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Introduction
Outline of Presentation
Quick Review of Attachment Styles/Patterns
o Bowlby and Ainworth
 Zeanah & Smyke (2008) - The most important breakthrough in attachment
research came when Mary Ainsworth and her colleagues developed a
laboratory paradigm for the assessment of attachment in infancy known as
the Strange Situation Procedure (SSP;Ainsworth, Blehar,Waters,&Wall,
1978). Important work by Sroufe (2005) and colleagues (Weinfield, Sroufe,
Egeland, & Carlson, 1999) established its construct validity for the
assessment of the quality of parent–child attachment in young children.
Main and colleagues’ (Main&Hesse, 1990; Main&Solomon, 1990) description
of disorganized attachment extended the value of SSP classifications to
clinical populations of young children, enhancing the interest of clinicians.
The SSP has been used in hundreds of studies of attachment around the
world, and although often maligned, it is still widely considered the gold
standard for assessing quality of attachment in the early years.
 It has been emphasized repeatedly that SSP classifications of secure,
avoidant, resistant, and disorganized are best considered risk and protective
factors for disorders rather than diagnostic entities themselves. Important
work has established increased risk for anxiety disorders, disruptive
behavior disorders, dissociative disorders, substance use, delinquency, and
personality disorders among children with insecure, and especially,
disorganized attachments, to their primary caregivers (Hauser&BormanSpurrell, 1996; Carlson, 1998; DeKlyen, 1996; Lyons-Ruth, 1996; Rosenstein
& Horowitz, 1996; Warren, Huston, Egeland, & Sroufe, 1997).
 Hardy (2007) – Attachment theory (AT) was developed by John Bowlby in
the 1960’s. Bowlby was a psychoanalyst who recognized the importance of
a child’s early relationship with the primary caregiver in the future
development of the child’s personality. AT basically suggests that infants are
evolutionarily primed to form a close, enduring, dependent bond on a
primary caregiver beginning in the first moments of life.
 HARDY (2007) - The vulnerability of the infant requires that care be
provided by an adult, and the infant’s behaviors and inherent faculties
ensure that a bond will be created. Infants attend to human voices, recognize
human faces, and gaze into parents’ eyes when being fed. They look to the
attachment object for cues when faced with novel stimuli. The fulfillment of
their physiological needs requires close and frequent physical contact
throughout infancy (Carlson, Sampson, & Sroufe, 2003). As they develop the
capacity for locomotion and intentional movement, they attempt to maintain
physical proximity to the caregiver and frequently return for “refueling”
when they are involved in an individual activity (Ainsworth et al., 1978).
Since infants are intrinsically driven to form attachments, they will attach to
o
o
the primary caregiver regardless of the type of interactions that occur. Thus,
attachment status is classified according to quality rather thanquantity
(Main, 1996).
 HARDY (2007)Four infant attachment styles have been identified: secure,
avoidant, resistant-ambivalent, and disorganizeddisoriented.
 Schwartz(2006) - Attachment theory provides a useful lens through which
to view the development of early relationships and the potential trajectory
for later interpersonal functioning. Bowlby (1982) defined attachment from
a bioevolutionary perspective, concluding that attachment is a fundamental
human need based in biology and intimately related to the survival of the
species. More specifically, attachment is the organization of a set of specific
behaviors designed to achieve four primary goals: proximity, security,
safety, and regulation of a child’s affective states (Bowlby, 1982; Schore,
2001). Recently, Schore (2001) reiterated Bowlby’s hypothesis, notingthat
an infant’s adaptive and coping capacities play a prominent and central role
in their mental health and that these domains of functioning cannot be
separated or understood apart from the child’s attachment and relationship
with his or her caregiver.
Secure Attachment
 HARDY (2007) - Infants with a secure pattern of attachment typically
protest when they are separated from their caregiver, and they attempt to
regain closeness to the caregiver upon reunion.
 Schwartz (2006) - In the development of a secure attachment, the infant is
able to draw upon the mother for responsive, nurturing, and reliable care for
regulating distress (Stern, 1985).
