Psychiatry Research 215 (2014) 747–752

Contents lists available at ScienceDirect

Psychiatry Research
journal homepage: www.elsevier.com/locate/psychres

Disinhibited reactive attachment disorder symptoms impair social
judgements from faces
Sebastien Miellet a,1, Roberto Caldara a,1, Christopher Gillberg c, Monika Raju b,
Helen Minnis c,na

Department of Psychology and Fribourg Center for Cognition, University of Fribourg, Fribourg, Switzerland
NHS Greater Glasgow and Clyde, Caledonia House, Yorkhill Hospital, Glasgow, G3 8SJ, UK
c
University of Glasgow, Mental Health and Wellbeing, Institute of Health and Wellbeing, Caledonia House, Yorkhill Hospital, Glasgow, G3 8SJ, UKb

art ic l e i nf o

a b s t r a c t

Article history:
Received 2 March 2013
Received in revised form
2 January 2014
Accepted 5 January 2014
Available online 11 January 2014

Typically developing adults and children can rapidly reach consensus regarding the trustworthiness of
unfamiliar faces. Maltreated children can have problems with trusting others, yet those with thedisinhibited form of reactive attachment disorder (dRAD) can be indiscriminately friendly. Whether
children with dRAD symptoms appraise and conform to typical judgements about trustworthiness of
faces is still unknown. We recorded eye movements of 10 maltreated dRAD children and 10 age andgender matched typically developing control children while they made social judgements from faces.
Children were presented with a series of pairs of faces previously judged by adults to have high or low
attractiveness or trustworthiness ratings. Typically developing children reached a consensus regarding
which faces were the most trustworthy and attractive. There was less agreement among the children
with dRAD symptoms. Judgments from the typically developing children showed a strong correlation
between the attractiveness and trustworthiness tasks. This was not the case for the dRAD group, whoshowed less agreement and no signiﬁcant correlation between trustworthiness and attractivenessjudgments. Finally, both groups of children sampled the eye region to perform social judgments. Our dataoffer a unique insight in children with dRAD symptoms, providing novel and important knowledge for
their rehabilitation.
& 2014 Elsevier Ireland Ltd. All rights reserved.

Keywords:
Reactive attachment disorder
Indiscriminate friendliness
Eye tracking
Appraisal of faces

1. Introduction
We present novel data regarding evaluation of faces in maltreated children suffering from symptoms of reactive attachment
disorder (RAD). A core clinical characteristic of RAD is indiscriminate friendliness and we wished to investigate whether or not thiswas associated with atypical appraisal of faces by these children—
especially as regards the evaluation of trustworthiness, a key
deﬁcit in the RAD syndrome.
1.1. Reactive attachment disorder
Reactive attachment disorder (RAD) is a serious disorder ofsocial functioning associated with maltreatment with two subtypes: Inhibited (wary, watchful behaviour) and Disinhibited(overfriendly behaviour).2 The Disinhibited form (that we focusnCorresponding author. Tel./fax: þ 44 141 201 9239.
E-mail address: helen.minnis@glasgow.ac.uk (H. Minnis).
1
Joint ﬁrst authors.
2
Please note the dRAD is labelled Social Engagement Disorder in the DSM-V.
We are keeping the appellation dRAD throughout the manuscript for clarity andconsistency with previous literature.
0165-1781/$ - see front matter & 2014 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.psychres.2014.01.004

on in this paper) is known to be associated with signiﬁcant
psychiatric morbidity (Rutter et al., 2007) and can persist despitechanges in care giving context (Gleason et al., 2011). The corecharacteristic of Disinhibited RAD (dRAD) is indiscriminate friendliness. We have already shown that children with indiscriminate
friendliness can have complex neurodevelopmental problems
including multiple psychiatric comorbidities (Kocovska et al.,2012). Children with indiscriminate friendliness are signiﬁcantly
socially impaired: despite being aware of the risks associated withspeaking to strangers and the efforts made by their caregivers toprotect them from danger, they demonstrate “a trust of newpeople and a craving for kindness from others” which may
introduce them to further risky situations (Bennett et al., 2009).

