Early adolescent outcomes for institutionally-deprived and non-deprived adoptees. I: Disinhibited...

Early adolescent outcomes for institutionally-deprived and non-deprived adoptees.

I: Disinhibited attachment

Michael Rutter,1 Emma Colvert,1 Jana Kreppner,1 Celia Beckett,1

Jenny Castle,1 Christine Groothues,1 Amanda Hawkins,1 Thomas G O’Connor,1

Suzanne E Stevens,1,2 and Edmund J.S. Sonuga-Barke1,21MRC Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, King’s College London, UK;

2Developmental Brain–Behaviour Unit, School of Psychology, University of Southampton, UK

Background: Disinhibited attachment is an important sequel of an institutional rearing, but questionsremain regarding its measurement, its persistence, the specificity of the association with institutionalrearing and on whether or not it constitutes a meaningful disorder. Method: Children initially reared inprofoundly depriving institutions in Romania and subsequently adopted into UK families were com-pared with respect to findings at 11 years with children who had not experienced institutional de-privation and who had been adopted within the UK before the age of 6 months. Measures includedparental reports, a Strange Situation procedure modified for use in the home and systematic stand-ardised investigator ratings of the children’s behaviour. Results: Disinhibited attachment, as reportedby parents, showed a high degree of persistence from 6 to 11, but also a reduction over time in itsfrequency. Investigator ratings validated the parental reports but suggested that much of the fall in rateof disinhibited attachment was a function of the parental measure being less developmentally appro-priate at 11 than it had been at 6. Disinhibited attachment was strongly associated with institutionalrearing but there was not a significant increase in relation to duration of institutional deprivationbeyond the age of 6 months. Mild, but not marked, disinhibited attachment was quite frequent in non-institutionalised adopted children but both the course and correlates indicated that its meaning wasprobably quite different. In the institution-reared children, disinhibited attachment was associatedwith a marked increase in service usage and associations with other forms of psychopatho-logy. Conclusions: Disinhibited attachment constitutes a valid, and handicapping, clinical patternthat is strongly associated with an institutional rearing. Keywords: Disinhibited attachment, ‘StrangeSituation’, prognosis, investigator-ratings, institutional rearing.

Studies of children in residential institutions provi-ding group care with multiple rotating caregivershave consistently noted that those admitted in earlylife tend to show a pervasive pattern of attention-seeking behaviour associated with a relative lack ofselectivity in social relationships (Rutter, 1981;Tizard & Rees, 1975; Zeanah, Smyke, & Koga, 2005).It might be thought that this represented no morethan an adaptive response to an abnormal socialsituation. If children are dealt with by a very largenumber of caregivers (50 to 70 in the Tizard 1977study), it would not be adaptive to have just a fewintense selective attachments to adults who wererarely available on a regular basis. Similarly, in sucha setting, children may need to be rather attentionseeking and clinging in order to get much attention.

Given that possible institution-adaptive explana-tion, it is striking, therefore, that follow-up studies ofchildren receiving their initial rearing in such in-stitutions but then adopted into well-functioningfamilies have shown that abnormalities in social re-lationships frequently persist (Hodges & Tizard,1989; Chisholm, 1998; Maclean, 2003; O’Connor,

Rutter, & the ERA Team, 2000; Smyke, Dumitrescu,& Zeanah, 2002). This has been so for children ex-periencing relatively good quality institutional care(apart from the multiple rotating caregivers) as wellas for those in grossly depriving institutions. Theabnormalities in social relationships have beendescribed in terms of a lack of close confidingrelationships, somewhat indiscriminate friendliness,a relative lack of differentiation in the response todifferent adults, a tendency readily to go off withstrangers, and a lack of checking back with a parentin anxiety-provoking situations. Both DSM-IV(American Psychiatric Association, 1994) and ICD-10 (World Health Organization, 1992) have broughtthese features together in the concept of reactiveattachment disorder – disinhibited type. Our follow-up study to age 6 years of institution-reared Roma-nian children adopted into UK families showed notonly a strong persistence of these sorts of featuresfrom age 4 years to age 6 years but also a continuingstrong effect of the duration of institutional de-privation (Rutter, O’Connor, & the ERA Study Team,2004). It was argued that the effects might reflectsome form of biological programming – meaning aneffect on brain structure and functioning that hasConflict of interest statement: No conflicts declared.

Journal of Child Psychology and Psychiatry 48:1 (2007), pp 17–30 doi:10.1111/j.1469-7610.2006.01688.x

� 2006 The AuthorsJournal compilation � 2007 Association for Child and Adolescent Mental Health.Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA

come about as a means of adaptation to theenvironmental circumstances operating at a sensit-ive period of development (Rutter, 2006). If that wasthe case, strong persistence into middle childhood/early adolescence would be expected and the effectsof duration of institutional deprivation should re-main. Here, we report the extent to which theseexpectations were borne out. In order to do that, welooked at the features of disinhibited attachment asmeasured in different ways, and at the correlates ofthese features. Specifically, in terms of the follow-upfindings at age 11 years, and of the course of devel-opment between 6 and 11 years, we examine 6 keyissues:

1. To what extent do the ratings of disinhibitedattachment based on parental interviews (andwhich use criteria more relevant for preschoolchildren than for early adolescence) tally withother measures of the same feature? For thisquestion we used ratings made by researchers onthe basis of their interactions with the children atages 6 and 11 years, and we also used (only at age6 years) the blindly rated video recordings of theStrange Situation procedure as modified for usein the home environment.

2. To what extent do the disinhibited behaviourpatterns as measured in these various ways atage 6 years persist to age 11? Insofar as they weresimply contemporaneously adaptive to the cir-cumstances of an institutional rearing, the fea-tures should diminish markedly with thechildren’s increasing time in the quite differentenvironment of the adoptive home. By contrast, ifsome form of biological programming had takenplace, persistence would be expected.

3. Are the consequences of mildly disinhibitedattachment behaviour similar to those of severedisinhibition and does this vary according to thepresence/absence of institutional deprivation?The need to pose this question was raised by thehigh frequency of mild (but not marked) dis-inhibited attachment in the non-institutionalcomparison group at 6 years of age (O’Connor etal., 2000). The apparent implication was that themild disinhibited attachment features were quitecommon in children who had not experienced aninstitutional rearing and, therefore, that theymight have a quite different meaning. On theother hand, this might not apply in the institu-tion-reared sample if the meaning of disinhibitedattachment was contingent on an associationwith institutional rearing. Accordingly, the ques-tion is whether the validity (as assessed on thebasis of other measures) of ‘mild’ disinhibitedattachment features is similar to ‘marked’ fea-tures and whether this differs according to thepresence-absence of institutional rearing.

4. Persistence could derive from biological pro-gramming or could reflect the post-adoption

environment. This is considered by asking whe-ther the strength of the effect of duration ofinstitutional care remained much the same as thechildren grew older, and whether reductions indisinhibited attachment were a function of vari-ations in the adoptive family environment, or se-cure selective attachments as measured at age 6.A biological programming hypothesis would pre-dict that the former should apply and that thelatter would not. The reverse would favour acontemporaneous situation-specific adaptationhypothesis.

