described as "quite concerning". the boy still evidenced self-endangering behaviors as well as avoidance in relationships and emotional expression, separation anxiety and impulsivity and attention difficulties. it was apparent that life stressors had impacted each child differently. the narrative measures used were considered helpful in tracking how early attachment disruption is associated with later expectations about relationships. one paper using questionnaires found that children aged three to six, diagnosed with rad, scored lower on empathy but higher on self-monitoring (regulating your behavior to "look good"). these differences were especially pronounced based on ratings by parents, and suggested that children with rad may systematically report their personality traits in overly positive ways. their scores also indicated considerably more behavioral problems than scores of the control children. epidemiology epidemiological data are limited, but reactive attachment disorder appears to be very uncommon. the prevalence of rad is unclear but it is probably quite rare, other than in populations of children being reared in the most extreme, deprived settings such as some orphanages. there is little systematically gathered epidemiologic information on rad. a cohort study of 211 copenhagen children to the age of 18 months found a prevalence of 0.9%. attachment disorders tend to occur in a definable set of contexts such as within some types of institutions, in the presence of repeated changes of primary caregiver or of extremely neglectful identifiable primary caregivers who show persistent disregard for the child's basic attachment needs, but not all children raised in these conditions develop an attachment disorder. studies undertaken on children from eastern european orphanages from the mid-1990s showed significantly higher levels of both forms of rad and of insecure patterns of attachment in the institutionalized children, regardless of how long they had been there. it would appear that children in institutions like these are unable to form selective attachments to their caregivers. the difference between the institutionalized children and the control group had lessened in the follow-up study three years later, although the institutionalized children continued to show significantly higher levels of indiscriminate friendliness. however, even among children raised in the most deprived institutional conditions the majority did not show symptoms of this disorder. a 2002 study of children in residential nurseries in bucharest, in which the dai was used, challenged the current dsm and icd conceptualizations of disordered attachment and showed that inhibited and disinhibited disorders could coexist in the same child. there are two studies on the incidence of rad relating to high risk and maltreated children in the u.s. both used icd, dsm and the dai. the first, in 2004, reported that children from the maltreatment sample were significantly more likely to meet criteria for one or more attachment disorders than children from the other groups, however this was mainly the proposed new classification of disrupted attachment disorder rather than the dsm or icd classified rad or dad. the second study, also in 2004, attempted to ascertain the prevalence of rad and whether it could be reliably identified in maltreated rather than neglected toddlers. of the 94 maltreated toddlers in foster care, 35% were identified as having icd rad and 22% as having icd dad, and 38% fulfilled the dsm criteria for rad. this study found that rad could be reliably identified and also that the inhibited and disinhibited forms were not independent. however, there are some methodological concerns with this study. a number of the children identified as fulfilling the criteria for rad did in fact have a preferred attachment figure. it has been suggested by some within the field of attachment therapy that rad may be quite prevalent because severe child maltreatment, which is known to increase risk for rad, is prevalent and because children who are severely abused may exhibit behaviors similar to rad behaviors. the apsac taskforce consider this inference to be flawed and questionable. severely abused children may exhibit similar behaviors to rad behaviors but there are several far more common and demonstrably treatable diagnoses which may better account for these difficulties. further, many children experience severe maltreatment and do not develop clinical disorders. resilience is a common and normal human characteristic. rad does not underlie all or even most of the behavioral and emotional problems seen in foster children, adoptive children, or children who are maltreated and rates of child abuse and/or neglect or problem behaviors are not a benchmark for estimates of rad. there are few data on comorbid conditions, but there are some conditions that arise in the same circumstances in which rad arises, such as institutionalization or maltreatment. these are principally developmental delays and language disorders associated with neglect. conduct disorders, oppositional defiant disorder, anxiety disorders, post-traumatic stress disorder and social phobia share many symptoms and are often comorbid with or confused with rad. attachment disorder behaviors amongst institutionalized children are correlated with attentional and conduct problems and cognitive levels but nonetheless appear to index a distinct set of symptoms and behaviors. history reactive attachment disorder first made its appearance in standard nosologies of psychological disorders in dsm-iii, 1980, following an accumulation of evidence on institutionalized children. the criteria included a requirement of onset before the age of 8 months and was equated with failure to thrive. both these features were dropped in dsm-iii-r, 1987. instead, onset was changed to being within the first 5 years of life and the disorder itself was divided into two subcategories, inhibited and disinhibited. these changes resulted from further research on maltreated and institutionalized children and remain in the current version, dsm-iv, 1994, and its 2000 text revision, dsm-iv-tr, as well as in icd-10, 1992. both nosologies focus on young children who are not merely at increased risk for subsequent disorders but are already exhibiting clinical disturbance. the broad theoretical framework for current versions of rad is attachment theory, based on work conducted from the 1940s to the 1980s by john bowlby, mary ainsworth and rené spitz. attachment theory is a framework that employs psychological, ethological and evolutionary concepts to explain social behaviors typical of young children. attachment theory focuses on the tendency of infants or children to seek proximity to a particular attachment figure (familiar caregiver), in situations of alarm or distress, behavior which appears to have survival value. this is known as a discriminatory or selective attachment. subsequently, the child begins to use the caregiver as a base of security from which to explore the environment, returning periodically to the familiar person. attachment is not the same as love and/or affection although they are often associated. attachment and attachment behaviors tend to develop between the ages of six months and three years. 