1.2. How does trust develop in childhood?
Trust “is essential to initiate, establish, and maintain social
relationships [and] encourages the initiation of mutual cooperative
relationships” (Balliet and Van Lange, 2013). A sense of trustdevelops in the context of a secure attachment relationship withparents (Corriveau et al., 2009) and behavioural genetic research
has shown that development of a sense of trust in family members

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and peers is based largely on environmental, rather than genetic
factors. A sense of trust is an important buffer against life stressors
and can reduce the likelihood of problems such as isolation or
bullying in school and the development of depression (Sakai,2010). It is also associated with prosocial (i.e. caring, helpful)
behaviour (Rotenberg et al., 2004) and with academic achievement (Goddard, 2003).
While very young children (aged 3 or 4) have difﬁculty
discriminating between “helpers” and “trickers” in experiments,
by age 5 typically developing children are systematically more
likely to take advice from individuals who have previously provenhelpful (Vanderbilt et al., 2011). By middle childhood, therefore,
typically developing children are not indiscriminately trusting.
Harris and Corriveau (2011) argue that “indiscriminate credulity isimplausible, both biologically and psychologically”.
Yet indiscriminate friendliness is a relatively common phenomenon in children who have experienced maltreatment (Rutter
et al., 2009). Lieberman has suggested that a basic problem for
maltreated children is the sense of mistrust that has emerged fromtheir lack of a predictable, loving caregiver in early childhood andthat this lack of trust is associated with a range of difﬁcult
behaviours including indiscriminate friendliness (Lieberman,
2003). We have previously suggested that indiscriminate friendliness might develop out of “discordant intersubjectivity” between achild and a maltreating caregiver in early life: in a secure attachment relationship, a concordant intersubjective relationshipresults in the development of “in-jokes” and other highly personal
codes shared between the child and caregiver. These will soon leadto a preference for caregiver over strangers. In a maltreating
relationship characterised by discordant clashes and failed
attempts at interaction, relationships with strangers may seem atleast as satisfying – or even preferable (Minnis et al., 2006). A
qualitative study of maltreated, indiscriminately friendly children
supported this view: despite being grossly over-inclusive in thosethey regarded as “friends”, these children were also preoccupied
with issues of trust (Bennett et al., 2009).
In typical development, very rapid judgements about faces are
possible (after less than 100 ms exposure to a face) based on a
range of factors such as trustworthiness, competence and aggressiveness (Willis and Todorov, 2006). Oosterhof and Todorov (2008)
argue that cues about whether to avoid or approach an individual
are important in making social decisions, even though suchdecisions may be based on rather crude information.
Despite the associations between maltreatment, lack of a senseof trust/indiscriminate friendliness and poor social, academic andpsychological outcomes, little is known about the mechanisms
involved during childhood. One possibility is that these difﬁculties
originate in a basic problem with visual processing of faces. The
other disorder well known to be associated with severe problems
in social interaction is Autism Spectrum Disorder (ASD) and there
is already a body of research investigating visual processing offaces ASD. Some eye-tracking studies in ASD have shown reduced
ﬁxations on socially salient aspects of visual scenes (Noris et al.,2012; Pierce et al., 2011; Riby and Hancock, 2009; Rice et al., 2012)
and there are reports that individuals with ASD look less at facial
features (eyes, nose, mouth) than typically developing peers(Chawarska and Shic, 2009; Pelphrey et al., 2002). Other studies
suggest a more complex picture with mixed results depending on
the cognitive sub-phenotypes in ASD (Norbury et al., 2009; Riceet al., 2012).
It is important to note that, in most of these studies, results
were analysed using a “Regions-Of-Interest” (ROI) approach. The
most critical limitations of such an approach rely on the fact thatthe subjective criteria used to deﬁne ROIs compromise thepotential to replicate ﬁndings across studies (Caldara andMiellet, 2011). Other factors might explain inconsistencies acrossstudies such as type of stimuli, task, subgroups of ASD observers,etc. For instance, the atypical ﬁxation pattern in children with ASD
is more pronounced in natural social settings than in experimental
settings with isolated stimuli. As yet, the precise impact of ASD on
visual exploration of socially relevant stimuli is not completely
understood.
In summary, the extant literature suggests that the ability todiscriminate rapidly between trustworthy and untrustworthy
individuals typically develops in the preschool period and thedevelopment of a sense of trust appears to be largely environmentally (rather than genetically) determined. Maltreated children
with indiscriminate friendliness are insecure about relationships,
lack trust and appear unable to make the correct judgements
about who they should and should not trust. Our knowledge about
the mechanisms of trustworthiness judgements largely comesfrom studies in typically developing adults and it has been shownthat such adults are able to rapidly come to a consensus, based on
facial traits, about who should be judged trustworthy and whoshould not.
To the best of our knowledge, appraisals of trustworthiness inchildren with indiscriminate friendliness have not yet been investigated. In this study we wished to ask whether, like adults,
typically developing children come to a consensus about whichfaces are trustworthy or untrustworthy; whether maltreatedchildren with indiscriminate friendliness suffering from dRAD
are able to make similar judgements and, lastly, whether typicallydeveloping and dRAD children differ in the way they appraisefaces in making these judgements.
Importantly, atypical social judgements of faces in children
with indiscriminate friendliness could originate from an inadequate strategy in facial feature sampling during social judgements(i.e., gaze avoidance to the eye region). Therefore, eye-movement
recording is the method of choice to isolate the facial information
sampled by the dRAD population compared to typically developing controls. Mapping eye movement ﬁxation in children withdRAD could thus provide invaluable insights into the mechanisms
relating to their potential atypical social judgements of faces.