 Essentially, the presence of a responsive, nurturing caregiver helps regulate
the infant’s arousal state and emotions, resulting in the infant’s expanding
and growing capacity to learn the skills necessary for self-regulation, ability
to cope with stress, and the development of a secure attachment. In the
context of a secure attachment, children are thus likely to be better equipped
to regulate their own affect. In turn, children who can better regulate their
emotions and behavior are more likely to be ready to enter school and
function effectively once in school. On the other hand, children with early
relational trauma, histories of maltreatment, and disruptions in their earliest
relationships have been shown to be at significant risk for both internalizing
and externalizing behavior problems
 (Kennedy & Kennedy, 2004).
Disorganized Attachment
 HARDY (2007) - The disorganized style of attachment is typically seen in
infants who have been maltreated by their attachment figure. They exhibit
conflicted behaviors such as simultaneously reaching for and turning away
from the caregiver. This is most likely related to the inherent conflict
between the attachment object being both the cause of distress and the
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infant’s only potential source of comfort from distress. The disorganized
attachment style is thought to
be most correlated with psychopathology (Main, 1996).
o Resistant-Ambivalent Attachment
 HARDY (2007) The resistant-ambivalent pattern is characterized by a
preoccupation or fixation on the caregiver in which the caregiver is
alternately sought for comfort and rejected.
o Avoidant Attachment
 HARDY (2007 - The avoidant attachment style involves behaviors that
resemble rejection. Infants with this pattern tend to ignore the caregiver’s
departure and return and actively avoid the caregiver’s attempts to regain
contact.
Attachment Disorders
o RAD
o Schwartz (2006) - Children with early relational trauma and disruptions in the
primary infant–parent relationship, resulting from grossly pathological care and
maltreatment, may be diagnosed with attachment disorders and, in some cases,
RAD; however, RAD, as a psychiatric diagnosis, extends well beyond the narrow
scope of the infant–parent relationship and reflects broad social abnormalities
across multiple contexts (Richters & Volkmar, 1994). In the Diagnostic and
Statistical Manual of Mental Disorders, fourth edition, text revision (DSM IV-TR;
American Psychiatric Association, 2000), the predominant feature of the disorder is
the presence of “markedly disturbed and developmentally inappropriate social
relatedness in most contexts beginning before age 5 years and is associated with
grossly pathogenic care” (p. 127). Grossly pathogenic care is characterized by (a) a
persistent disregard for the child’s emotional needs for comfort, stimulation, and
affection; (b) persistent disregard for the child’s physical needs; and (c) repeated
changes of primary caregivers (American Psychiatric Association, 2000).
o Similar to the behaviors associated with maltreatment, the descriptive
symptomatology of RAD suggests maladaptive patterns of interpersonal functioning
and emotional regulation that have far-reaching consequences for children
(American Psychiatric Association, 2000). For example, it has been found that
children with RAD demonstrate maladaptive attachment behaviours specifically
with regard to how they cope with exploration, fear, and wariness (O’Connor,
Brendenkamp, & Rutter, 1999). Aber, Allen, Carlson, and Cicchetti (1989) found that
children who are RAD maltreated exhibit poor self-esteem and self-regulation, poor
peer relations, and developmental and cognitive delays. They concluded that the
predominant issue for these maltreated children was a concern for security and
reflected an expectation of adults as unresponsive, unavailable, and rejecting (Aber
et al., 1989). Children diagnosed with RAD have similar difficulties selfregulating
and modulating their emotions and behaviors (Kay-Hall & Geher, 2003).
o Children with attachment disorders such as RAD struggle to form typical, reciprocal
relationships with others (Reber, 1996). According to a number of researchers,
o
children with RAD display a wide variety of maladaptive behaviors including
property destruction, aggression, hoarding food, stealing, lying, bullying, and cruelty
to animals and people (Parker & Forrest, 1993; Reber, 1996). Additionally, children
diagnosed with RAD may seek out strangers at inappropriate times, and experience
difficulties both giving and receiving affection (Reber, 1996). Kirschner (1992)
found these children tend to seek out other children with similar emotional and
behavioral disturbances. Other behaviors reportedly seen in children diagnosed
with RAD include poor impulse control, poor self-regulation, hyperactivity, low
frustration tolerance, and seeking out and associating with other children with
behavioral problems and superficiality (Kirschner, 1992; Reber, 1996). Kay-Hall and
Geher (2003) found that children diagnosed with RAD evidenced significantly more
violent behaviors, were less empathic, and had more personality difficulties than did
children who were not diagnosed with RAD. The problems typically seen in children
with RAD are typically intense and pervasive; children with problems related to
attachment struggle to find joy, mutuality, and reciprocity in their interactions with
others (Hughes, 1997). These children have not experienced the necessary sense of
reciprocity and security of a responsive, attuned parent. They have grown up in a
world that is often chaotic, neglectful, and frightening. These experiences are
reflected in their inability to regulate and modulate their emotions and behaviors,
often appearing out of control.
