Normal infants are born with the capacity to attach to their parents and to elicit care from them. Defects in the infant’s capacity to attach or elicit care, and deficiencies or disruption in the response of the caregiver, can be associated with a number of conditions such as reactive attachment disorder, rumination disorder of infancy, nonorganic failure to thrive, and psychosocial dwarfism. These conditions commence in infancy and, if not corrected, distort later social and intellectual development. Sleep problems often commence in the first 2 years of age. Pica and elimination disorders are usually first diagnosed between 2 and 5 years of age.

Essentials of Diagnosis

DSM-IV-TR Diagnostic Criteria

Reactive Attachment Disorder

1. 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)

2. 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.

3. 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)

4. 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).

(Reprinted, with permission, from Diagnostic and Statistical Manual of Mental Disorders, 4th edn., Text Revision. Copyright 2000, Washington, DC: American Psychiatric Association.)

General Considerations

Epidemiology

Although this condition is believed to be rare, it has not been included in any population-based studies and its prevalence is unknown.

Etiology

Bowlby conceptualized attachment as the biologically based tendency for infants to elicit care from and maintain proximity to their mothers. Babies elicit care by crying, vocalizing, reaching, sucking, making eye contact, and smiling. They maintain proximity first by clinging and following and later by using their mother as a secure base from which to explore the world. The mother, in turn, ministers to the infant’s physical, emotional, and social needs and protects the infant from danger. Both mother and infant monitor proximity in the second year, so that the child’s exploration is curtailed when danger is perceived by one or both attachment partners.

The infant who perceives the mother as consistently sensitive and responsive to his or her needs develops a secure relationship. In contrast, if the mother’s availability is perceived as unpredictable, the child will develop a sense of insecurity. A loss or severing of the attachment relationship leads to a condition interpreted as the early equivalent of grief.

By 12 months of age, the normal infant has developed a primary attachment figure, the caregiver to whom the child preferentially seeks proximity when threatened or insecure. Infants also have one or more secondary attachment figures to whom they will go if the primary figure is unavailable. Through multiple transactions involving the dual-attachment system of mother and infant, the child constructs working models of attachment—internal representations of the self in relation to others, with perceptual, mnemonic, affective, and behavioral components. These structures have profound implications for later social relationships and for the child’s capacity to trust other people. The child’s working models of attachment may be associated with a sense of predictability, reliability, affection, and well-being, or with inconsistency, ambivalence, rejection, loss, rage, anxiety, or sadness.

Disordered attachment is characterized by a capacity for attachment to a primary figure, however, the attachment relationship is pervaded by excessive inhibition, heedlessness, or role reversal. In disrupted attachment, the mother-infant relationship has been severed, and the infant reacts with developmental arrest, disturbances of eating and sleep, loss of interest in surroundings and play, social withdrawal, and apparent depression.

Severe disturbances or disruptions of the attachment relationship are likely to disrupt or impair one or more of the following aspects of development: (1) relationships with and interest in other people, (2) the capacity to explore the world, (3) cognitive development, (4) the regulation of activity, sleep, feeding, and elimination, or (5) physical growth.

By the end of the first year of life, mother-infant attachment relationships can be characterized as secure, avoidant, resistant, or disorganized. Upon reunion with the mother after a brief separation, the infant will greet the mother and seek proximity (secure), avoid the mother (avoidant), resist the mother with irritation and ambivalence (resistant), or demonstrate freezing, confusion, stereotyped movements, and incoherent, contradictory behavior (disorganized). Disorganized attachment predicts later disruptive behavior disorder. Table 45–1 describes the factors that cause disorders of attachment.

The mother’s working models of attachment, developed from her own early attachment experiences, affect her capacity to respond to the infant’s attachment needs. If the mother’s working models of self-other attachment are suffused with ambivalence, rage, sadness, or emptiness, and her representation of an attachment figure is characterized by rejection, sadism, explosiveness, inconsistency, or remoteness, a similar pattern of behavior is likely to be repeated with the infant. Thus when unresolved conflicts are reactivated in the parent by the demands of infant care, these “ghosts in the nursery” can disrupt or preclude good mothering.

Genetics

Twin studies indicate that additive genetic effects are present in disorders of attachment, particularly among boys.

Clinical Findings

Reactive Attachment Disorder

Reactive attachment disorder represents a failure of the infant to develop a normal attachment relationship to a primary attachment figure. The infant demonstrates one of two types of reaction: (1) socially withdrawn, emotionally constricted, anergic, and apparently unable to derive pleasure from social contact or play or (2) socially indiscriminate and emotionally shallow. Both types of reactive attachment disorder are associated with parental neglect or maltreatment or institutional child-rearing with multiple caregivers. Infants exposed to early maltreatment demonstrate disorganized attachment as toddlers and grow into socially withdrawn or aggressive, disruptive children.

