definition beyond the ICD-10 and DSM-IV-TR definitions because those definitions are limited to situations where the child has no attachment or no attachment to a specified attachment figure.

Boris and Zeanah use the term "disorder of attachment" to indicate a situation in which a young child has no preferred adult caregiver. Such children may be indiscriminately sociable and approach all adults, whether familiar or not; alternatively, they may be emotionally withdrawn and fail to seek comfort from anyone. This type of attachment problem is parallel to Reactive Attachment Disorder as defined in DSM and ICD in its inhibited and disinhibited forms as described above.

Boris and Zeanah also describe a condition they term "secure base distortion". In this situation, the child has a preferred familiar caregiver, but the relationship is such that the child cannot use the adult for safety while gradually exploring the environment. Such children may endanger themselves, may cling to the adult, may be excessively compliant, or may show role reversals in which they care for or punish the adult.

The third type of disorder discussed by Boris and Zeanah is termed "disrupted attachment. " This type of problem, which is not covered under other approaches to disordered attachment, results from an abrupt separation or loss of a familiar caregiver to whom attachment has developed. The young child's reaction to such a loss is parallel to the grief reaction of an older person, with progressive changes from protest (crying and searching) to despair, sadness, and withdrawal from communication or play, and finally detachment from the original relationship and recovery of social and play activities.

Problems of attachment style

Main article: Attachment theory

Main article: Attachment in children

The majority of 12-month-old children can tolerate brief separations from familiar caregivers and are quickly comforted when the caregivers return. Attachment theory, originating in the work of John Bowlby, is a Psychological, evolutionary and ethological theory that provides a descriptive Attachment in children is a theory of attachment between children and their caregivers specifically addressing the behaviors and emotions that children direct toward familiar adults These children also use familiar people as a "secure base" and return to them periodically when exploring a new situation. Such children are said to have a secure attachment style, and characteristically continue to develop well both cognitively and emotionally.

Smaller numbers of children show less positive development at age 12 months. Their less desirable attachment styles may be predictors of poor later social development. Although these children's behavior at 12 months is not a serious problem, they appear to be on developmental trajectories that will end in poor social skills and relationships. Because attachment styles may serve as predictors of later development, it may be appropriate to think of certain attachment styles as part of the range of attachment disorders.

Insecure attachment styles in toddlers involve unusual reunions after separation from a familiar person. The children may snub the returning caregiver, or may go to the person but then resist being picked up. These children are more likely to have later social problems with peers and teachers, but some of them spontaneously develop better ways of interacting with other people.

A small group of toddlers show a distressing way of reuniting after a separation. Called a disorganized/disoriented style, this reunion pattern can involve looking dazed or frightened, freezing in place, backing toward the caregiver or approaching with head sharply averted, or showing other behaviors that seem to imply fearfulness of the person who is being sought. ^[15] Disorganized attachment has been considered a major risk factor for child psychopathology, as it appears to interfere with regulation or tolerance of negative emotions and may thus foster aggressive behavior. ^[16] Disorganized patterns of attachment have the strongest links to concurrent and subsequent psychopathology, and considerable research has demonstrated both within-the-child and environmental correlates of disorganized attachment. ^[17]

Diagnosis

Main article: Attachment measures

Recognised assessment methods of attachment styles, difficulties or disorders include the Strange Situation procedure (Mary Ainsworth),^[18][19][20] the separation and reunion procedure and the Preschool Assessment of Attachment ("PAA"),^[21] the Observational Record of the Caregiving Environment ("ORCE")^[22] and the Attachment Q-sort ("AQ-sort"). Attachment measures refer to the various procedures used to assess attachment in children and adults Attachment measures refer to the various procedures used to assess attachment in children and adults Mary D Salter Ainsworth (December 1913 - 1999 was an American Developmental psychologist known for her work in early emotional attachment with "The Strange Attachment measures refer to the various procedures used to assess attachment in children and adults ^[23] More recent research also uses the Disturbances of Attachment Interview or "DAI" developed by Smyke and Zeanah, (1999). Attachment measures refer to the various procedures used to assess attachment in children and adults ^[24] This is a semi-structured interview designed to be administered by clinicians to caregivers. It covers 12 items, namely having a discriminated, preferred adult, seeking comfort when distressed, responding to comfort when offered, social and emotional reciprocity, emotional regulation, checking back after venturing away from the care giver, reticence with unfamiliar adults, willingness to go off with relative strangers, self endangering behavior, excessive clinging, vigilance/hypercompliance and role reversal.