HISTORY OF RAD
o ZEANAH & SMYKE(2008) – The clinical perspective on attachment derives from
descriptive studies of young children raised in extreme caregiving environments,
such as those who have been maltreated or those who have been reared in
institutional settings (Goldfarb, 1945; Main & George, 1979; Spitz, 1945; Wolkind,
1974). Drawing upon these studies, Tizard and Rees (1975) reported that at age 4
years, a majority of young children (18/26) who had been raised in residential
nurseries in the United Kingdom since birth exhibited aberrant attachment
behavior. A group of 8 children were described as emotionally withdrawn and
unresponsive, and another group of 10 children were indiscriminate, attention
seeking, and socially superficial. These two groups became the basis for RAD, which
was first described in the DSM-III (American Psychiatric Association, 1980) and
later revised in subsequent editions. The criteria for RAD in the Diagnostic and
Statistical Manual of Mental Disorders, fourth edition (DSM-IV; American Psychiatric
Association, 1994) and the ICD-10 (World Health Organization, 1992) are notably
similar, although DSM-IV criteria include inhibited/emotionally withdrawn and
disinhibited/indiscriminately social subtypes whereas ICD-10 criteria define the
inhibited type as Reactive Attachment Disorder and the disinhibited type as
Disinhibited Attachment Disorder.
o In addition to the disturbed social behaviors that form the core of contemporary
descriptions of attachment disorders, both the DSM and the ICD specify that the
etiology of the disorder is extremely poor caregiving. The DSM-IV criteria require
“pathogenic care,” and the ICD-10 description cautions against making the diagnosis
in the absence of maltreatment. Both also noted that the signs and symptoms of the
disorder are not due to developmental delay or to pervasive developmental
disorder.
 DSM Definition
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HARDY (2007) In them Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition-Text Revision (American Psychiatric
Association, 2000), the only pathology that is officially related to
attachment is reactive attachment disorder of infancy or early
childhood (RAD) (see Table 1). The diagnostic criteria for this
disorder include: a pattern of disturbed and developmentally
inappropriate social relationships prior to age five, a history of
pathogenic care that predates the presentation of the disturbances,
and the assumption that the disturbances are not better accounted
for by other diagnoses (p. 130). There are two subtypes of RAD,
inhibited type and disinhibited type. The DSM-IV-TR (2000) criteria
do not include any descriptors of associated behaviors, and there are
no validated instruments for assessing or diagnosing RAD (Minde,
2003). A wide variety of behaviors have been attributed to RAD, but
there is limited empirical research in this area (Hanson & Spratt,
2000; Minde). While diagnosis and treatment of disordered
attachment patterns are vitally important, limiting the conception of
attachmentrelated psychopathology to the narrow diagnostic
criteria of RAD significantly understates the importance of other
attachment-related conditions and may limit the use of potentially
effective interventions. Identifying the links between these disorders
will guide interventions to impact the attachment problems by
targeting underlying issues rather than focusing on just the
symptoms.
Diagnostic Criteria
 Schwartz (2006) – In differentiating RAD from other developmental
disorders, the DSM IV-TR emphasizes that the diagnosis is
predicated upon an etiology of documented grossly pathogenic care,
and may include the experience of frequent and repeated changes in
caregivers. For RAD to develop, grossly pathogenic care also must
include limited opportunities to develop selective attachments.
Examples include children brought up in institutions with multiple
caregivers or children who have a history of being reared in atypical
environments characterized by extreme neglect and abuse. Children
raised in these types of environments have been shown to manifest
abnormal social behaviors such as lack of responsiveness, excessive
inhibition, hypervigilance, indiscriminate sociability, or pervasively
disorganized attachment behaviors (O’Connor & Rutter, 2000).