5. Is the disinhibited attachment pattern at age 11simply a stylistic feature or is it associated withsignificant malfunction or psychopathology asmeasured in other ways? The need to pose thisquestion arises from the concept of disinhibitedattachment as an attachment disorder. If it trulyrepresents a disorder it should be associated withan increased likelihood of other forms of psycho-pathology or of psychological malfunction (as, forexample, shown in peer relationships) and itshould often entail a need for services. Accord-ingly, we used the measures at age 11 as a way oftackling this question.

6. The converse of the fifth question is the query asto whether disinhibited attachment is no morethan a non-specific feature of any type of psycho-pathology. The specific disorder concept, basedon the hypothesised causal association withinstitutional rearing, carries the expectation thatthe disinhibited attachment features should beevident in the time period immediately followinginstitutional rearing (here defined as present atage 6 years) and should not arise anew at laterages as an accompaniment of newly emergingpsychopathology. The follow-up data at age 11are used to test that hypothesis.

Methods

Sample

The sample of children from Romanian institutionsadopted into UK families was drawn from the 324children adopted into UK families between February1990 and September 1992 who were processed throughthe Department of Health and/or the Home Office. Astratified random sampling design was used for all theage of entry groupings in which the number of childrenavailable exceeded the number planned for the re-search. The final sample included 58 children placedbefore 6 months (27 girls), 59 children placed between 6and under 24 months (33 girls), and a further 48 late-placed adoptees who entered the UK between 24 and42 months of age (31 girls). The great majority of thechildren had entered an institution in the neonatalperiod (the mean age at entry was .34 months, SD ¼1.28), but many moved institutions in the period beforeadoption. So far as is known, during the period of thesechildren’s lives, those admitted to institutions rarely

18 Michael Rutter et al.

� 2006 The AuthorsJournal compilation � 2007 Association for Child and Adolescent Mental Health.

returned to their biological parents and none wasadopted. Accordingly, unlike most previous adoptionsof children from institutions, those available for adop-tion were not a biased sample, of those not adoptedwhen younger. Also, because of the placement in theneonatal period, the children were not admitted tothe institutions because of recognised handicap. Theprospective parents were given a limited choice of chil-dren to choose from and the mixture of motives foradoption (including altruism in relation to the plight ofsuffering children, as well as infertility) meant thatsome children were selected because of their plight aswell as some who appeared promising (see Beckettet al., 2006). Children were assessed at ages 4, 6, and11 years; however, the 48 children adopted into the UKafter 24 months of age were too old at first contact to beseen at age 4 years; data on this group were available atages 6 and 11 years. The total sample of adoptees onwhom age 4 data was available is 111. Overall, 81% ofthe parents of Romanian adoptees who wereapproached agreed to participate. The random samp-ling selection procedure has the advantage of neitherover- nor under-estimating the adjustment problems ofchildren adopted into the UK from Romania.

The comparison sample consisted of 52 UK-bornchildren (18 girls) who were placed into adoptivefamilies between 0 and 6 months of age. Intra-countryadoptees were obtained through adoption agencies andsocial services departments. None of the UK adopteesexperienced institutional care or severe deprivation. Itwas not possible to determine the rate of participationamong the intra-country adoptees because a name wasprovided to the project by the adoption agency only afterthe family consented to participate. Available informa-tion suggests that approximately 50% of the familieswho were contacted agreed to participate.

Families of within-UK and Romanian children weregenerally middle-class and slightly better educatedthan the general UK population (as is typical of adoptivefamilies), but did not differ in these respects from oneanother. Differences that existed between parentsadopting from the UK and Romania were a direct con-sequence of UK adoption policies (e.g., presence ofbiological children); these demographic variables werenot associated with child outcome variables and weretherefore not included in analyses. Among the familieswith Romanian adoptees, although some differencesassociated with family characteristics (such as adoptiveparents’ educational level and whether the main reasonfor adoption was altruistic or response to infertility)were found (Beckett et al., 2006), these were largelyunrelated to child outcomes. However, a somewhathigher proportion of children with disinhibited attach-ment at age 6 came from families where neitheradoptive parent had a degree (30% vs. 15%; p < .05);this difference was not significant at age 11.

The remainder of the Romanian adoptee sample wereadopted from other settings (data at age 11 years wereavailable on 20 of the 21 children who were adoptedfrom non-institutional settings). Information on whychildren were placed in institutions was not systemat-ically available, but it is reasonable to suppose thatsevere economic adversity played a major role becausea) austere economic conditions were widespread, b)most children entered the institution in the first weeks

of life, c) anecdotal evidence suggests that this was thecase. In any event, given the very early age at whichchildren entered the institution (85% entered within thefirst month of life), it is clear that institutionalisedchildren were not placed there because of develop-mental delay or handicap.

Of the 196 children (144 institution-reared Roma-nian adoptees and 52 within-UK adoptees) initiallytargeted for study, parent report data at age 11 wereavailable on 193 (98.2%). In two cases the families re-fused participation and in one case the family could notbe located. All three of these children were from Ro-mania.

Procedures

Families were visited around the time of the child’sfourth, sixth, and eleventh birthdays (with the excep-tion of the late-placed children who were not assessedat age 4 years). The home visits consisted of a tape-recorded intensive interview with the primary caregiverby a trained interviewer; parents also completed beha-vioural and family relationship questionnaires. Withinapproximately 3 months of the parent assessment,children were visited in the home by different researchworkers (two researchers at ages 4 and 6 years, oneresearcher at age 11 years). Child assessments in-cluded standardised cognitive and developmentalmeasures and observations; in addition, at the age 11assessment, children were interviewed and completedquestionnaires about behavioural and emotionaladjustment and peer and family relationships. Teacherquestionnaires on the children’s behaviour were alsoobtained. For Romanian adoptees only, information oncondition at entry into the UK was available frommedical records and retrospective parental accountscollected at the first visit.

Measures relating to the situation at, or prior to,adoption

Duration of institutional deprivation. This was as-sessed in two ways. Firstly, it was indexed by the chil-dren’s age at the time of arrival in the UK. This provideda reasonable index of duration of institutional depriva-tion because in the great majority of cases the childrenwent straight from an institution to the adoptive home.The child’s age at entry was treated both as a dimen-sional measure and in terms of specific age cut-offs. Thelatter was necessary because earlier findings on alloutcomes at age 4 and 6 years had shown that thechildren who entered the UK under the age of 6 monthsdid not differ significantly from the within-UK adopteesnone of whom had experienced institutional care(Kreppner et al., submitted; Rutter et al., 1998).Accordingly, it was necessary to start analysis with thecomparison between the institution-reared childrenwho entered the UK under 6 months (n ¼ 44) and thosewho entered between 6 and 42 months (n ¼ 88). Thiscould then be followed by analyses to determine vari-ations in outcome within the 6 to 42 month range. Thechildren from Romania who had not experienced insti-tutional care (n ¼ 21) were included as an additionalcomparison group in order to determine whether deficits

Disinhibited attachment and institutional deprivation 19


were restricted to children experiencing institutionaldeprivation rather than deprivation in a family setting.

Institutional care was operationally defined in termsof a period lasting at least two weeks. In practice, how-ever, the children experiencing institutional care did sofor most of their life prior to their adoption. Of the 165Romanian adoptees assessed, 144 experienced institu-tionalised rearing, defined by 2 or more weeks in aninstitution. The majority (n ¼ 80) had spent all their lifein institutions, more than a third (n ¼ 53) had been ininstitutions for over half their life (but not all of it), andonly 11 had spent less than half their life in an institu-tion. The remainder were adopted from other settings.Because a few children went in and out of institutions,duration of institutional care was also assessed dimen-sionally according to a measure of total months ofinstitutional rearing. As expected, the two indices werestrongly correlated (r ¼ .89, p < .001, n ¼ 132).