Alternative diagnosis

Main article: Attachment therapy

In the absence of officially recognized diagnostic criteria, and beyond the ambit of the discourse on a broader set of criteria discussed above, the term attachment disorder has been increasingly used by some clinicians to refer to a broader set of children whose behavior may be affected by lack of a primary attachment figure, a seriously unhealthy attachment relationship with a primary caregiver, or a disrupted attachment relationship. Diagnosis is the identification by Process of elimination, of the nature of anything ^[25] Although there are no studies examining diagnostic accuracy, concern is expressed as to the potential for over-diagnosis based on broad checklists and 'snapshots'. ^[26]

A common feature of this form of diagnosis within attachment therapy is the use of extensive lists of "symptoms" which include many behaviours that are likely to be a consequence of neglect or abuse, but are not related to attachment, or not related to any clinical disorder at all. Such lists have been described as "wildly inclusive". ^[27] The APSAC Taskforce (2006) gives examples of such lists ranging across multiple domains from some elements within the DSM-IV criteria to entirely non-specific behavior such as developmental lags, destructive behaviors, refusal to make eye contact,cruelty to animals and siblings, lack of cause and effect thinking, preoccupation with fire, blood, and gore, poor peer relationships, stealing, lying, lack of a conscience, persistent nonsense questions or incessant chatter, poor impulse control, abnormal speech patterns, fighting for control over everything, and hoarding or gorging on food. Some checklists suggest that among infants, “prefers dad to mom” or “wants to hold the bottle as soon as possible” are indicative of attachment problems. The APSAC Taskforce expresses concern that high rates of false positive diagnoses are virtually certain and that posting these types of lists on Web sites that also serve as marketing tools may lead many parents or others to conclude inaccurately that their children have attachment disorders. In Statistics, the terms Type I error (also α error, or false positive) and type II error ( β error, or a false negative "^[28]

Treatment

Main article: Child therapy

Main article: Attachment therapy

There is a variety of mainstream prevention programs and treatment approaches for attachment disorder, attachment problems and moods or behaviors considered to be potential problems within the context of attachment theory. Mental health interventions for children vary with respect to the problem being addressed and to the age and other individual characteristics of the child Attachment theory, originating in the work of John Bowlby, is a Psychological, evolutionary and ethological theory that provides a descriptive All such approaches for infants and younger children concentrate on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, changing the caregiver. ^[29][30][31] Such approaches include 'Watch, wait and wonder,'^[32] manipulation of sensitive responsiveness,^[33][34] modified 'Interaction Guidance,'. ^[35] 'Preschool Parent Psychotherapy,'. ^[36] 'Circle of Security',^[37][38] Attachment and Biobehavioral Catch-up (ABC),^[39] the New Orleans Intervention,^[40][41][42] and Parent-Child psychotherapy. ^[43] Other known treatment methods include Developmental, Individual-difference, Relationship-based therapy (DIR) (also referred to as Floor Time) by Stanley Greenspan, although DIR is primarily directed to treatment of pervasive developmental disorders^[44] Some of these approaches, such as that suggested by Dozier, consider the attachment status of the adult caregiver to play an important role in the development of the emotional connection between adult and child. Stanley Greenspan (born 1941 is a clinical professor of Psychiatry, Behavioral Science and Pediatrics at George Washington University Medical School The diagnostic category pervasive developmental disorders (PDD as opposed to Specific developmental disorders (SDD refers to a group of five disorders characterized This includes foster parents as children with poor attachment experiences often do not elicit appropriate caregiver responses from their attachment behaviors despite 'normative' care. ^[45]

There is also a considerable variety of treatments for alleged attachment disorders diagnosed on the controversial alternative basis outlined above, popularly known as attachment therapy. These therapies have little or no evidence base and vary from talking or play therapies to more extreme forms of physical and coercive techniques, of which the best known are holding therapy, rebirthing, rage-reduction and the Evergreen model. In general these therapies are aimed at adopted or fostered children with a view to creating attachment in these children to their new caregivers. Critics maintain these therapies are not based on an accepted version of attachment theory. Attachment theory, originating in the work of John Bowlby, is a Psychological, evolutionary and ethological theory that provides a descriptive ^[46] The theoretical base is broadly a combination of regression and catharsis, accompanied by parenting methods which emphasise obedience and parental control. Catharsis ( Κάθαρσις) is a Greek word meaning "purification" "cleansing" or "clarification Obedience, in human behavior is the quality of being obedient, which describes the act of carrying out commands or being actuated ^[47] These therapies concentrate on changing the child rather than the caregiver. ^[48] An estimated six children have died as a consequence of the more coercive forms of such treatments and the application of the accompanying parenting techniques. ^[49][50][51]