These symptoms suggest a growing link between children with
major attachment disruptions and the presence of a disorganized
attachment status. Children classified with a disorganized
attachment or diagnosed with RAD are seen as controlling and
punishing, and engage in role-reversal behavioural patterns when
reunited with the parent (Hughes, 1997; Main & Cassidy, 1988;
Solomon & George, 1996). Research also has shown that the
disorganized attachment pattern is linked to aggressive externalizing
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behavior (Lyons-Ruth, Repacholi, McLeod, & Silva, 1991; Shaw,
Owens, Vondra, & Keenan, 1996). Hanson and Spratt (2000)
suggested that “the purpose of the RAD diagnosis is to provide a
clinical description that includes the problems in the child’s ability to
relate to people and the context in which this behavior develops” (p.
138).
 SCHWARTZ (2006) - children diagnosed with RAD must have a
documented history of parenting characterized by grossly
pathogenic care.
 Hardy (2007) - Since the diagnostic criteria for RAD are relatively
nonspecific, the diagnosis may be given to children who come from a
range of different backgrounds. Research has focused on children
who have been institutionalized as well as on children who have had
a primary caregiver but developed a disordered attachment due to
maltreatment. In another study, Zeanah et al. (2004) found evidence
of disordered attachment in maltreated toddlers who were removed
from their primary caregiver and placed in foster care. Marvin and
Whelan (2003) further emphasize some of the difficulties associated
with the RAD diagnosis and with the assessment of attachment
disturbances. Because attachment has typically been studied by
applying Ainsworth’s original model of qualitative differences
between attachment typology, focusing on the RAD criteria and
associated behaviors presents a difficult transition. The RAD
diagnosis does not fit neatly into the categorization of the four
attachment styles that have been identified by Ainsworth and Main.
Core Symptoms
 HARDY (2007) - Haugaard and Hazan (2004) describe the inhibited
type of RAD as a pattern resulting from experience with caregivers
who do not provide emotional support and comfort when needed.
Because children who have been treated in this way expect to be
rejected by others, they avoid social contact. Behaviors that are
typically associated with this pattern include withdrawal from
others, avoidance of comforting gestures, self-soothing behaviors,
vigilance, aggression, and awkwardness in social situations. In the
disinhibited type, behaviors are believed to be related to experience
with caregivers who are not responsive but can be coerced into
providing affection. This results in behaviours such as inappropriate
familiarity and comfort-seeking with strangers, exaggeration of
needs for assistance, chronic anxious appearance, and inappropriate
childishness (p. 158).
Subtypes
o ZEANAH & SMYKE (2008) – EXCELLENT TABLE ON PAGE 223 Schwartz (2006) RAD is divided into two subtypes: the Inhibited subtype and the Disinhibited
subtype. The Inhibited subtype refers to children who persistently and pervasively
fail to initiate and to respond to social interactions in a developmentally acceptable
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way. The Disinhibited subtype describes children who are indiscriminately sociable
or demonstrate lack of selectivity in their attachments.
o Disinhibited
 ZEANAH & SMYKE (2008) - Indiscriminate/Disinhibited Pattern of RAD
The essence of this pattern of RAD is the failure to exhibit developmentally
expectable reticence around unfamiliar adults. This ismanifest by the child’s
lack of reticence about engaging socially with them, failure of the child to
check back with the caregiver in unfamiliar settings and instead tending to
wander off, and the child’s willingness to approach, interact with, and “go
off” with a stranger. Developmentally, stranger wariness appears early in the
second half of the first year of life. Though individual differences are evident,
some degree of stranger wariness is evident in all typically developing
children. In the indiscriminate/disinhibited pattern, wariness around
strangers is absent or substantially diminished.
o Inhibited
 ZEANAH & SMYKE (2008) - Emotionally Withdrawn/Inhibited RAD The
essence of this pattern of RAD is a young child who exhibits minimal or no
discriminated attachment behavior, even at times when the child’s
attachment behaviors should be activated. Phenomenologically, it is
characterized by the absence of organized attachment behaviors, impaired
social engagement and reciprocity, emotion regulation difficulties (i.e., low
levels of positive affect, outbursts of irritability, unexplained fear and
hypervigilance). Children with this pattern do not seek comfort consistently
or at all even when distressed and are not easily soothed when they do
become distressed. Individual differences in soothability are rightfully
considered a temperamental disposition, but what distinguishes RAD is the
degree and pervasiveness of the child’s unresponsiveness in the context of
minimal or no attachment behaviors. **** THIS ARTICLE ALSO PROVIDES A
GREAT DISTINCTION BETWEEN RAD AND PDD ON PAGE 223.