Individual institutional care. When the adoptiveparents were interviewed for the first time, they wereasked to describe the conditions in the institutions inwhich their child had been living. Individual care re-ceived by the child was coded on a four-point scale, as:

• very poor: ‘0’ – frequent change of staff and/or indi-vidual care strongly discouraged

• poor: ‘1’ – some individual care but frequent staffchanges

• adequate: ‘2’ – child predominately cared for by sameperson

• good: ‘3’ – individual care by the same person (seeCastle et al., 1999).

Other codes similarly dealt with opportunities for motordevelopment and with the overall psychological envir-onment (see Castle et al., 1999). In general, the qual-ities in the institutions varied between poor andabysmal.

Child’s state on arrival. Weight on arrival was avail-able for 128 children; head circumference on arrivalwas available for 121 children. These measurementswere taken from assessments carried out when thechildren arrived in the UK or as part of the entry clear-ance process that involved assessments in Romania.Physical measures in the study were entered into thechild health growth programme to assess the measuresrelative to population norms (Boyce & Cole, 1993, basedon Buckler, 1990). This metric provided a continuousstandardised measure of physical development in termsof standard deviations above or below the UK generalpopulation norm for the age. Previous research hasshown that head circumference is a reasonably goodindex of brain volume (Cooke et al., 1977; Wickett et al.,2000). There was no systematic developmental assess-ment of the children either in Romania or on arrival inthe UK. To assess developmental level on arrival it wasthus necessary to rely on reports from adoptive parents.The adoptive parents were asked to complete DenverDevelopmental Scales (Frankenburg et al., 1986) ret-rospectively on the children’s development at the time ofarrival in the UK. The scales were designed to focus onattainments in different domains: personal/socialdevelopment, language development, gross and finemotor skills. It is possible from these scales to provide a

global measure of the children’s development at arrivaland also a measure of their performance on the indi-vidual sub-scales. Previous analyses performed on theentire sample demonstrated the validity of the retro-spective Denver scales (Rutter et al., 1998).

Measures relating to the adoptive homeenvironment

Educational qualities of the adoptive homes. Theeducational qualities of the adoptive homes were as-sessed in two different ways. First, details of theadoptive parents’ educational qualifications were as-sessed and combined on a 3-point scale: neither parenthad a degree or professional qualification (score ‘0’); oneparent, but not both, had such a qualification (score‘1’); and both parents had such a qualification (score‘2’). Second, an approximate assessment was made ofthe mothers’ cognitive abilities using The National AdultReading Test (NART) (Nelson & Willison, 1994). This is anon-phonetic reading task of 50 words of increasingdifficulty – with scores shown to be highly correlatedwith IQ (Bird et al., 2004).

Possible family functioning risk factors. Seven as-pects of post-adoption environmental risk were testedfor possible associations with disinhibited attachment:thoughts about divorce and negative rating of themarriage (both from the Dyadic Adjustment Scaleparental questionnaire, Spanier, 1976), changes inmother’s partner prior to the age 11 assessment,the Malaise Inventory (Rodgers, Pickles, Power, Colli-shaw, & Maughan, 1999; Rutter, Tizard, & Whitmore,1970) measure of maternal depression, mother’s pre-vious mental health problems and those of the partnerand a measure of marriage evaluation taken from theage 6 parental interview measure. A cut-off was estab-lished for each of the seven areas, above which risk wasdeemed to be present if exceeded (see Colvert et al.,submitted, for details of the composition of these).

As is often the case in adoptive families, the overalllevel of possible family risks was low, with very fewfamilies showing malfunction in the seven areas. Theseven indices were therefore chosen as alternative typesof family difficulty, there being no expectation that theywould intercorrelate to any significant degree and itwould not ordinarily be possible therefore to combinethem into a total score (see, e.g., Burchinal et al., 2000).Nevertheless, given a generally low family risk sample,the fact that the measures were chosen to representalternative scores of risk, and that it was desirable todetermine if post-adoption risk factors were influential,a total score was calculated by combining all seven cut-offs. Internal consistency was only moderate, as shownby a Cronbach’s alpha of .48. A total risk cut-off point of3 (out of 7) was selected, but mean risk scores were alsoexamined. The total risk cut-off score was exceeded by15% of the Romanian institutional group and 13% ofthe within-UK adoptees.

Measures of child functioning

Disinhibited attachment. At the start of the studythere was no established protocol to assess attachment



features in children aged 4 to 6 years. Therefore, thiswas assessed using an investigator-based semi-struc-tured interview designed to assess variations in thechild’s (attachment) behaviour toward the parent andstrange adults in novel and familiar settings. When thechildren were 4 and 6 years old, the assessment ofdisinhibited attachment was made according to paren-tal responses to questions about three essential com-ponents of disinhibited behaviour: definite lack ofdifferentiation among adults with respect to the child’ssocial response to them; clear indication that the childwould readily go off with a stranger; and definite lack ofchecking back with the parent in anxiety-provokingsituations. For each of the above three components, ascore of ‘1’ was given if there was some or mild evidence;a score of ‘2’ was given if the behaviour was marked orpervasive; the scores for each of the three items werethen summed (i.e., total scores ranged from 0–6; inter-nal consistency ¼ .80). The average weighted kappacoefficients across 3 raters on 20 interviews were 1.00,.94, .86 for the 3 items listed above, respectively. Forthe age 11-year assessment, parents were again askedabout the three components assessed at ages 4 and6 years (although the items were expressed in a slightlydifferent way in order to take account of likely age dif-ferences). Reliability analyses were not undertaken atage 11, but the researchers were the same and thequestions were closely comparable. Cross-checks wereundertaken on all interviews and where there werediscrepant views on coding, these were discussed andconsensus codes used. The more detailed instructionson coding are provided in an appendix, together withthe comparable items at age 6. Marked disinhibitedattachment (at both 6 and 11) was defined as a score of4 or more, and mild disinhibited attachment as a scoreof 1 to 3.

Investigator ratings of physical contact at age 6. Atage 6, the child’s interaction with the investigator (astranger) was assessed over the course of three tasks –puppets, Bus Story (Renfrew, 1991) and balloons. Arating of 0/1/2 was made with respect to the extent towhich the child made use of socially inappropriatephysical contact in these three situations, and thesewere summated to produce a total score with a range of0 to 6. Marked inappropriate contact was defined asmultiple instances of holding the experimenter’s handor staying exceptionally close; child often had a hand onthe experimenter; child cuddled in; or child eager to siton the experimenter’s lap. The inter-rater reliability on15 cases as measured by weighted kappa was .80(p < .001).