2. Materials and methods
This study was carried out at the Department of Psychology, University ofGlasgow between August 2010 and February 2012. There were 20 participants aged
between 6 and 16 years: 10 children and adolescents with symptoms of reactive
attachment disorder (RAD) and 10 typically developing controls group-matched forage and gender. The study was approved by the Ethics Committee of the
Department of Psychology, University of Glasgow.
For participant characteristics, see Table 1.
2.1. Clinical group
All clinical children were recruited from a pool of participants from a previous
research study regarding neurodevelopmental difﬁculties in maltreated children
with indiscriminate friendliness (Kocovska et al., 2012). All participating children
had experienced severe maltreatment in the early years, prior to being adopted(age of adoption range 16 months to 7 years), including emotional and/or physicalneglect and/or physical abuse often in the context of parental mental illness and/or
drug and alcohol problems. In addition, all participating children had indiscriminate friendliness as measured by standardised instruments (for detail regarding theTable 1
Participant characteristics.

Age (Mean, SD)
GenderMean (SD) SDQ total difﬁculties score
Mean (SD) RPQ total score
History of abuse and/or neglect

Controls

Clinical

9.62 (1.41)
50% Female
4.10 (3.93)
1.0 (2.83)
0%9.80 (2.74)
50% Female
19.50 (6.26)
6.62 (5.26)
100%

