Other Disorders of Infancy, Childhood, and Adolescence

44.1 Reactive Attachment Disorder of Infancy or Early Childhood

Reactive attachment disorder (RAD) is a clinical disorder characterized by aberrant social behaviors in a young child reflecting an environment of maltreatment that interfered with the development of normal attachment behavior. Unlike most disorders in the text revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), a diagnosis of RAD is based on the presumption that the etiology is directly linked to environmental deprivation experienced by the child. The diagnosis of RAD is a relatively recent entity, added to the third edition of the DSM (DSM-III) in 1980. The formation of this diagnosis is largely based on the building blocks of attachment theory, which describes the quality of a child’s generalized affective relationship with primary caregivers, usually parents. This basic relationship is the product of a young child’s need for protection, nurturance, and comfort and the interaction of the parents and child in fulfilling these needs.

The disorder may result in a picture of failure to thrive, in which an infant shows physical signs of malnourishment and does not exhibit the expected developmental motor and verbal milestones. When this is the case, the failure to thrive is coded on Axis III.

EPIDEMIOLOGY

Few data exist on the prevalence, sex ratio, or familial pattern of RAD. It has been estimated to occur in less than 1 percent of the population. Studies have used selected high-risk populations. In a retrospective report of children in one county of the United States who were removed from their homes because of neglect or abuse before the age of 4 years, 38 percent exhibited signs of emotionally withdrawn or indiscriminate RAD. A study in 2004 established the reliability of the diagnosis by reviewing videotaped assessments of children at risk interacting with caregivers along with a structured interview with caregivers. Given that pathogenic care, including maltreatment, occurs more frequently in the presence of general psychosocial risk factors, such as poverty, disrupted families, and mental illness among caregivers, these circumstances are likely to increase the risk of RAD. In unusual circumstances, however, a caregiver may be fully satisfactory for one child, whereas another child in the same household is maltreated and develops RAD.

ETIOLOGY

The essence of RAD is the malformation of normal attachment behaviors. The inability of a young child to develop normative social interactions that culminate in aberrant attachment behaviors in RAD is inherent in the disorder’s definition. RAD is linked to maltreatment, including emotional neglect, physical abuse, or both as well. Grossly pathogenic care of an infant or young child by the caregiver presumably causes the markedly disturbed social relatedness that is usually evident. The emphasis is on the unidirectional cause; that is, the caregiver does something inimical or neglects to do something essential for the infant or child. In evaluating a patient for whom such a diagnosis is appropriate, however, clinicians should consider the contributions of each member of the caregiver-dyad and their interactions. Clinicians should weigh such things as infant or child temperament, deficient or defective bonding, a developmentally disabled or sensorially impaired child, and a particular caregiver-child mismatch. The likelihood of neglect increases with parental mental retardation; lack of parenting skills because of personal upbringing, social isolation, or deprivation and lack of opportunities to learn about caregiving behavior; and premature parenthood (during early and middle adolescence), in which parents are unable to respond to, and care for, an infant’s needs and in which the parents’ own needs take precedence over their infant’s or child’s needs. Frequent changes of the primary caregiver—as may occur in institutionalization, repeated lengthy hospitalizations, and multiple foster care placements—may also cause a reactive attachment disorder of infancy or early childhood.

DIAGNOSIS AND CLINICAL FEATURES

Children with RAD may initially be identified by a preschool teacher or by a pediatrician based on direct observation of the child’s inappropriate social responses. The diagnosis of RAD is based on documenting evidence of pervasive disturbance of attachment leading to inappropriate social behaviors present before the age of 5 years. The clinical picture varies greatly, depending on a child’s chronological and mental ages, but expected social interaction and liveliness are not present. Often, the child is not progressing developmentally or is frankly malnourished.
Perhaps the most typical clinical picture of an infant with one form of RAD is the nonorganic failure to thrive. Such infants usually exhibit hypokinesis, dullness, listlessness, and apathy with a poverty of spontaneous activity. Infants look sad, joyless, and miserable. Some infants also appear frightened and watchful, with a radar-like gaze. Nevertheless, they may exhibit delayed responsiveness to a stimulus that would elicit fright or withdrawal from a normal infant (Table 44.1-1). Infants with failure to thrive and RAD appear significantly malnourished, and many have protruding abdomens. Occasionally, foul-smelling, celiaclike stools are reported. In unusually severe cases, a clinical picture of marasmus appears.

The infant’s weight is often below the third percentile and markedly below the appropriate weight for his or her height. If serial weights are available, the weight percentiles may have decreased progressively because of an actual weight loss or a failure to gain weight as height increases. Head circumference is usually normal for the infant’s age. Muscle tone may be poor. The skin may be colder and paler or more mottled than skin of a normal child. Laboratory findings are usually within normal limits, except for abnormal findings coincident with any malnutrition, dehydration, or concurrent illness. Bone age is usually retarded. Growth hormone levels are usually normal or elevated, a finding suggesting that growth failure in these children is secondary to caloric deprivation and malnutrition. The children improve physically and gain weight rapidly after they are hospitalized.

Table 44.1-1 DSM-IV-TR Diagnostic Criteria for Reactive Attachment Disorder of Infancy or Early Childhood

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 of primary caregiver 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).
Specify type:
	Inhibited type: if Criterion A1 predominates in the clinical presentation
	Disinhibited type: if Criterion A2 predominates in the clinical presentation
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; copyright 2000, with permission.

Socially, the infants usually show little spontaneous activity and a marked diminution of both initiative toward others and reciprocity in response to the caregiving adult or examiner. Both mother and infant may be indifferent to separation on hospitalization or to termination of subsequent hospital visits. The infants frequently show none of the normal upset, fretting, or protest about hospitalization. Older infants usually show little interest in their environment. They may not play with toys, even if encouraged; however, they rapidly or gradually take an interest in, and relate to, their caregivers in the hospital.

Classic psychosocial dwarfism or psychosocially determined short stature is a syndrome that usually is first manifest in children 2 to 3 years of age. The children are typically unusually short and have frequent growth hormone abnormalities and severe behavioral disturbances. All of these symptoms result from an inimical caregiver-child relationship. The affectionless character may appear when there is a failure, or lack of opportunity, to form attachments before the age of 2 to 3 years. Children cannot form lasting relationships, and their inability is sometimes accompanied by a lack of guilt, an inability to obey rules, and a need for attention and affection. Some children are indiscriminately friendly.

A 6-year-old boy was referred by his adoptive parents because of hyperactivity and disruptive behavior at school. He had been adopted at 5 years of age, after living most of his life in a Romanian orphanage in which he received care from a rotating shift of caregivers. Although he had been below the 5th percentile for height and weight on arrival, he quickly approached the 10th percentile in his new home. However, both of his adoptive parents were frustrated by their inability to “reach him.” They had initially worried about a hearing disturbance, although testing and his capacity to engage many adults and children verbally suggested otherwise. He showed interest in anyone and would often follow strangers willingly. He showed little empathy when others were hurt and blandly resisted redirection in school. He was frequently injured because of seemingly reckless behavior, although he had an extremely high tolerance for pain. Intensive intervention focused on problem behaviors at home decreased his self-endangering behavior, although he remained oddly overfriendly and nonempathic at home and in school. The boy was diagnosed with reactive attachment disorder, disinhibited type. (Courtesy of Neil W. Boris, M.D. and Charles H. Zeanah, Jr., M.D.)

PATHOLOGY AND LABORATORY EXAMINATION

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