Ratings of children’s interaction with the investig-ator at age 11. At age 11, more detailed ratings weremade by the investigator with respect to children’sinteractions with her over the course of the assessmentsession. It was not possible for these to be made blindlywith respect to group membership. Eight variables(selected on the basis of pilot studies) were rated and acorrelation matrix showed substantial correlationsamong them (in the range of .01 to .80, but with most inthe .50 to .60 s). A factor analysis suggested a two-factor solution with a violation of boundaries compositemade up of general disinhibition (lack of social reserve),

overall relationship with the examiner, verbal violationof boundaries, social violation of boundaries, andamount of spontaneous comments; and a physicalcontact composite made up of unsolicited intrusivephysical contact, uncomfortably close physical prox-imity (giving rise to a feeling of invasion of personalspace), and child-initiated intimate closeness (such aswhispering in the investigator’s ear). Internal consis-tency (alpha) for these two composites was respectively.86 and .78.

Security of attachment at age 6. As at age 4(O’Connor et al., 2003), a Strange Situation proceduremodified for use in the home was used at age 6. A tri-partite classification was employed: secure (i.e., ‘B’type); insecure (i.e., ‘A’ or ‘C’ types); and ‘other’ (acombination of disorganised, which was rated in scar-cely any children, and ‘other-insecure’, a category thatindicated clearly abnormal behaviour that fitted neitherthe categories ‘secure’ nor ‘insecure’). Inter-rater reli-ability between two raters on the 3-way classificationmeasure as used at age 6 was good (kappa ¼ .71 asassessed on 59 of 199 tapes).

Quality of peer relations at age 11. Peer relationshipproblems at age 11 were assessed through a combina-tion of the Rutter parents’ and teachers’ scales (Elander& Rutter, 1996; Hogg, Rutter, & Richman, 1997), to-gether with information obtained from the parental in-terview. The peer relationship information from theparental Rutter scales were standardised within rater(mother or father) and combined by calculating themean score across both raters. The teacher scale wasalso standardised. The parental interview items werecombined to generate a composite score. Subsequently,the parental Rutter scale mean score, the teacher Rut-ter scale score and the parental interview scale scorewere combined by calculating the average across thethree components to create a composite score. Sig-nificant peer relationship problems were considered tobe present if a child’s score was above the 85th per-centile on the distribution of scores in the entire pooledsample (Romanian and within-UK groups) on theequivalent measure assessed at age 6. The same valuewas then applied to the 11-year scale.

The items on the Rutter parent scale were ‘not muchliked by other children’, ‘tends to be solitary’, and ‘doesnot get on well with other children’. The three items onthe teacher Rutter scale were ‘not much liked by otherchildren’, ‘tends to be on own’ and ‘cannot work in asmall peer group’. Parents were additionally interviewedabout their children’s peer relationships. The itemswere ‘difficulty making friends’, ‘concerns regarding theway the child relates to other children’, ‘differentiationbetween friends and non-friends’, ‘child shows over-eagerness in interaction with other children’, ‘childseeks physical contact with other children’, ‘beingbullied’, and ‘bullies others’. Each parental interviewitem was scored as 0 for ‘no abnormality’, 1 for ‘prob-able problem’ and 2 for ‘definite problem’. Cronbach’salpha for the peer composite at 11 years was .83.

Behavioural and emotional problems. Behaviouraland emotional problems at ages 4, 6, and 11 yearswere measured using a modification of a widely used



measure of problem behaviour in preschool and school-age children (Elander & Rutter, 1996). The measure hasseveral subscales: emotional problems, disruptivebehaviour, and hyperactivity/inattention. As describedfor peer relationships, mothers’ and fathers’ standard-ised scale scores were averaged (the intercorrelationsbetween them ranging across .78 and .82) to produce aparent score. This was then averaged with the teachers’scale score to produce an overall composite measure.The approach provided an assessment of disturbancethat was pervasive over situations, giving equal weightto home and school. Disturbance was defined as a scorein the top 15% of the pooled samples. The rationale anddetails are provided in Colvert et al. (submitted).

Quasi-autism. Quasi-autism at age 6 was assessed onthe basis of the Autism Diagnostic Interview (revised)(see Lord, Rutter, & Le Couteur, 1994) and at age 11 bythe same measure combined with the Autism Dia-gnostic Observation Schedule (Lord et al., 1989).

Cognitive development. Cognitive development at age11 was assessed using a short form of the WechslerIntelligence Scale for Children WISC-III-UK Edition(Wechsler, 1992), the most widely used scale of in-tellectual functioning in children (see Beckett et al.,2006). Four subsets were administered: vocabulary,similarities (from the verbal scale), together with blockdesign and object assembly from the performance scale.These four subtests were selected to provide a goodestimate of full-scale IQ (reliability coefficient ¼ .94;Sattler, 2002). The prorated full scale IQ was used inanalyses below.

Data analysis. The central analyses are restricted tothe Romanian institutional sample because of therequirement that children with attachment disorderexperience pathogenic care. For some purposes, com-parisons are restricted to the children whose institu-tional care extended beyond the age of 6 months (i.e.,those aged 6–42 months at the time of UK entry). Thatis because, at all ages and with all variables, the under6 months group did not differ significantly from thecomparison group of within-UK adoptees and because,above 6 months, no analyses showed a significant lin-ear association with age of entry or duration of insti-tutional deprivation, although some had done so at ages4 and 6 (see Beckett et al., 2006: Kreppner et al., sub-mitted; Rutter & the ERA Study Team, 1998). Never-theless, data on the within-UK sample are reported insupplementary analyses because of the interest in thefrequency and meaning of disinhibited attachment in a

non-deprived/non-institutionalised sample. Analysesinvolving duration of deprivation are based on a con-tinuous measure of age at entry into the UK aswell as on categorical groups: 0– < 6 month within-UK,0– < 6 month Romanian, 6– < 24 month Romanian and(where available)b 24–42 month Romanian; however,the categorical distinction is not meant to imply athreshold effect. In addition, duration of institutionalcare was measured in months, disregarding age of entryto the UK.

Previous analyses at age 6 years excluded 10 chil-dren who were classified as showing definitely autistic(n ¼ 3) or quasi-autistic (n ¼ 7) behaviour (see Rutteret al., 1999). Although in most cases the children whowere previously described as quasi- or even severelyautistic showed substantial improvements between theage 6 and 11 assessments, these children are excludedfrom the current analyses to be consistent with theDSM-IV exclusion criterion and to facilitate comparab-ility between the age 6 and 11 year findings. Excludingthese 10 children did not substantively alter the patternof findings reported below.

Results

Preliminary analyses

Boys and girls are combined for all analyses belowbecause there were no sex differences on the twocentral outcome measures, disinhibited attachment,at either 6 or 11 years or peer relationship disturb-ance at 11, or the other measures of behavioural/emotional problems; furthermore, there were nosignificant interactions by gender.

Anecdotally, 10 children in the sample (all Roma-nian) had received a diagnosis of ‘attachment dis-order’ (by professionals) by the time of the age 11assessment. Of these, three exhibited no signs ofdisinhibited attachment at age 11 years, fourexhibited mild disinhibition, and three exhibitedmarked disinhibited attachment, as assessed by uson the basis of parental reports.