Disordered Attachment

In disordered attachment, the infant has a primary attachment figure, but the attachment relationship is pathologic, with an imbalance between proximity seeking and exploration. There are three types: (1) disordered attachment with inhibition, (2) disordered attachment with self-endangerment, and (3) disordered attachment with role reversal.

In disordered attachment with inhibition, the infant is emotionally constricted, lacking in vitality, socially avoidant, and loath to explore the environment even when it is apparently safe to do so. The child clings persistently to the mother or avoids contact with her.

Children who demonstrate disordered attachment with self-endangerment are reckless, heedless, and accident-prone. Even when hurt, they rebuff their mother’s attempts to comfort them. Sometimes they are self-injurious, banging their heads or biting themselves. When anxious, they are more likely to run away than to seek contact comfort from their parents.

In disordered attachment with role reversal, the child exhibits a precocious, overdeveloped solicitousness to the mother, alternating with punitive, bossy, controlling behavior.

Disrupted Attachment

Infants older than 6 months (the age at which the primary attachment figure is first recognized) react to separation from or loss of the attachment figure with the following sequence of behavior: (1) protest, (2) depression, and (3) detachment. Children in the stage of protest cry, demand that the parent return, and reject the attempts of others to comfort them. Depression and detachment are associated with sad face, anergia, insomnia, anorexia, loss of interest in surroundings, social withdrawal, “empty” clinging, and developmental arrest or regression. The child reacts to reminders of the primary attachment figure by ignoring or rejecting them or with a reactivation of protest.

Differential Diagnosis (Including Comorbid Conditions)

Attachment disorders should be distinguished from pervasive developmental disorder, mental retardation, and language disorder. Pervasive developmental disorder, particularly infantile autism, is characterized by delay and deviance in the development of social relationships, language, and intellect. The impairment of social relationships in autism is profound and not reversible by effective parenting. Furthermore, a history of parental failure, maltreatment, or loss is not usually encountered, and autism is associated with characteristic peculiarities of movement, language, and intellectual patterning.

Mental retardation aggravated by parental neglect or maltreatment presents a difficult differential diagnosis. Attachment relationships are intact in uncomplicated cases of mental retardation, other than in the profoundly retarded. Similarly, children with developmental language disorders do not demonstrate attachment pathology unless the language delay is associated with gross parental neglect.

Comorbidity

Reactive attachment disorder is a serious biopsychosocial condition. Older studies reported significant mortality and severe psychosocial morbidity associated with this disorder. However, the negative outcomes of these studies are compounded by the very poor quality of the institutions in which the studied children were housed. A number of investigations have compared the outcome of higher quality institutional rearing with that of early adoption or placement in foster care. Children raised initially in institutions tend to become more restless, distractible, disobedient, oppositional, and irritable than do control subjects. Children adopted early from institutions are better attached to their adoptive parents and siblings than are those who have been reunited with their families of origin.

For maximum benefit to intellectual development, children should probably be placed in a family well before 4 1/2 years of age. However, this question remains: Is there a watershed age beyond which the effects of early institutionalization or parental neglect are irreversible? In any case, a radical change of circumstances is required to remedy reactive attachment disorder and, despite the likelihood of individual differences in the capacity to benefit from environmental enrichment, it would be prudent to place children with adoptive families as early as possible.

Treatment

In the most egregious circumstances, parental rights must be terminated and early adoption sought. In most cases, however, remedial treatment will be appropriate.

The assessment of the family, and particularly of the parent–child interaction, has therapeutic implications, as described in Chapter 5. Parent–infant psychotherapy addresses (1) parental problems that impair caregiving, (2) the constitutional or temperamental factors in the infant that impede attachment, and (3) the match between the infant’s needs and temperament and the parent’s style of nurturance. Parenting problems could be related to current psychopathology (e.g., depression); unresolved conflict related to past experiences (e.g., of trauma, abuse, rejection, or neglect); or inexperience and lack of flexibility. Other, more experienced parents in mutual support groups can offer helpful advice concerning feeding, daily care, methods of consolation, and play. Nurse home visitors can work with parents to improve the quality of the match between the infant’s needs and temperament and the parent’s sensitivity and responsiveness, and to help parents enjoy their children.

Complications/Adverse Outcomes of Treatment

Data related to specific interventions for Reactive Attachment Disorder are limited at best. Although some treatments have advocated “holding” during periods of intense rage, coercive restraint, when applied for reasons other than imminent safety, is misdirected and may further the child’s negative self-perceptions and further complicate the course of the disorder.