S. Miellet et al. / Psychiatry Research 215 (2014) 747–752
sampling, please see (Kocovska et al., 2012) and had cognitive functioning in thenormal range.
2.2. Controls
7 controls were recruited from the same sample as the clinical children and an
additional 3 controls were recruited through outreach.
All cases and controls were screened using the strengths and difﬁculties
questionnaire (SDQ), that explores child and adolescent psychopathology and therelationship problems questionnaire (RPQ) that explores reactive attachment
disorder symptoms (see Table 1).
Fully informed parental consent was obtained before each child participatedand children were also asked to give verbal assent. Adolescents (aged 12 and over)were asked to give written consent before the start of the study. Participants were
paid d20 to cover travel expenses and received a small token of thanks for their
participation in the study at the end of the experiment.
2.3. Facial stimuli
Stimuli were obtained from the KDEF (Lundqvist and Litton, 1998) databases
and consisted, for each task (attractiveness and trustworthiness judgment), of 18
Western Caucasian identities containing equal numbers of males and females. Only
neutral expressions were used. For each task, the 18 identities were chosen, froman on-going study with adults (Lao et al., 2010), in order to form contrasted groupsof low, medium and high attractiveness/trustworthiness. Thus, the 1st faces of thestimuli lists for both tasks were corresponding not because originating from thesame identity but because they have been judged as being the most attractive andthe most trustworthy according to the adult participants. We used those two highly
correlated social judgements to further verify the normal evaluation of faces.
The individual face images were 382  390 pixel in size, subtending 15.61 ofvisual angle vertically and 15.31 of visual angle horizontally, which represents thesize of a real face (approximately 19 cm in height). Faces from the original
databases were aligned by the authors on the eye and mouth positions; the images
were rescaled to match those facial features position and normalized for luminance. Images were viewed at a distance of 70 cm, reﬂecting a natural distanceduring human interaction (Hall, 1990). All images were cropped around the face toremove clothing and were devoid of distinctive features (scarf, jewelry, facial
hair etc.).
For each trial, 2 faces were presented simultaneously on the screen, both
centered vertically and each centered horizontally on the left or right half-screen.
All the possible pairs were generated (combinations without repetition) leading toa total of 153 pairs for each task. The pairs order was randomized. The stimuli were
presented on a 800  600 pixel grey background displayed on a Dell P1130 21″ CRT
monitor with a refresh rate of 170 Hz.
2.4. Apparatus
Eye movements were recorded at a sampling rate of 1000 Hz with the SR
Research Desktop-Mount EyeLink 2 K eyetracker (with a chin/forehead rest), which
has an average gaze position error of about 0.251, a spatial resolution of 0.011 and alinear output over the range of the monitor used. Only the dominant eye wastracked, although viewing was binocular. The experiment was implemented in
Matlab (R2009b, The MathWorks, Natick, MA), using the Psychophysics (PTB-3) andEyeLink Toolbox extensions (Brainard, 1997; Cornelissen and Peters, 2002). Calibrations of eye ﬁxations were conducted at the beginning of the experiment using anine-point ﬁxation procedure as implemented in the EyeLink API (see EyeLink
Manual) and using Matlab software. Calibrations were then validated with the
EyeLink software and repeated when necessary until the optimal calibration
criterion was reached. At the beginning of each trial, participants were instructed
to ﬁxate a dot at the center of the screen to perform a drift correction. If the drift
correction was more than 11, a new calibration was launched to insure an optimal
recording quality.
2.5. Procedure
All participants had normal or corrected vision and were performing the two
experimental tasks successively: trustworthiness and attractiveness judgments.
The task order was counterbalanced across participants. At the beginning of eachtask, the participants were informed that they would be presented with a series offace pairs on the screen and that they will have to indicate via button press whichface they thought was the most attractive/trustworthy. They were also informedthat there was no correct answer and that only their opinion was important. They
were advised to go with their ﬁrst choice without pondering too much on the task.
The duration of testing ranged from 30 to 50 min. Each trial started with thepresentation of a central ﬁxation cross allowing for calibration check. When theparticipant was ﬁxating the central cross, a face pair was presented until response.
The participants were responding on a keyboard with their left (right) hand index if

749

they thought that the face on the left (right) on the screen was the most attractive/
trustworthy. Each trial was subsequently followed by a 2 s delay and the next trial
was starting with the central ﬁxation cross. Trustworthiness and attractivenessjudgments were collected and analyzed for the purpose of the present experiment.
Response times were not taken into account as the children were not instructed toanswer fast.