Patterns of disinhibition at age 6

The starting point for the follow-up findings was thepattern of disinhibited attachment as evident at age6 years. Table 1 summarises the key findings asprovided by the parental reports. Marked disinhib-ited attachment was extremely uncommon (circa 4%)

Table 1 Disinhibited attachment at 6 years in the key adopted groups

No disinhibitionN (%)

Mild disinhibitionN (%)

Marked disinhibitionN (%)

Within-UK adoptees (n ¼ 52) 21 (40.4) 29 (55.8) 2 (3.8)Romanian adoptees entering the UK below 6 mo,having experienced institutional rearing (n ¼ 45)

24 (53.3) 17 (37.8) 4 (8.9)

Romanian adoptees entering the UK between 6 and 42 mo,having experienced institutional rearing (n ¼ 98)

26 (29.5) 39 (44.3) 23 (26.1)

Romanian adoptees who did not experience institutionalcare (n ¼ 20)

11 (52.4) 8 (38.1) 2 (9.5)



in the within-UK adoptees, was significantly morecommon in the Romanian adoptees (Fisher’s ExactTest p < .01), and was significantly associated withthe duration of institutional deprivation (v2 ¼ 6.63,df ¼ 2, p < .05). The findings on mild disinhibitedattachment were, however, quite different. Therewere no significant differences between the within-UK group and the Romanian group, and mild disi-nhibition was surprisingly common in the within-UKadoptees, being present in over half of the sample.Inevitably, this raises the question as to whethermild disinhibition did, or did not, carry the samemeaning as severe disinhibition.

Validity of parental measure of disinhibitedattachment at age 6

Validity was examined using two measures that wereindependent of the parental reports: the blind rat-ings of attachment security made from videorecordings of the modified Strange Situation proced-ure, and the investigator ratings of undue physicalcontact. The latter showed a mean score of .92 (sd ¼1.44) for the marked disinhibition group versus .60(sd ¼ 1.14) for the mild disinhibition group and .31(sd ¼ .79) for the children without disinhibitedattachment (F(2, 119) ¼ 2.52, p ¼ .08) – differencesthat seemed big enough to be potentially meaningfulbut which fell short of statistical significance.

The security of attachment ratings showed thatthe pooled mild and marked disinhibition groups,within the institution-reared Romanian sample, dif-fered significantly from the no disinhibition group(v2 ¼ 8.28, d.f. ¼ 2, p < .05), mainly with respect to ahigher proportion classified as ‘other’ (38.8% vs.7.0%) and a somewhat lower proportion rated secure(53.4% vs. 79.1%). There were no between-group

differences on the usual ‘A’ and ‘C’ insecure cate-gories, either considered separately or incombination (Table 2).

Predictive validity was assessed by considering theage 11 investigator ratings (within the institution-reared Romanian sample) in relation to the presenceof disinhibited attachment at age 6. The mean scoreon the violations of boundaries composite at age 11was significantly greater (t ¼ )3.07, df ¼ 117,p < .01) in the children with mild or marked disin-hibited attachment (mean ¼ .34; sd ¼ .51) than inthose without disinhibition (mean ¼ .12; sd ¼ .26).A similar difference was found for the physical con-tact composite at age 6 (mean of .17; sd ¼ .36 vs..03; sd of .10), the difference being statistically sig-nificant (t ¼ )3.08, df ¼ 114, p < .01) (Table 3).

Association with institutional rearing

The above findings provide substantial validation forthe parental report measure of disinhibited attach-ment at age 6 in the institution-reared children fromRomania. Two further validation queries need to beaddressed. First, it is usually supposed that thispattern is specifically associated with an institu-tional rearing. Accordingly, it is necessary to consi-der the investigator ratings for the children adoptedfrom Romania who, despite being deprived in variousways, had not experienced institutional rearing for2 weeks or more. The sample was too small foradequate statistical comparison but the findingsshow a lower proportion with the indices of disin-hibited attachment. Thus, as shown in Table 1, only9.5% showed marked disinhibition at age 6, com-pared with 8.9% in the institution-reared Romanianchildren who entered the UK before 6 months and3.8% in the within-UK adoptees sample. The inves-tigator ratings of physical contact at age 6 showed amean for the non-institutional group of .90 (sd ¼1.58) as compared with .39 (sd ¼ .90) in the insti-tutional children entering the UK under 6 monthsand .29 (sd ¼ .68) in the within-UK sample. Theinvestigator ratings at age 11 showed that the non-institutional group showed similar ratings to those ofthe within-UK group for the two composites (viola-tion of boundaries composite: Romanian non-institutional: mean ¼ .11; sd ¼ .27; within-UK:mean ¼ .21; sd ¼ .46; Romanian < 6mth: mean ¼.09; sd ¼ .21) (physical composite: Romanian non-institutional: mean ¼ .07; sd ¼ .18; within-UK:

Table 2 Ratings of attachment security at age 6 according todisinhibited attachment categories at age 6 (Romanian sampleexperiencing institutional deprivation)

Attachment securityclassification

Disinhibited attachment at age 6

NoneN (%)

MildN (%)

MarkedN (%)

Secure (B) 34 (79.1) 28 (56.0) 11 (47.8)Insecure (A & C) 6 (14.06) 8 (16.0) 5 (21.7)Other (D, insecure-other) 3 (7.0) 14 (28.0) 7 (30.4)

Table 3 Investigator-ratings at age 11 according to disinhibited attachment categories at age 6 (Romanian sample of childrenexperiencing institutional deprivation)

Investigator rating

Disinhibited attachment

None (n ¼ 50)mean (S.D.)

Mild (n ¼ 56)mean (S.D.)

Marked (n ¼ 27)mean (S.D.)

Statisticalsignificance p

Physical contact composite .03 (.10) .13 (.32) .23 (.42) .05Violation of boundaries composite .12 (.26) .33 (.45) .37 (.61) .05



mean ¼ .02; sd ¼ .11; Romanian < 6mth: mean ¼.01; sd ¼ .04). In summary, the findings suggestedthat disinhibited attachment in the Romanian sam-ple was indeed a function of an institutional rearingand not just deprivation within the family.

Validity of reported disinhibited attachment in non-institutionalised within-UK adoptees

The second query is whether disinhibited attach-ment in the within-UK adoptees was also valid, asdetermined in the same ways as used for theRomanian sample. Because there was almost nomarked disinhibition in the within-UK group, atten-tion had to be restricted to the mild disinhibitiongroup. That represents an important constraint inthat it was the marked disinhibited group in theRomanian sample that was most distinctive. Never-theless, comparing the mild disinhibition and nodisinhibition subgroups at age 6 in the within-UKsample showed no substantial or statistically signi-ficant differences.

The investigator ratings of physical contact at age6 showed no difference (mild disinhibited attach-ment group: mean ¼ .22; sd ¼ .58; no disinhibitedattachment group: mean ¼ .42; sd ¼ .84) and boththe investigator composite ratings at age 11 showedno difference according to the presence of disin-hibited attachment at age 6 (.02 for the no disin-hibited attachment group vs. .03 for the milddisinhibited attachment group, for the physicalcontact composite and .23 for the no disinhibitedattachment group vs. .16 for the mild disinhibitedattachment group, for the violation of boundariescomposite). Thus, within the UK-adopted group nodifferences were found between the mild disinhibi-tion and no disinhibition sub-samples, suggestingthat in the absence of institutional rearing, milddisinhibited attachment is not a valid category.

