Attachment theory has asserted that the quality of chil- dren’s caregiving experiences is predictive of the kind of attachment that develops between them and their care- givers. Most of the evidence in support of this assertion has come from studies of infant attachment as assessed by the Strange Situation Procedure (Ainsworth et al., 1978). Specific styles of interaction between mothers and infants during the first year of life, particularly with regard to maternal sensitivity, have been related to secure or to var- ious types of insecure attachment in the Strange Situation Procedure (DeWolff and van IJzendoorn, 1997), although the magnitude of the association between style of interac- tion and later security/insecurity has been modest overall. One of the assumptions of the Strange Situation Procedure is that the infants being assessed are attached to their caregivers and that the quality of the attachment is revealed by an examination of the organization of infants’ attachment and exploratory behaviors in the pro- cedure. In some extreme caregiving environments, how- ever, the assumption that infants have developed focused attachments to their caregivers may not be warranted. Infants raised in institutions have far more limited opportunities to develop selective attachments than infants raised in more normative environments because the care- givers in these institutions perform shift-work and because they usually are responsible for the care of many young children (Johnson, 2000; Muhamedrahimov, 2000). Several factors may limit caregivers’ emotional investment in the children in their care, including being responsible for large numbers of children, having scant resources, and work- ing on rotating shifts, further reducing the probability that the young children will develop selective attachments. Accepted March 20, 2002. Drs. Smyke and Zeanah are with the Institute of Infant and Early Childhood Mental Health, Department of Psychiatry and Neurology, Tulane University Health Sciences Center, New Orleans. Ms. Dumitrescu is with the ABC News Bureau in Bucharest, Romania. This work was supported by the John D. and Catherine T. MacArthur Foundation Research Network on Early Experience and Brain Development. The authors thank Alina Codres and her staff for their cooperation and hard work, which made this project possible. Cristian Tabacaru, Adrian Gaspar, Ronald Federici, and Dana Johnson also provided invaluable assistance. Drs. Julie Larrieu and Michael Scheeringa provided helpful suggestions about an earlier version of the manuscript. Article Plus (online only) materials for this article appear on the Journal’s Web site: www.jaacap.com. Correspondence to Dr. Smyke, Department of Psychiatry, Tulane University Health Sciences Center, Tidewater Building TB-52, 1440 Canal Street, New Orleans, LA 70112; e-mail: asmyke@tulane.edu. 0890-8567/02/4108–09722002 by the American Academy of Child and Adolescent Psychiatry. Attachment Disturbances in Young Children. I: The Continuum of Caretaking Casualty ANNA T. SMYKE, PH.D., ALINA DUMITRESCU, B.A., AND CHARLES H. ZEANAH, M.D. ABSTRACT Objective: To determine whether signs of disordered attachment were greater in young children being reared in more socially depriving caregiving environments. Method: Three groups of children were studied by means of structured inter- views with caregivers that were administered over several months in Bucharest, Romania, in 1999: (1) 32 toddlers living in a typical unit (standard care) in a large institution in Bucharest; (2) 29 toddlers living in the same institution on a “pilot unit” designed to reduce the number of adults caring for each child; and (3) 33 toddlers living at home who had never been institutionalized.The presence of attachment disorders and other behavioral problems was assessed by caregiver/ parent report. Results: Children on the typical unit (standard care) had significantly more signs of disordered attach- ment than children in the other two groups. Both the emotionally withdrawn and the indiscriminately social pattern of attachment disorder were apparent in these children, but cluster analysis suggested that mixed patterns are more typi- cal. Conclusions: The continuum of caretaking casualty is reflected by increasing signs of disordered attachment in tod- dlers living in more socially depriving environments. J. Am. Acad. Child Adolesc. Psychiatry, 2002, 41(8):972–982. Key Words: reactive attachment disorder, inhibited attachment disorder, children in institutions, deprivation, neglect. 972 J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 41:8, AUGUST 2002