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. caregiver responses lead to the development of patterns of attachment, that in turn lead to internal working models which will guide the individual's feelings, thoughts, and expectations in later relationships. for a diagnosis of reactive attachment disorder, the child's history and atypical social behavior must suggest the absence of formation of a discriminatory or selective attachment. the pathological absence of a discriminatory or selective attachment needs to be differentiated from the existence of attachments with either typical or somewhat atypical behavior patterns, known as styles or patterns. there are four attachment styles ascertained and used within developmental attachment research. these are known as secure, anxious-ambivalent, anxious-avoidant, (all organized) and disorganized. the latter three are characterised as insecure. these are assessed using the strange situation procedure, designed to assess the quality of attachments rather than whether an attachment exists at all. a securely attached toddler will explore freely while the caregiver is present, engage with strangers, be visibly upset when the caregiver departs, and happy to see the caregiver return. the anxious-ambivalent toddler is anxious of exploration, extremely distressed when the caregiver departs but ambivalent when the caregiver returns. the anxious-avoidant toddler will not explore much, avoid or ignore the parent—showing little emotion when the parent departs or returns—and treat strangers much the same as caregivers with little emotional range shown. the disorganized/disoriented toddler shows a lack of a coherent style or pattern for coping. evidence suggests this occurs when the caregiving figure is also an object of fear, thus putting the child in an irresolvable situation regarding approach and avoidance. on reunion with the caregiver, these children can look dazed or frightened, freezing in place, backing toward the caregiver or approaching with head sharply averted, or showing other behaviors implying fear of the person who is being sought. it is thought to represent a breakdown of an inchoate attachment strategy and it appears to affect the capacity to regulate emotions. although there are a wide range of attachment difficulties within the styles which may result in emotional disturbance and increase the risk of later psychopathologies, particularly the disorganized style, none of the styles constitute a disorder in themselves and none equate to criteria for rad as such. a disorder in the clinical sense is a condition requiring treatment, as opposed to risk factors for subsequent disorders. reactive attachment disorder denotes a lack of typical attachment behaviors rather than an attachment style, however problematic that style may be, in that there is an unusual lack of discrimination between familiar and unfamiliar people in both forms of the disorder. such discrimination does exist as a feature of the social behavior of children with atypical attachment styles. both dsm-iv and icd-10 depict the disorder in terms of socially aberrant behavior in general rather than focusing more specifically on attachment behaviors as such. dsm-iv emphasizes a failure to initiate or respond to social interactions across a range of relationships and icd-10 similarly focuses on contradictory or ambivalent social responses that extend across social situations. the relationship between patterns of attachment in the strange situation and rad is not yet clear. there is a lack of consensus about the precise meaning of the term "attachment disorder". the term is frequently used both as an alternative to reactive attachment disorder and in discussions about different proposed classifications for disorders of attachment beyond the limitations of the icd and dsm classifications. it is also used within the field of attachment therapy, as is the term reactive attachment disorder, to describe a range of problematic behaviors not within the icd or dsm criteria or not related directly to attachment styles or difficulties at all. research research from the late 1990s indicated there were disorders of attachment not captured by dsm or icd and showed that rad could be diagnosed reliably without evidence of pathogenic care, thus illustrating some of the conceptual difficulties with the rigid structure of the current definition of rad. research published in 2004 showed that the disinhibited form can endure alongside structured attachment behavior (of any style) towards the child's permanent caregivers. some authors have proposed a broader continuum of definitions of attachment disorders ranging from rad through various attachment difficulties to the more problematic attachment styles. there is as yet no consensus, on this issue but a new set of practice parameters containing three categories of attachment disorder has been proposed by c.h. zeanah and n. boris. the first of these is disorder of attachment, in which a young child has no preferred adult caregiver. the proposed category of disordered attachment is parallel to rad in its inhibited and disinhibited forms, as defined in dsm and icd. the second category is secure base distortion, where 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, cling to the adult, be excessively compliant, or show role reversals in which they care for or punish the adult. the third type is disrupted attachment. disrupted attachment is not covered under icd-10 and dsm criteria, and results from an abrupt separation or loss of a familiar caregiver to whom attachment has developed. this form of categorisation may demonstrate more clinical accuracy overall than the current dsm-iv-tr classification, but further research is required. the practice parameters would also provide the framework for a diagnostic protocol. most recently, daniel schechter and erica willheim have shown a relationship between some maternal violence-related posttraumatic stress disorder and secure base distortion (see above) which is characterized by