Persistence/non-persistence of disinhibitedattachment from 6 to 11 years

The second major question concerned the persist-ence/non-persistence of disinhibited attachmentfrom age 6 to age 11 in institution-reared Romanianadoptees (see Figure 1). Substantial continuity isevident with 44 out of the 50 (88.0%) children with-out disinhibition at age 6 being similarly without atage 11. Of the 83 children with mild or marked dis-inhibition at age 6, 45 (54.2%) showed disinhibitionat age 11. However, it is apparent that there has beena substantial drop in the proportion showing markeddisinhibition at age 11 as compared with that at age6: 9.9% vs. 20.3%. Nevertheless, the effect of insti-tutional rearing on disinhibited attachment at age 11was closely similar to that at age 6. The phi coeffi-cient, dealing with the under 6 month versus 6 to42 month age at entry contrast, was .205 at 6 and.186 at 11, both being significant at the 5% level. The

Pearson correlation between age at entry within the 6to 42 months range and disinhibited attachment atage 6 was .162 and at age 11 it was .206. UsingSpearman’s rho the equivalent correlations were.202 and .214 (p ¼ .059 and p < .05 respectively).

The pattern for the within-UK adoptees was quitedifferent (see Figure 2). Whereas 55.8% had shownmild disinhibition at age 6, only 3.8% did so at age11. At both ages there were only two children withmarked disinhibition. Between 6 and 11 almost all(28 out of 29) of the children with mild disinhibitionat age 6 has ceased to show any of the disinhibitedattachment features at age 11. In order to test whe-ther this group difference reflected a difference in thedegree of disinhibition within the mild group, ananalysis of covariance was undertaken, treating thedisinhibition score at 6 as the covariate and thedisinhibition score at 11 as the dependent variable.The F value was 9.34, giving a p value of .003. Theimplication is that the predictive validity of milddisinhibition was quite different in the two groups.

Validity of disinhibited attachment at age 11

As with the age 6 measures, it was important tocheck the validity of the disinhibited attachmentmeasures at age 11. Because disinhibited attach-ment scarcely ever occurred in the within-UK adop-tees, the comparison could be undertaken only

6 years 11 years

No disinhibition

(n = 49)

No disinhibition

(n = 80)

Marked disinhibition

(n = 27)

Mild disinhibition

(n = 54)

Mild disinhibition

(n = 37)


(n = 13)

n = 44

n = 30

n = 6 n = 3

n = 19

n = 2

n = 6

n = 5

n = 15

Figure 1 Disinhibited attachment from 6 to 11 years(institution-reared Romanian adoptees)

6 years 11 years

No disinhibition

(n = 21)

No disinhibition

(n = 48)


(n = 2)

Mild disinhibition

(n = 29)

Mild disinhibition

(n = 2)


(n = 2)

n = 19

n = 28

n = 1n = 1

n = 1

n = 1

n = 1

Figure 2 Disinhibited attachment from 6 to 11 years(within-UK adoptees)



within the Romanian institutional sample with anage at entry between 6 and 42 months. The findingsshowed a significant difference (according to whetherthere was no, mild, or severe disinhibited attach-ment) with respect to the violation of boundariescomposite (F(2, 116) ¼ 5.96, p < .01) – as well aswith its components of disinhibition (F(2, 113) ¼4.84, p < .05), spontaneous comments (F(2, 113) ¼4.41, p < .05), verbal violation of boundaries (F(2,113) ¼ 6.64, p < .01), and social violation of bound-aries (F(2, 113) ¼ 4.84, p < .05). In each case, posthoc analyses showed that the differences lay be-tween the mild disinhibition and the no disinhibitiongroup, but for verbal violation of boundaries therewas a significant difference between the markeddisinhibition and no disinhibition groups. The find-ings validate the disinhibited attachment category atage 11 as based on parental reports, but the lack ofdifference between mild and marked disinhibitionraises the question of whether the apparent reduc-tion in marked disinhibition as seen on the parentalmeasure might be an artefact of the diminished ap-propriateness of the indices of disinhibited attach-ment based on parental reports at age 11.

Offset of disinhibited attachment between ages 6and 11

The query could be tackled by comparing the offsetand persistence of disinhibited attachment betweenages 6 and 11, in relation to the independent invest-igator ratings at age 11. The first comparison, usingthe investigator ratings, was between the 36 childrenwho ceased to show disinhibited attachment be-tween 6 and 11 and the 45 whose disinhibition per-sisted. With the exception of spontaneouscomments, the variables that showed a significantdifference in relation to the age 6 group did sosimilarly in relation to the changes between 6 and11. The details of the statistics for disinhibition were

t ¼ )2.12, df ¼ 72, p < .05; for verbal violation ofboundaries were t ¼ )2.30, df ¼ 72, p < .05; forsocial violation of boundaries were t ¼ )2.19, df ¼72, p < .05; and for the violation of boundariescomposite were t ¼ )2.04, df ¼ 74, p < .05. It may beconcluded that the measure of disinhibited attach-ment based on parental information at 11 was valid(Table 4).

Because the queried validity mainly applied to thechange from marked to mild disinhibited attach-ment, the same comparisons needed to be made forthis change even though the groups were small (n ¼15 for offset from marked to mild, and n ¼ 19 forpersistence from mild to mild – see Figure 1). Thefindings showed that the investigator ratings for thegroup that changed from marked to mild were moreabnormal than the mild to mild persistence, andwere more comparable to the marked–marked per-sistence. The implication is that the measure ofdisinhibited attachment based on the parentalinformation may provide a somewhat misleadingimpression of a reduced frequency of marked disin-hibition (Table 5).

Predictors of offset/persistence of disinhibitedattachment

The only other relatively strong predictor of offset vs.persistence was the score on disinhibited attach-ment at age 6. The children with higher disinhibitedattachment scores were significantly more likely toshow persistence than offset. The attachment scoreat age 6 for the persistent group was 3.22 (sd ¼ 1.68)vs. 2.11 (sd ¼ 1.45) for the offset group (t ¼ )3.14,df ¼ 79, p < .01). The group with persistent dis-inhibited attachment was substantially more likelyto receive a higher investigator rating of physicalcontact at age 6 (.90 vs. .44) but the variation wasgreat and the difference fell short of statistical sig-nificance. Neither the ratings of ‘other’ on the more

Table 5 Investigator ratings at age 11 in relation to the change from marked to mild disinhibition between 6 and 11

Age 11 Composites

Marked tomarked

mean (S.D.)

Markedto mild

mean (S.D.)

Mild tomild

mean (S.D.)

StatisticsMarked to mild vs.

mild to mild

Physical contact .22 (.47) .25 (.44) .14 (.24) t ¼ ).85, df ¼ 28, p ¼ .40Violation of boundaries .30 (.64) .49 (.70) .38 (.36) t ¼ ).58, df ¼ 29, p ¼ .57

Table 4 Investigator ratings at age 11 in relation to the offset and persistence of disinhibited attachment between 6 and 11(Romanian sample experiencing institutional deprivation)

No disinhibition(n ¼ 44) mean (S.D.)

Offset (n ¼ 36)mean (S.D.)

Persistence (n ¼ 45)mean (S.D.)