Theoretical Conceptualization
o HARDY (2007) - There are two major theoretical perspectives that inform our
understanding of the process of attachment. According to the developmental
psychology perspective, the early relationship with the attachment object causes an
infant to form internal working models for relationships that will influence
interpersonal relationships throughout life. These working models consist of
representational structures that define one’s perception of self and others and
contribute to the internal processes that define one’s selective experience of the
external world (Pietromonaco & Barrett, 2000). The psychoanalytic perspective
maintains that self and object representations form as a result of early childhood
experiences and that these representations will influence all future affective
exchanges. Similarly, these processes function from the unconscious mind (Schore,
2002). Although there are some differences in the construction and application of
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the developmental psychology and psychoanalytic perspectives, they seem to differ
primarily in semantics.
o Neuroanalytic Perspective explained on page 2 of the HARDY article ******
Major Issues in Conceptualizing and Identifying RAD
o ZEANAH & SMYKE (2008) - Studies of Children in Institutions Signs of RAD have
been readily identified among young children living in institutions. Smyke,
Dumitrescu, and Zeanah (2002) reported signs of both emotionally
withdrawn/inhibited and indiscriminately social/disinhibited attachment in a
substantial number of young children being raised in a large institution for young
children in Bucharest, Romania. In another sample, Zeanah et al. (2005b) similarly
found signs of both types of RAD among young children living in institutions.
o Quality of Caregiving and RAD Given that pathogenic care is required as a
diagnostic criterion for RAD, it is important to know if the care-giving environment
is related to signs of the disorder. It is clear that RAD has been reported only in
children with histories of either maltreatment or institutional rearing, but this may
be because the pathogenic care criterion is required. Furthermore, the pathogenic
care criterion is particularly important in distinguishing indiscriminate/disinhibited
RAD from conditions such as Williams syndrome and fetal alcohol syndrome, both of
which have been reported to be associated with indiscriminate social behavior
(Jacobson &Jacobson, 2003; Jones et al., 2000).
o MEASUREMENT ISSUES As with most psychiatric disorders, RAD is most often
measured by caregiver report, but there has been some attention to convergent
validity through behavioral observations. Boris et al. (2004), for example, used a
combination of a structured interview and behavioral assessment to determine if
young children met criteria for RAD. This study used a behavioral assessment of
attachment behavior designed for use in clinical settings.
o HARDY (2007) speaks about assessing RAD and the challenges inherent to it – page
31, 32, and top of 33.
Treatment Implications
o HARDY (2007) - Treatment of Attachment Disturbances. Since attachment
disturbances have been linked to a variety of different outcomes in children and
adults, using attachment theory to inform psychiatric treatment in general is
warranted. In children who show significantly maladapted attachment patterns
and/or those who meet the criteria for RAD, more directed interventions may be
required. Empirical evidence in this area is limited. Furthermore, interventions may
differ for children who have been adopted into a stable home, those who are in
foster care, those who still reside in institutions, those who reside with their original
attachment figure, those who developed attachment disturbances at varying ages,
etc. The connection between attachment insecurity and other non-attachmentspecific disorders is also far from clear, and the existence of co-occuring disorders is
likely to increase the complexity required for effective treatment. Thus far,
treatment of disordered attachment and related behaviors tends to be focused in
several areas: enhancing current attachment relationships, creating new attachment
o
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relationships, and reducing problematic symptoms and behaviors. Due to the
current propensity towards diagnosis-focused research, most of the related
recommendations are focused on children who meet criteria for RAD. Hanson and
Spratt (2000) identify treatment strategies based on interventions that have been
effective in populations of children who have been abused. Their rationale is that
RAD is more common in children who have been maltreated and that it involves
similar symptom profiles. Their preferred interventions include cognitive
behavioral management of mood symptoms, behavioral modification, and
psychoeducation. Since RAD is characterized by impaired social relationships, the
addition of social support and coaching may enhance peer relationships (Haugaard
& Hazan, 2004; Minde, 2003). Interventions designed to enhance self-esteem and
increase self-efficacy could also improve functioning (Haugaard & Hazan Children
who have a healthy and supportive relationship with an adult (not necessarily a
caregiver) are less likely to be negatively affected by insecure attachments.
