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DSM-III

In DSM-III, this disorder is called Reactive Attachment Disorder of Infancy

Diagnostic Criteria

A. Age at onset before eight months.

B. Lack of the type of care that ordinarily leads to the development of affectional bonds to others, e.g., gross emotional neglect, imposed social isolation in an institution.

C. Lack of developmentally appropriate signs of social responsivity, as indicated by at least several of the following (the total number of behaviors looked for will depend on the chronological age of the child, corrected for prematurity):

  1. lack of visual tracking of eyes and faces by an infant more than two months of age
  2. lack of smiling in response to faces by an infant more than two months of age
  3. lack of visual reciprocity in an infant of more than two months; lack of vocal reciprocity with caretaker in an infant of more than five months
  4. lack of alerting and turning toward caretaker's voice by an infant of more than four months
  5. lack of spontaneous reaching for the mother by an infant of more than four months
  6. lack of anticipatory reaching when approached to be picked up, by an infant more than five months of age
  7. lack of participation in playful games with caretaker by an infant of more than five months

D. At least three of the following:

  1. weak cry
  2. excessive sleep
  3. lack of interest in the environment
  4. hypomotility
  5. poor muscle tone
  6. weak rooting and grasping in response to feeding attempts

E. Weight loss or failure to gain appropriate amount of weight for age unexplainable by any physical disorder. In these cases usually the failure to gain weight (falling weight percentile) is disproportionately greater than failure to gain length; head circumference is normal.

F. Not due to a physical disorder, Mental Retardation, or Infantile Autism.

G. The diagnosis is confirmed if the clinical picture is reversed shortly after institution of adequate caretaking, which frequently includes short-term hospitalization.

Differential Diagnosis

Mental Retardation

Children with Mental Retardation develop slowly, but show no medically unexplainable failure to thrive unless Reactive Attachment Disorder of Infancy is also present.

Infantile Autism

Children with Infantile Autism may display lack of attachment behavior as infants, but they usually show no failure to thrive, and there is generally no evidence of lack of caretaking. However, Infantile Autism and and Reactive Attachment Disorder of Infancy can coexist.

Neurological abnormalities

Children with a variety of severe neurological abnormalities such as deafness, blindness, profound multisensory defects, major CNS disease, or severe chronic physical illness may have very specific needs and few means of satisfying them and thus may suffer minor secondary attachment disturbances.

Psychosocial dwarfism

In psychosocial dwarfism there may also be apathy, parental neglect, and disappearance of symptoms with hospitalization. However, psychosocial dwarfism generally has a later onset than Reactive Attachment Disorder of Infancy, and the failure of the infant to gain in length with little change or actual increase in weight is the major manifestation.

Major Depression

Major Depression should be considered if this clinical picture develops after eight months of age.

DSM-IV

In DSM-IV, this disorder is called Reactive Attachment Disorder of Infancy or Early Childhood

Diagnostic Criteria

A. Markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5 years, as evidence 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 contraditory 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 familiarily 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., 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

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.

Differential Diagnosis

Mental Retardation

In Mental Retardation, appropriate attachments to caregivers usually develop consistent with the child's general developmental level. 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.

Pervasive Developmental Disorders

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 behaior. Reactive Attachment Disorder is not diagnosed if the criteria are met for a Pervasive Developmental Disorder,

Attention-Deficit/Hyperactivity Disorder

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 attempting to form a social attachment after a very brief acquaintance.

Child Neglect or Parent-Child Relational Problem

Grossly pathogenic care is a defining feature of Reactive Attachment Disorder. An additional notation of Child Abuse, Child Neglect, or a 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.

DSM-5

Diagnostic Criteria

A. A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following:

  1. The child rarely or minimally seeks comfort when distressed.
  2. The child rarely or minimally responds to comfort when distressed.

B. A persistent social and emotional disturbance characterized by at least two of the following:

  1. Minimal social and emotional responsiveness to other.
  2. Limited positive affect.
  3. Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers.

C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:

  1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults.
  2. Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care).
  3. Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios).

D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the lack of adequate care in Criterion C).

E. The criteria are not met for autism spectrum disorder.

F. The disturbance is evident before age 5 years.

G. The child has a developmental age of at least 9 months.

Specify if:

  • Persistent: The disorder has been present for more than 12 months.

Specify current severity:

Reactive attachment disorder is specified as severe when a child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels.

Differential Diagnosis

Autism spectrum disorder

Aberrant social behaviors manifest in young children with reactive attachment disorder, but they also are key features of autism spectrum disorder. Specifically, young children with either condition can manifest dampened expression of positive emotions, cognitive and language delays, and impairments in social reciprocity. As a result, reactive attachment disorder must be differentiated from autism spectrum disorder. These two disorders can be distinguished based on differential histories of neglect and on the presence of restricted interests or ritualized behaviors, specific deficit in social communication, and selective attachment behaviors. Children with reactive attachment disorder have experienced a history of severe social neglect, although it is not always possible to obtain detailed histories about the precise nature of their experiences, especially in initial evaluations. Children with autistic spectrum disorder will only rarely have a history of social neglect. The restricted interests and repetitive behaviors characteristic of autism spectrum disorder are not a feature of reactive attachment disorder. These clinical features manifest as excessive adherence to rituals and routines; restricted, fixated interests; and unusual sensory reactions. However, it is important to note that children with either condition can exhibit stereotypic behaviors such as rocking or flapping. Children with either disorder also may exhibit a range of intellectual functioning, but only children with autistic spectrum disorder exhibit selective impairments in social communicative behaviors, such as intentional communication (i.e., impairment in communication that is deliberate, goal-directed, and aimed at influencing the behavior of the recipient). Children with reactive attachment disorder show social communicative functioning comparable to their overall level of intellectual functioning. Finally, children with autistic spectrum disorder regularly show attachment behavior typical for their developmental level. In contrast, children with reactive attachment disorder do so only rarely or inconsistently, if at all.

Intellectual disability (intellectual developmental disorder)

Developmental delays often accompany reactive attachment disorder, but they should not be confused with the disorder. Children with intellectual disability should exhibit social and emotional skills comparable to their cognitive skills and do not demonstrate the profound reduction in positive affect and emotion regulation difficulties evident in children with reactive attachment disorder. In addition, developmentally delayed children who have reached a cognitive age of 7-9 months should demonstrate selective attachments regardless of their chronological age. In contrast, children with reactive attachment disorder show lack of preferred attachment despite having attained a developmental age of at least 9 months.

Depressive disorders

Depression in young children is also associated with reductions in positive affect. There is limited evidence, however, to suggest that children with depressive disorders have impairments in attachment. That is, young children who have been diagnosed with depressive disorders still should seek and respond to comforting efforts by caregivers.