Statisticalsignificance p

Disinhibition .10 (.28) .22 (.54) .51 (.65) .01Verbal violation of boundaries .06 (.29) .15 (.42) .44 (.64) .01Social violation of boundaries .06 (.24) .09 (.38) .36 (.68) .05Violation of boundaries composite .11 (.26) .21 (.42) .44 (.56) .01



defined Strange Situation procedure or of attach-ment security predicted offset/persistence. Sevenout of 32 in the offset group (21.9%) and 14 of 39children in the persistence group (35.9%) wereclassified as ‘other’. Of the children rated as showingsecure selective attachments at age 6, 23.9% showedpersistence of disinhibited attachment as comparedwith 28.2% who showed offset – a nonsignificantdifference. A lower head circumference at age 6 wasof some predictive importance (t ¼ 2.34, df ¼ 76,p < .05) and children with high inattention/over-activity at age 6 were significantly more likely toshow persistence (Fisher’s Exact Test, p < .05). Inaddition, the mean number of months of institu-tional care was significantly greater in those whosedisinhibition persisted (n ¼ 45) than in those whoceased to show disinhibition (n ¼ 36): 19.36 (sd ¼11.57) vs. 12.50 (sd ¼ 10.75) (t ¼ )2.73, df ¼ 79,p < .01). Nevertheless, neither at age 6 nor at age 11were there significant associations with either age atentry to the UK or total months of institutional care(correlations of .16 and .13 respectively at age 6 and.21 and .17 at 11).

The possibility that offset/persistence might belargely a function of the post-adoption environment(other than as reflected in attachment security) wasexamined using the family risk index. The mean riskscore was somewhat higher (mean ¼ 1.42; sd. ¼1.50) in the persistence subgroup than in the offsetgroup (mean ¼ 1.29; sd ¼ 1.18) but the differencefell well short of statistical significance (t ¼ ).56,df ¼ 79, p ¼ .57). The number above the risk cut-offof 3 was similar in the offset and persistence group(17.8% vs. 19.4%). Similarly, there was no signific-ant association with the presence of disinhibitedattachment at age 11. Additionally, there was noassociation with the educational level of the adoptiveparents.

Disinhibited attachment and other malfunction

Finally, is disinhibited attachment just a stylisticfeature of little or no clinical significance or is it aform of disturbance that is associated with appreci-able social malfunction? We approached that ques-tion in two different ways. First, we compared theuse of services by the families whose child showedmarked disinhibition at either 6 or 11, those whosechild showed mild (but not marked) disinhibition ateither age, and those without disinhibition at 6 or 11.

Of those with marked disinhibition at either 6 or 11,41.2% received at least two sessions of mental healthprovision, compared with 25.0% of those with milddisinhibition and 0% of the children with no prob-lems in any domain. The comparable figures formajor special education provision (see Castle et al.,2006) were 41.2%, 17.3% and 0% (excluding, inkeeping with all the analyses reported above, thechildren who also showed quasi-autism). The find-ings show that the children with disinhibition re-ceived a high rate of both mental health and specialeducation services.

The second approach (see Table 6) was to deter-mine the proportions in the same three groups whoshowed malfunction on at least one other domain atage 11 (including for this purpose the previouslyomitted subgroup of ten children showing a quasi-autistic pattern). What the findings show is that bothmarked and mild disinhibition (especially marked)are associated with a considerably raised rate ofcognitive impairment, quasi-autism, peer relation-ship problems, inattention/overactivity and con-duct. The rates of emotional disturbance were alsosomewhat raised, but not significantly so. Comparedwith the children without disinhibition at either 6 or11 (only 37% of whom showed a problem on someother domain), the majority of those with eithermarked (75.0%) or mild (55.1%) disinhibitedattachment showed problems in at least one otherdomain (v2 ¼ 11.42, df ¼ 2, p < .01).

The last query concerned the rate of new cases ofdisinhibited attachment arising between 6 and 11.The theoretical construct postulates a basis in earlyattachment relationships and, if that is correct, newcases should not develop after age 6. The findingsshowed that there were only two such new cases ofmarked disinhibition (i.e., those moving from nodisinhibition at age 6 to marked disinhibition at age11) in the Romanian sample and one in the within-UK sample. The detailed descriptions of behaviourshowed that these cases clearly showed markedpsychopathology; they also exhibited behaviour thatincluded elements of disinhibited attachment, butthe overall pattern was rather different from that ofdisinhibited attachment that had been present fromthe preschool years in terms of its being imbedded ingeneral disturbance. These three individuals didshow a lack of selectivity in relationships but theparental reports and investigator observations sug-gested that it was not mainly a result of a failure to

Table 6 Frequencies of other problem areas at age 11 for those children showing marked attachment problems at either time point,mild problems at either time point and those showing no attachment problems at either time point

GroupCognitive

(%)Quasi-autism

(%)Peer(%)

I/O(%)

Conduct(%)

Emotional(%)

Marked at either 6 or 11 (N ¼ 40) 14 (35.0) 10 (25.0) 18 (45.0) 14 (35.0) 13 (32.5) 14 (35.0)Mild at either 6 or 11 (N ¼ 55) 8 (16.3) 5 (9.1) 12 (21.8) 6 (11.1) 8 (14.8) 12 (22.2)No disinhibition at 6 or 11 (N ¼ 45) 3 (7.5) 1 (2.2) 3 (6.7) 5 (11.6) 6 (14.0) 8 (18.6)



develop selective attachments. Moreover, of thechildren who developed new emotional (n ¼ 21),conduct (n ¼ 17), or inattention/overactivity prob-lems between 6 and 11 (n ¼ 12), only one (withemotional disturbance) developed disinhibitedattachment. It may be concluded that whereas dis-inhibited attachment was strongly associated withproblems in other domains of functioning, the re-verse did not apply. Scarcely any of the children whodeveloped new problems in other domains betweenages 6 and 11 showed an onset of disinhibitedattachment.

Discussion

The main findings can be summarised in relation tothe six issues that we tackled. First, the evidenceshowed that the ratings of disinhibited attachmentbased on parental information agreed moderatelywell with independent blind ratings by interviewersof inappropriate physical contact during the childassessments at age 6 and violation of boundariesduring the assessments at age 11. Given that theratings based on parental behaviour were derivedfrom concepts that largely applied to preschoolbehaviour, the independent validation may besomewhat surprising. Two points are relevant in thatconnection. First, the disinhibited attachment thatwe studied in the institution-reared children fromRomania involved quite marked behaviour and theexperiences that gave rise to such behaviour werealso extreme by any standard. It cannot be assumedthat the same degree of validity would apply in othercircumstances. Indeed, as we discuss below, thevalidity of measures of mild disinhibited attachmentin the children adopted within the UK did not showthe same validity. Second, although the ratingsbased on parental reports worked surprisingly well,the only moderate degree of association amongmeasures suggests that the categorisation of clinic-ally significant disinhibited attachment should bebased on a combination of several measures. The keyfeatures would seem to be the child’s lack of differ-entiation among adults with respect to the child’ssocial response to them, combined with a clearindication that the child might readily go off with astranger, and a definite lack of checking back withthe parent in anxiety-provoking situations. With re-spect to interactions with other people, the moststriking features seemed to be the extent of sociallyinappropriate physical contact, a lack of social re-serve, an unusual relationship with the examiner,verbal and social violation of conventional bound-aries, and a high level of spontaneous comments.The Strange Situation procedure (modified for use inthe home) showed (at age 6) unusual responses thatwere obviously different from those ordinarily foundwith typically developing children but, equally, apattern that did not fit in with the usual categories of

attachment insecurity. In summary, the concept in-volves unusual behaviour in relation to both familymembers and strangers.