Prognosis

The prognosis of reactive attachment disorder and disordered and disrupted attachment has not been studied thoroughly. Insecure and, particularly, disorganized attachment during infancy have been found to predict disruptive behavior, impulse-control problems, peer relationship problems, oppositional behavior, low self-esteem, and lower social competence in preschool and school-aged children.

Pica

Essentials of Diagnosis

DSM-IV-TR Diagnostic Criteria

1. Persistent eating of nonnutritive substances for a period of at least 1 month.

2. The eating of nonnutritive substances is inappropriate to the developmental level.

3. The eating behavior is not part of a culturally sanctioned practice.

4. If the eating behavior occurs exclusively during the course of another mental disorder (e.g., mental retardation, pervasive developmental disorder, schizophrenia), it is sufficiently severe to warrant independent clinical attention.

(Reprinted, with permission, from Diagnostic and Statistical Manual of Mental Disorders, 4th edn., Text Revision. Copyright 2000, Washington, DC: American Psychiatric Association.)

General Considerations

Epidemiology

The prevalence of pica varies widely. It is much more common among rural pregnant African-American women and among institutionalized mentally retarded patients.

Etiology

The cause of pica is not known. Several theories have been proposed. The nutritional theory relates pica to iron deficiency and an appetite for minerals. However, it is uncertain whether iron deficiency, which is often found in association with pica, is primary or secondary. Another theory suggests that pica, a normal phenomenon in infancy when the mouth is used as a perceptual organ, is a manifestation of delayed development; that is, it represents the retention of developmentally immature behavior, particularly in socially disadvantaged and mentally retarded children. Yet another theory, which applies to pregnant women who chew starch or clay, emphasizes the role of cultural beliefs and custom.

Genetics

Except as mediated by various forms of mental retardation, there are no known genetic factors specifically associated with pica.

Clinical Findings

Children with pica eat dirt, stones, ice, paint, burned match heads, starch, feces, hair, and so on.

Treatment

The proper treatment of pica is unclear. Proper supervision of young children and behavioral techniques for older children are recommended. Ferrous sulfate therapy has been recommended on the theory that the condition is caused by iron deficiency.

Complications/Adverse Outcomes of Treatment

Laboratory studies are needed to rule out lead poisoning. Aside from lead poisoning, pica can lead to excessive weight gain, malnutrition, intestinal blockage, intestinal perforation, and malabsorption.

Prognosis

Depending on the circumstances with regard to associated etiological conditions and the level of supervision the prognosis varies.

Rumination Disorder

Essentials of Diagnosis

DSM-IV-TR Diagnostic Criteria

1. Repeated regurgitation and rechewing of food for a period of at least 1 month following a period of normal functioning.

2. The behavior is not due to an associated gastrointestinal or other general medical condition (e.g., esophageal reflux).

3. The behavior does not occur exclusively during the course of anorexia nervosa or bulimia nervosa. If the symptoms occur exclusively during the course of mental retardation or a pervasive developmental disorder, they are sufficiently severe to warrant independent clinical attention.

(Reprinted, with permission, from Diagnostic and Statistical Manual of Mental Disorders, 4th edn., Text Revision. Copyright 2000 Washington, DC: American Psychiatric Association.)

General Considerations

Epidemiology

The incidence of rumination in the general population of infants is unknown. Rumination among the mentally retarded occurs more commonly in males, particularly among the profoundly retarded. The prevalence in institutional populations is 6–10%.

Etiology

In infants, rumination is thought to be associated with deprivation of maternal attention or neglect. In older, mentally retarded patients, rumination has been ascribed to self-stimulation and is most often encountered in a setting of institutional neglect. Gastroesophageal reflux, hiatus hernia, or esophageal spasm may be diagnosed, but the significance of these conditions is not clear, and it should not be assumed that, even if present, they cause rumination. Rumination has been interpreted as a complex, learned behavior reinforced by maternal attention or oral sensory gratification.

Genetics

Except as mediated by various forms of mental retardation, there are no known genetic factors specifically associated with rumination.

Clinical Findings

Ruminators stimulate their gag reflexes manually or adopt postures that facilitate regurgitation. The frequency can vary from several times per minute to once per hour. Regurgitated food fills the cheeks and may be stirred about by the tongue before being reswallowed or spit out. Ruminators can sometimes be diverted from the practice temporarily, if they are offered interesting things to do after eating.

Differential Diagnosis

Rumination should be differentiated from other causes of vomiting and gastroesophageal reflux.

Treatment