2.6. Data analyses
The behavioral responses were coded in a dichotomous way for each face pairand each participant (1 for the face judged as the most attractive/trustworthy, 0 for
the other face). The group results were then summarized as the proportion ofparticipants in a given group judging one of the identities in the face pair more
attractive/trustworthy than the other one. We then compared the global judgmentagreement between participants between groups and tasks. If all the participants ina group converge to stereotypical attractive/trustworthy faces then the proportionof choosing a face rather than the other in the face pairs should be far from chancelevel (0.5). We thus performed a 2 (participants group: clinical/control)  2(task: attractiveness/trustworthiness) ANOVA on an agreement index deﬁned as
qﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃﬃðprobij  0:5Þ2 /0.5 (normalized distance to chance) and ranging, for each face pair,from 0 for absence of agreement to 1 for a perfect agreement.
We also correlated the groups0 choice probability matrices between the twotasks for each group of participants. We then computed within-subjects correlation
analyses in order to investigate whether the attractiveness and trustworthinessjudgments were related at an individual level. For each participant we computed aﬁrst within-subject Pearson0 s correlation between the proﬁle of responses for theattractiveness and the trustworthiness tasks. Since correlation coefﬁcients are notadditive, they must be z-normalized (Chung et al., 2005) before performing
statistical analyses. We thus normalized the obtained correlation coefﬁcientsby using Fisher0 s transform Z¼ 0.5  loge|1þ r/1 r| and then preformed a two-tailed
t-test between groups.
Saccades and ﬁxations were determined using a custom algorithm using thesame ﬁlter parameters as the EyeLink software (saccade velocity threshold¼301/s;
saccade acceleration threshold¼ 40001/s2) and merging ﬁxations close spatiallyand temporally (o 20 ms, o 0.31). Fixation distribution maps were extracted
individually for each observer. The statistical ﬁxation maps were computed with
the iMap toolbox, version 3 (Caldara and Miellet, 2011). iMap3 uses pixelwise
t-values and bootstrapped TFCE transformed scores to correct for multiple
comparisons (TFCE: threshold-free cluster-enhancement; Pernet et al., 2011;
Smith and Nichols, 2009).

3. Results
Fig. 1 shows the pairwise probability of choice matrices for bothgroups of participants and both tasks. This representation suggests,
for both tasks, more inter-participant agreement for the controls thanfor the clinical children (darker colors, dark red or dark blue
corresponding to more extreme probabilities). Fig. 1 also shows, forboth tasks, more structure in the judgments for the controls than forthe clinical children. For instance, number 8 has been consistently
judged more attractive than any other face by the control children
and, face 17 consistently less than any other face by controls.
The 2 (participants group: clinical/control)  2(task: attractiveness/trustworthiness) ANOVA on the agreement index revealed amain effect of the group (F(1, 304) ¼126.75, p o.0001, pη2 ¼.29).
This result conﬁrms a stronger agreement between the control
participants (average agreement across the face pairs: 0.54 and0.49 for the attractiveness and trustworthiness task) than between
the clinical participants (0.29 and 0.27). No other effect wassigniﬁcant. The choice probability matrices were strongly correlated between the attractiveness and trustworthiness tasks for thecontrol participants (r ¼0.66, po .0001) but not the clinical participants (r ¼ 0.11, p ¼.19). In order to conﬁrm the previous result at
an individual level (that the same control participants chose a given
face in both tasks), we performed within-subjects correlations.
This analysis conﬁrmed a stronger correlation between the twotasks for the control than for the clinical children (average
normalized r: 0.4 and 0.09 respectively, t(18) ¼ 4.06, p o.001).
The correlation between the attractiveness and the trustworthiness task was signiﬁcantly different from 0 for the control children(t(9) ¼6.64, p o.0001) but not for the clinical children.

