Reactive attachment disorder of infancy or early childhood

313.89 Reactive Attachment Disorder of Infancy or Early Childhood

Diagnostic Features

The essential feature of Reactive Attachment Disorder is markedly disturbed and developmentally inappropriate social relatedness in most contexts that begins before age 5 years and is associated with grossly pathological care (Criterion A). There are two types of presentations. In the Inhibited Type, the child persistently fails to initiate and to respond to most social interactions in a developmentally appropriate way. The child shows a pattern of excessively inhibited, hypervigilant, or highly ambivalent responses (e.g., frozen watchfulness, resistance to comfort, or a mixture of approach and avoidance) (Criterion A1). In the Disinhibited Type, there is a pattern of diffuse attachments. The child exhibits indiscriminate sociability or a lack of selectivity in the choice of attachment figures (Criterion A2). The disturbance is not accounted for solely by developmental delay (e.g., as in Mental Retardation) and does not meet criteria for Pervasive Developmental Disorder (Criterion B). By definition, the condition is associated with grossly pathological care that may take the form of persistent disregard of the child's basic emotional needs for comfort, stimulation, and affection (Criterion C1); persistent disregard of the child's basic physical needs (Criterion C2); or repeated changes of primary caregiver that prevent formation of stable attachments (e.g., frequent changes in foster care) (Criterion C3). The pathological care is presumed to be responsible for the disturbed social relatedness (Criterion D).

Subtypes

The predominant type of disturbance in social relatedness may be indicated by specifying one of the following subtypes for Reactive Attachment Disorder:

Inhibited Type. In this subtype, the predominant disturbance in social relatedness is the persistent failure to initiate and to respond to most social interactions in a developmentally appropriate way.
Disinhibited Type. This subtype is used if the predominant disturbance in social relatedness is indiscriminate sociability or a lack of selectivity in the choice of attachment figures.

Associated Features and Disorders

Associated descriptive features and mental disorders.

Certain situations (e.g., prolonged hospitalization of the child, extreme poverty, or parental inexperience) may predispose to the development of pathological care. However, grossly pathological care does not always result in the development of Reactive Attachment Disorder; some children may form stable attachments and social relationships even in the face of marked neglect or abuse. Extreme neglect-and especially institutional care with limited opportunities to form selective attachments-increases risk of developing the disorder. Reactive Attachment Disorder may be associated with developmental delays, Feeding Disorder of Infancy or Early Childhood, Pica, or Rumination Disorder.

Associated laboratory findings.

Laboratory findings consistent with malnutrition may be present.

Associated physical examination findings and general medical conditions.

Physical examination may document associated general medical conditions that are associated with extreme neglect (e.g., growth delay, evidence of physical abuse, malnutrition, vitamin deficiencies, or infectious diseases).

Prevalence

Epidemiological data are limited, but Reactive Attachment Disorder appears to be very uncommon.

Course

The onset of Reactive Attachment Disorder is usually in the first several years of life and, by definition, begins before age 5 years. The course appears to vary depending on individual factors in child and caregivers, the severity and duration of associated psychosocial deprivation, and the nature of intervention. Considerable improvement or remission may occur if an appropriately supportive environment is provided. Otherwise, the disorder follows a continuous course. Indiscriminate sociability may persist even after the child has developed selective attachments.

Differential Diagnosis

In Mental Retardation, appropriate attachments to caregivers usually develop consistent with the child's general developmental level, and these attachments are clearly present by the time a child has a mental age of 10 months. However, some infants and young children with Severe Mental Retardation may present particular problems for caregivers and exhibit symptoms characteristic of Reactive Attachment Disorder. Reactive Attachment Disorder should be diagnosed only if it is clear that the characteristic problems in formation of selective attachments are not a function of the retardation.

Reactive Attachment Disorder must be differentiated from Autistic Disorder and other Pervasive Developmental Disorders. In the Pervasive Developmental Disorders, selective attachments either fail to develop or are highly deviant, but this usually occurs in the face of a reasonably supportive psychosocial environment. Autistic Disorder and other Pervasive Developmental Disorders are also characterized by the presence of a qualitative impairment in communication and restricted, repetitive, and stereotyped patterns of behavior. Reactive Attachment Disorder is not diagnosed if the criteria are met for a Pervasive Developmental Disorder.

The Inhibited Type of Reactive Attachment Disorder must be distinguished from Social Phobia. In Social Phobia, the social inhibition is apparent in social settings or in anticipation of social encounters but does not occur with familiar caregivers in familiar settings. Socially deviant behavior in Reactive Attachment Disorder, including inhibition, is apparent across social contexts.

The Disinhibited Type must be distinguished from the impulsive or hyperactive behavior characteristic of Attention-Deficit/Hyperactivity Disorder. In contrast to Attention-Deficit/Hyperactivity Disorder, the disinhibited behavior in Reactive Attachment Disorder is characteristically associated with being overly familiar with or seeking comfort from an unfamiliar adult caregiver rather than with generally impulsive behavior.

Reactive Attachment Disorder should also be differentiated from Disruptive Behavior Disorders such as Conduct Disorder and Oppositional Defiant Disorder. The term "affectionless psychopath" has been used to describe children who were raised in settings that limited opportunities for the child to develop selective attachments (e.g., institutions) and who exhibited a pattern of antisocial and aggressive behavior, inability to form lasting relationships with adults, and miscellaneous symptoms such as enuresis and stereotypies. Nevertheless, no direct link between Reactive Attachment Disorder and "affectionless psychopathy" has been established. Disturbances of attachment in the early years may increase the risk for antisocial behaviors in later childhood and adolescence, but antisocial behaviors are not necessarily signs of Reactive Attachment Disorder. Grossly pathogenic care is a defining feature of Reactive Attachment Disorder. An additional notation of Child Abuse, Child Neglect, or Parent-Child Relational Problem may be warranted. When grossly pathogenic care does not result in marked disturbances in social relatedness, Child Neglect or Parent-Child Relational Problem may be noted rather than Reactive Attachment Disorder.

Diagnostic criteria for 313.89 Reactive Attachment Disorder of Infancy or Early Childhood

Markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5 years, as evidenced by either (1) or (2):
1. persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hypervigilant, or highly ambivalent and contradictory responses (e.g., the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting, or may exhibit frozen watchfulness)
2. diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures)
The disturbance in Criterion A is not accounted for solely by developmental delay (as in Mental Retardation) and does not meet criteria for a Pervasive Developmental Disorder.
Pathogenic care as evidenced by at least one of the following:
1. persistent disregard of the child's basic emotional needs for comfort, stimulation, and affection
2. persistent disregard of the child's basic physical needs
3. repeated changes of primary caregiver that prevent formation of stable attachments (e.g., frequent changes in foster care)
There is a presumption that the care in Criterion C is responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C).

Specify type:

Inhibited Type: if Criterion A1 predominates in the clinical presentation
Disinhibited Type: if Criterion A2 predominates in the clinical presentation