Possible mechanisms

One study has reported a connection between a specific genetic marker and disorganized attachment (not RAD) associated with problems of parenting. A genetic marker is a known DNA sequence. It can be described as a variation which may arise due to mutation or alteration in the genomic loci that can be observed ^[52] Another author has compared atypical social behavior in genetic conditions such as Williams syndrome with behaviors symptomatic of RAD. Williams syndrome ( WS; also Williams-Beuren syndrome or WBS) is a rare Neurodevelopmental disorder caused by a deletion of about 26 genes from ^[53]

Typical attachment development begins with unlearned infant reactions to social signals from caregivers. The ability to send and receive social communications through facial expressions, gestures and voice develops with social experience by seven to nine months. This makes it possible for an infant to interpret messages of calm or alarm from face or voice. At about eight months, infants typically begin to respond with fear to unfamiliar or startling situations, and to look to the faces of familiar caregivers for information that either justifies or soothes their fear. This developmental combination of social skills and the emergence of fear reactions results in attachment behavior such as proximity-seeking, if a familiar, sensitive, responsive, and cooperative adult is available. Further developments in attachment, such as negotiation of separation in the toddler and preschool period, depend on factors such as the caregiver's interaction style and ability to understand the child's emotional communications. ^[54]

With insensitive or unresponsive caregivers, or frequent changes, an infant may have few experiences that encourage proximity seeking to a familiar person. An infant who experiences fear but who cannot find comforting information in an adult's face and voice may develop atypical ways of coping with fearfulness such as the maintenance of distance from adults, or the seeking of proximity to all adults. These symptoms accord with the DSM criteria for reactive attachment disorder. ^[55] Either of these behavior patterns may create a developmental trajectory leading ever farther from typical attachment processes such as the development of an internal working model of social relationships that facilitates both the giving and the receiving of care from others. ^[56][57]

Atypical development of fearfulness, with a constitutional tendency either to excessive or inadequate fear reactions, might be necessary before an infant is vulnerable to the effects of poor attachment experiences. ^[58]

Alternatively, the two variations of RAD may develop from the same inability to develop "stranger-wariness" due to inadequate care. Appropriate fear responses may only be able to develop after an infant has first begun to form a selective attachment. An infant who is not in a position do this cannot afford not to show interest in any person as they may be potential attachment figures. Faced with a swift succession of carers the child may have no opportunity to form a selective attachment until the possible biological-determined sensitive period for developing stranger-wariness has passed. It is thought this process may lead to the disinhibited form. ^[59]

In the inhibited form infants behave as if their attachment system has been "switched off". However the innate capacity for attachment behavior cannot be lost. This may explain why children diagnosed with the inhibited form of RAD from institutions almost invariably go on to show formation of attachment behavior to good carers. However children who suffer the inhibited form as a consequence of neglect and frequent changes of caregiver continue to show the inhibited form for far longer when placed in families. ^[60]

Additionally, the development of Theory of Mind may play a role in emotional development. " Theory of mind " is the ability to attribute mental states—beliefs intents desires pretending knowledge etc Theory of Mind is the ability to know that the experience of knowledge and intention lies behind human actions such as facial expressions. Although it is reported that very young infants respond differently to humans and objects, Theory of Mind develops relatively gradually and possibly results from predictable interactions with adults. However, some ability of this kind must be in place before mutual communication through gaze or other gesture can occur, as it does by seven to nine months. Some early emotional disorders, such as autism, have been attributed to the absence of the mental functions that underlie Theory of Mind. Language development. The terminology It is possible that the congenital absence of this ability, or the lack of experiences with caregivers who communicate in a predictable fashion, could underlie the development of reactive attachment disorder. ^[61][62]

See also

• Attachment theory
• Attachment therapy
• Candace Newmaker
• Child therapy
• Emotional dysregulation
• John Bowlby
• Michael and Sharen Gravelle
• Reactive attachment disorder
• Stanley Greenspan

Notes

References

Further reading

• Holmes, J (2001). The Search for the Secure Base. Philadelphia: Brunner-Routledge. ISBN 1583911529
• Cassidy, J; Shaver, P (eds. ) (1999). Handbook of Attachment: Theory, Research, and Clinical Applications. New York: Guilford Press. ISBN 1-57230-087-6.
• Zeanah, CH (ed. ) (1993). Handbook of Infant Mental Health. New York: Guilford Press. ISBN 1593851715
• Bowlby, J (1988). A Secure Base: Parent-Child Attachment and Healthy Human Development. London: Routledge; New York: Basic Books. ISBN 0-415-00640-6.