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S. Miellet et al. / Psychiatry Research 215 (2014) 747–752

Fig. 1. Probability of choice matrices for both children groups (dRAD and controls) and both tasks (attractiveness and trustworthiness judgment). Each line of the matrices
shows the probability of choosing a given face over all the remaining faces. The hot colors (yellow to red) indicate that the face corresponding to line number was chosen
more (4 0.5) than the face corresponding to the column number. The cold colors (light blue to dark blue) indicate that it has been chosen less ( o 0.5). The diagonal does notcontain any value, as faces were never compared with themselves. (For interpretation of the references to color in this ﬁgure legend, the reader is referred to the web versionof this article.)

Fig. 2 shows ﬁxation maps and the regions signiﬁcantly ﬁxatedabove chance level according to iMap (version 3) for control andclinical children during both judgment tasks. The ﬁxation maps
show that both dRAD and typically developed children use thesame sampling strategies to extract facial information duringsocial judgment.
Note that the central ﬁxation cluster is due to the ﬁrst ﬁxationof each trial. The presentation of the faces pair was preceded by acentral ﬁxation cross allowing for calibration check. Hence, when
the recording started, as faces were presented, the participants0eyes were still ﬁxating the center of the screen until the ﬁrst
saccade towards one the faces.

4. Discussion
Our ﬁndings show that, like adults, typically developing children show clear preferences and high inter-observer agreement
while evaluating unfamiliar faces on both attractiveness andtrustworthiness. In contrast, the dRAD group of maltreated children with indiscriminate friendliness showed less clear preferences on these tasks (lower inter-participant agreement and lessstructure in the pairwise choice matrices). Moreover, only thetypically developing, and not the children with dRAD symptoms,
show the expected strong correlation (at group and individuallevels) in their trustworthiness and attractiveness judgments. This
link between attractiveness and trustworthiness judgments has
been clearly established in adults in previous studies (for instance
Oosterhof and Todorov, 2008; Willis and Todorov, 2006). Hence,the control children display a pattern of results consistent withwhat is observed in adults and consistent with the ﬁndings ofAntonakis and Dalgas (2009), which is not the case for the dRAD
children. Finally, dRAD children use the same facial information
sampling strategy as control children, with both groups of children
looking preferentially in the eyes region, a ﬁxation pattern that is
not modulated by the task (trustworthiness vs. attractivenessjudgment). Critically, this observation rules out the possibility thatthe impairment in making social judgments from faces in dRAD
population is arising from an inappropriate ﬁxation towards
diagnostic facial features. It should be noted that these ﬁndings
apply to maltreated children who have the core symptom ofRAD, namely indiscriminate friendliness and may not apply to allmaltreated children.
Considering that children with dRAD sample faces in a similar
way to typically developing children, their atypical social judgments may result from a speciﬁc problem with processing thevisual information available for social judgment. When designing,
analysing and interpreting eye-movement studies it is crucial tokeep in mind that eye movement recordings in natural viewing
conditions do not provide unequivocal evidence regarding themeasure of the visual information being used by observers. As amatter of fact, despite being tight, the coupling between ﬁxatedand processed information is not perfect (concepts of overt vs.
covert attention, Posner, 1980). Hence, critical visual information is
extracted from extrafoveal vision (see Caldara et al., 2010; Miellet
et al., 2012). Our results reveal that the scanning strategy adopted
by RAD and control children is similar. However, they do notnecessarily imply that both populations use the same informationin order to perform the task at hand. Future studies, using gazecontingent techniques, would allow more ﬁne-grained investigation of the information use for social judgment in RAD children.
Indeed, gaze-contingent techniques can overcome limitations

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Fig. 2. Fixation maps based on the ﬁxation durations for each task and each children group. Subtracting the ﬁxation maps for the control children from the ﬁxation maps forthe dRAD children resulted in the group difference maps for each task (third column). Similarly, subtracting the ﬁxation maps for the trustworthiness task from the ﬁxation
maps for the attractiveness task resulted in the task difference maps for each group (third row). On the ﬁxation maps, the colored clusters show areas that are ﬁxatedsigniﬁcantly longer than the average ﬁxation duration. No signiﬁcant areas are visible on the difference maps.