In addition, caregiver involvement in the treatment process, providing the caregiver
is psychologically healthy enough to participate appropriately, is believed to be an
important contributor to positive treatment outcomes. Treatment of caregivers’
own attachment difficulties and current psychopathology may also be indicated
(Hanson & Spratt; Haugaard & Hazan). Other psychotherapeutic approaches to the
treatment of RAD include encouraging the development of a healthy attachment
relationship to the therapist and processing traumatic events through play therapy
(Haugaard & Hazan, 2004). Interventions designed to enhance caregivers’ ability to
understand the meaning behind the behaviors of children with RAD are also
believed to be an important part of treatment in children with severely disturbed
attachment-related behavior (Minde, 2003; Marvin & Whelan, 2003). This approach
goes beyond traditional psychoeducational or supportive therapies in that it
addresses children whose symptoms have not been reduced by the formation of a
healthy attachment. Particularly for children who have been adopted or are in foster
care, caregivers may already have the knowledge and sensitivity required to form
healthy attachments, but the children’s behaviours may be extremely complex and
contradictory. Marvin and Whelan state that the interpretation of these behaviors is
difficult even for clinicians. They suggest that if caregivers are taught to interpret
and address the meaning behind the behaviors, they may be better able to assist the
children in developing more adaptive relational patterns.
Schwatz (2006) - Specific therapeutic interventions for children diagnosed with
RAD have not been well validated in peer-reviewed journals; however, if RAD is
linked to maltreatment (by fulfilling the criteria for grossly pathogenic care), then
interventions that have been used with children who have been maltreated may
offer guidelines for interventions with children with RAD (Hanson & Spratt, 2000).
Perry (2001) outlined the following interventions for maltreated children: (a)
Nurture the child; (b) understand behaviors before punishing; (c) interact with
these children based on emotional age; (d) be consistent, predictable, and repetitive;
(e) model and teach appropriate social behaviors; (f ) listen, talk, and play with
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these children; (g) maintain realistic expectations; (h) be patient with the child and
yourself; (i) take care of yourself; and ( j) use other resources. Considering the four
basic goals of attachment, (proximity, security, safety, and self-regulation), it is
important to provide children with a sense of stability. Environmental and relational
stability provides children with an opportunity to feel safe and secure, and must
include caregivers who are sensitive to the child’s need for proximity while
maintaining awareness that closeness in the past has meant danger. The school
psychologist, knowing the crucial role of stability, can take a prominent role in
guiding and directing teachers and other school staff in ways to enhance the child’s
sense of security. Teachers and school personnel, such as counselors and school
psychologists, must help children learn how to regulate and modulate their affect
and behavior, and have the unique opportunity to act as a secure base for the child
(Kobak et al., 2001). In attempting to aid children who are unable to effectively
regulate emotions and behaviors, it is critical for those who intervene to be
cognizant of their own capacity to modulate and regulate their own emotions and
behaviors.
o Schwartz (2006) - Lieberman and Zeanah (1999) summarized the basic ideas
behind interventions for children with attachment disorders. They pointed to the
need for interventions to be child specific, to be developmentally appropriate, and to
minimize the use of negative practices such as scolding, embarrassment, and
condemning. Interventions which rely on emotional pressure invariably lead to
empathic failures which reinforce the child’s existing impaired internal working
models and increase the likelihood of escalating behaviors.
Limitations
o Zeanah & Smyle(2008) – bottom of pg 221 and top of 222.
o HARDY (2007) - There are two subtypes of RAD, inhibited type and disinhibited
type. The DSM-IV-TR (2000) criteria do not include any descriptors of associated
behaviors, and there are no validated instruments for assessing or diagnosing RAD
(Minde, 2003). A wide variety of behaviors have been attributed to RAD, but there is
limited empirical research in this area (Hanson & Spratt, 2000; Minde). While
diagnosis and treatment of disordered attachment patterns are vitally important,
limiting the conception of attachment related psychopathology to the narrow
diagnostic criteria of RAD significantly understates the importance of other
attachment-related conditions and may limit the use of potentially effective
interventions. Identifying the links between these disorders will guide interventions
to impact the attachment problems by targeting underlying issues rather than
focusing on just the symptoms. Pg 31 challenge to the current disinhibited pattern.
*** Numerous limitation and cautions discussed in the HARDY (2007) ARTICLE.
Conclusion
Q&A
REFERENCES