91 Reactive Attachment Disorder of Infancy or Early Childhood (313.89)

DSM-IV-TR criteria

• A. 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).
• B. 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.
• C. 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 or primary caregivers that prevent formation of stable attachments (e.g., frequent changes in foster care).
• D. 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).

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

Associated features

Certain situations may cause parents to develop a way of caring, known as pathological caring. These situations may include things such as long hospitalization of the child, extreme poverty, and the inexperience of the parents or caretaker (DSM-IV-TR, 2000). Pathological care is defined as a parental caring type in which they ignore the child’s basic needs; these needs may be emotional and/or physical needs. Grossly pathological care does not always cause the development of Reactive Attachment Disorder (DSM-IV-TR, 2000). Some children cared for in this manner are still able to form “normal” social attachments. Extreme neglect does however increase the risk for development of Reactive Attachment Disorder. This disorder may also be associated with developmental delays, Feeding Disorder of Infancy or Early Childhood, Pica, or Rumination Disorder (DSM-IV-TR, 2000).

Child vs. adult presentation

Reactive Attachment Disorder typically begins before the child is 5 years of age. Remission of this disorder can occur by receiving proper care and a supportive environment. If such things are not provided, the disorder will follow a continuous course, causing the individual’s inability to form “normal” social attachments. Therefore Reactive Attachment Disorder can present in both children and adults, but will ultimately be diagnosed in children before age 5 years.

Gender and cultural differences in presentation

There is no research indicating that there are gender differences in Reactive Attachment Disorder. Reactive Attachment Disorder is more commonly diagnosed in the UK . Also, this disorder may be more commonly diagnosed in children who live in inner city neighborhoods and rural areas. This is due to the fact that children may be subjected to severe isolation especially for those that are part of a minority group who are not properly cared for by their parents or guardians.

Epidemiology

• There is not much information or research found on Reactive Attachment Disorder. It is believed to be a fairly uncommon disorder.
• The prevalence of reactive attachment disorder has been estimated at 1% of all children under the age of five. Children orphaned at a young age have a much higher likelihood of this problem.

Etiology

• All children are affected differently by pathogenic caring, some go on to develop attachments despite of the pathogenic caring, others do not.
• Reactive Attachment Disorder is mainly caused by abuse or neglect of an infant’s needs (for example: food, physical safety, and touching).

Empirically supported treatments

• Little research has been done for the treatment of Reactive Attachment Disorder. Teaching the caretaker proper nurturing skills may improve Reactive Attachment Disorder in some children if the caretaker implements the newly learned skills into the child’s life. Holding therapy is a possible treatment for Reactive Attachment Disorder, although there has been little research confirming its effectiveness. This procedure consists of the mother or the caretaker holding the child while incorporating eye contact, touch, smiling, and talking. The anticipated end result is recreating the bond between caretaker and child that was not present when the child was an infant.
• Behavioral Management Training has been seen as a fairly effective treatment for Reactive Attachment Disorder. Children undergoing Behavioral Management Training show decreased problematic behaviors as well as increased compliance with caregiver and teacher commands. These children also show increased play with age-appropriated peers.

LINKS:

• A story about a couple who adopted a son from a Romanian orphanage when he was seven years old. During the time he was in the orphanage, he lived in a crib with another child and never developed relationships with his caregivers. About six months after he was adopted, he began acting out and was later diagnosed with Attachment Disorder. Story begins at minute 9:30 and ends at minute 36.
  • Attachment Disorder
  • “Unconditional Love.” This American Life. Chicago Public Radio. Aug. 31, 2007