inherent in simple eye-movement recording. By precise online
control of the information projected in different parts of the visualﬁeld, the gaze-contingent techniques permit us to disentangle
what is ﬁxated and what is processed. Therefore, the gazecontingent technique is a powerful method to control for thevisual information feeding the visual system and to isolate
information use (Miellet et al., 2011, 2013).
Regardless of the inherent limitations of natural eye movement
recordings, the present data provide an interesting contrast to
children with ASD who show atypical gaze pattern towards social
relevant stimuli and particularly during face exploration. Despite
being an on-going debate, the ﬁxation bias in ASD has been
replicated in a substantial number of studies (Noris et al., 2012;
Pierce et al., 2011; Riby and Hancock, 2009; Rice et al., 2012;
Chawarska and Shic, 2009; Pelphrey et al., 2002; Dalton et al.,2005; Jones et al., 2008; Kliemann et al., 2010; Klin and Jones,
2008; Klin et al., 2002). Thus, it seems that, in contrast withchildren with ASD, the difﬁculties experienced by children with
RAD are not linked to sampling of facial features but to a problem
with speciﬁc processing of the very same visual information that isavailable to typically developed children. Various authors havedescribed reactive attachment disorder as a social impairment,
rather than as a disorder of attachment (Green and Goldwyn,
2002; Minnis et al., 2006) and these results support this view:despite its environmental aetiology, it appears that neurologicalprocesses may have been set in train by the early environmental
insult that are perpetuated through development.
Our ﬁndings are somewhat limited by our modest sample size,
hence interpretations and generalizations of the present ﬁndings
have to be made with caution given the potential heterogeneity ofboth causes and symptomatology in RAD. Although our main
analyses were adequately powered it would be interesting in
future research to recruit large enough samples to explore, forexample, whether there are within group differences according to
IQ or symptom severity.

Our ﬁndings have important implications for the way weunderstand indiscriminate friendliness in maltreated children.
If children with dRAD are less effective than controls at using
available information from faces, resulting in similar problems tothose experienced by children with ASD, although through different mechanisms, then treatment strategies such as those that are
effective in ASD may be worth trialing in this group. For example,
the “Lets Face It” program has been useful in working withchildren with ASD in both understanding the nature of the deﬁcits
and in effecting actual improvement in facial emotion recognition(Tanaka et al., 2013). Using similar programs with indiscriminately
friendly children may help us better understand the nature of theirproblems in this domain and improve their functioning.
This study is a ﬁrst step in teasing out the nature of the deﬁcits
in face processing in indiscriminately friendly children and there
are various avenues for future research. fMRI studies will be
important in identifying the brain regions associated with these
difﬁculties and may further deepen our understanding of thenature of the deﬁcits. It will also be important to conduct detailed
face processing studies comparing indiscriminately friendly children to maltreated children who do not suffer from indiscriminate
friendliness, before we can be conﬁdent that the face processing
deﬁcits and clinical phenomenology are linked. Comparisons withchildren suffering from other neurodevelopmental disorders such
as ASD and William0 s syndrome may also help determine whether
or not there is a signature “indiscriminate friendliness” syndrome
as regards face processing deﬁcits or whether these children are infact suffering from similar difﬁculties to other groups of children.

Acknowledgements
RC was supported by the National Center of Competence in
Research (NCCR) Affective sciences ﬁnanced by the Swiss National
Science Foundation (no 51NF40-104897). We are grateful to all

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S. Miellet et al. / Psychiatry Research 215 (2014) 747–752

participating families, to Mrs. Fiona Lettice from Adoption UK for
facilitating recruitment of our adoptive sample and to Dr. Jasmeet
Bindra, Dr. Lisa Collin, Kay Foreman and Junpeng Lao for their help
with data collection. The funding for the study came from the Weir
Bequest for Child and Adolescent Psychiatric Research.
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