The second issue concerned the extent to whichdisinhibited behaviour patterns, as measured inthese various ways, persisted from age 6 to age 11.The findings showed a very substantial degree ofpersistence at both the individual and the grouplevel. This had been reported in the parallel Canadianstudy of adoptees from Romania who had experi-enced institutional deprivation (Maclean, 2003).Gunnar and van Dulmen’s (in press) cross-sectionalstudy found that social problems were particularlyassociated with institutional deprivation and themuch earlier small-scale study by Hodges and Tizard(1989) noted that these sometimes persisted intoadolescence. Our study, however, is the first to havesystematic data on persistence into adolescence.

The finding is remarkable in view of the fact thatthe causal factor seems to be depriving institutionalrearing but the pattern showed persistence over aperiod of at least 7 years following adoption intogenerally well-functioning families. The period fromage 6 to 11 also involved changes in school experi-ences and peer relationships. Given the lack ofevidence that persistence was related to the post-adoption environment, the findings point to thelikely operation of some form of intra-organismicchange. In an earlier report dealing with the age 6findings (Rutter et al., 2004), we concluded thatsome form of biological programming was likely to beoperating. However, with respect to the age 11 find-ings, we are unable to assess the possible role ofpsychological representations and internal workingmodels. That constitutes a major focus in our on-going study. In that connection, it is relevant that theassociation with duration of institutional deprivationwithin the 6 to 42 month group fell short of statis-tical significance at age 11, but with no diminution ofeffects between 6 and 11.

We conclude that it takes some months for theeffects to be established (because there were nonedetected with institutional deprivation that did notextend beyond 6 months) but that with any durationbeyond that the effects were not greatly increased bythe overall length of the period of institutionaldeprivation. The apparent drop in the level of disin-hibited attachment between 6 and 11 on the parentalmeasure is likely to reflect, in part, limitations in theindices of attachment used at age 11 in the parentalinterview. Because we did not have comparableinvestigator ratings at ages 6 and 11, we are not ableto quantify the extent to which improvement was realand the extent to which it was an artefact of meas-urement. The overall pattern of findings, however,suggests that both apply.

The third question was whether the mild disin-hibited attachment pattern showed the same fea-tures as those associated with marked disinhibitedattachment. The findings showed that, within the



sample of institution-reared children, the meaningof the two was remarkably similar. Not surprisingly,the features tended to be somewhat more striking inthe marked disinhibited attachment group but thedifferences from the mild disinhibited attachmentgroup rarely reached the level of statistical signific-ance. In sharp contrast, the categorisation of milddisinhibited attachment in children adopted withinthe UK (and who had not experienced institutionalrearing or any marked degree of deprivation) wasquite different. The great majority of these ceased toshow disinhibition by age 11 and, on the whole, thepattern of correlates was similar to the childrenwithout disinhibition at age 6. The pattern of changefor mild disinhibition between 6 and 11 was quitedifferent in the within-UK adoptees as comparedwith the institution-reared children from Romania;moreover, an analysis of covariance showed thatthis marked between-group difference was not afunction of the level of disinhibition at age 6. In theRomanian adoptees, mild disinhibition at age 6 wasvalidated by the investigator ratings at both age 6and age 11. By contrast, in the within-UK adoptees,mild disinhibition and no disinhibition at age 6 didnot differ according to the investigator ratings ateither 6 or 11. The findings on the deprived childrenfrom Romania who had not received an institutionalrearing were somewhat intermediate and ratherinconclusive. The size of this group was too small formuch confidence to be placed on the findings, butthe disinhibited attachment was less striking thanin the institution-reared sample. It may be conclu-ded that both mild and marked disinhibitedattachment, when found in children who had re-ceived an institutional rearing and for whom theparent reports are confirmed by independentobservations, are likely usually to be clinically sig-nificant. The ‘Strange Situation’ findings, however,suggest that the pattern is not equivalent to in-secure selective attachments. By contrast, the milddisinhibition in children who have not received aninstitutional rearing is likely in most instances notto be clinically significant.

Because the only strong predictor of persistence ofsocial disinhibition from age 6 to age 11 was theexperience of institutional rearing that had persistedbeyond the age of 6 months, there is the implicationthat some form of biological programming is likely tohave been responsible. In keeping with that sugges-tion is the finding that the few other measures pre-dicting persistence all concerned the pre-adoptionenvironment. In keeping with evidence on otheradoptee samples, there was little evidence of seriouspsychosocial dysfunction in the adopting familiesand such measures as we had of family functioningdid not predict persistence of social disinhibition.That is not to argue that the post-adoption environ-ment is of no significance, but it is to suggest thatvariations within this basically normal range were oflittle prognostic significance.

The fifth issue concerned the question of whetherdisinhibited attachment was simply a stylistic fea-ture of no great importance, or rather an index ofclinically significant psychopathology. The evidencepointed strongly to the latter. The majority of thechildren with disinhibited attachment exhibitedproblems in other domains of behaviour and theywere more likely to have received services of one kindor another than the children without social disin-hibition at age 6. On those grounds, we concludethat disinhibited attachment, when seen in childrenfrom an institutional background, probably usuallydoes reflect a clinically significant disorder. The lastissue was whether disinhibited attachment consti-tuted merely a non-specific feature of any type ofpsychopathology or rather a distinctively differentpattern in its own right. The evidence pointedstrongly to the latter. Although the majority of thechildren with disinhibited attachment showed otherforms of social malfunction, scarcely any of thechildren who develop new disorders in otherdomains develop new manifestations of disinhibitedattachment between the ages of 6 and 11 years.Disinhibited attachment was essentially a patternthat was evident from the preschool years and didnot develop anew in middle childhood.

Limitations

Our sample of non-institution-reared, but deprived,adoptees was too small to provide an adequate test ofthe possibility that other forms of deprivation maypredispose to disinhibited attachment. There is apaucity of validated measures of disinhibitedattachment in older children. We lacked adequatemeasures of the institutional environments in Ro-mania. There is a lack of knowledge on family cir-cumstances that might influence the course ofdisinhibited attachment, and both the range ofvariation and its measurement in adoptee familieslimited our ability to test post-adoption effects.

Conclusion

In summary, we conclude that the pattern of dis-inhibited attachment, when seen in children whohave experienced institutional rearing lasting atleast until the age of 6 months, constitutes a mean-ingfully distinctive behavioural pattern that isindicative of a clinically significant disorder.

Acknowledgements

We are most grateful to all the families who havegenerously given their time to participating in thisstudy, and whose comments and suggestions havebeen very helpful in relation to the interpretation offindings. The data collection phase of the study wassupported by grants from the Helmut Horten Foun-



dation and the UK Department of Health. Ongoingsupport is provided by grants from the Departmentof Health, the Nuffield Foundation and the JacobsFoundation. We are glad to express our thanks toour external Advisory Group, whose input has beeninvaluable. We also thank Robert Marvin and hiscolleagues for their coding of the modified StrangeSituation videotapes (undertaken blind to the groupsfrom which the children came). The views expressedin this article are ours and do not necessarily rep-resent those of the funders.

Correspondence to

Michael Rutter, PO 80, MRC SGDP Centre, Instituteof Psychiatry, De Crespigny Park, Denmark Hill,London SE5 9AF, UK; Email: [email protected]

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Manuscript accepted 19 July 2006



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