Reactive Attachment Disorder of Infance or Early Childhood

The essential characteristic 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.

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. 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; persistent disregard of the child's basic physical needs; or repeated changes of primary caregiver that prevent formation of stable attachments (e.g., frequent changes in foster care).The pathological care is presumed to be responsible for the disturbed social relatedness.

Subtypes

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.

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).

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.

The child exhibits indiscriminate sociability or a lack of selectivity in the choice of attachment figures.

Associated Features

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.

Mathematics Disorder and Disorder of Written Expression are commonly associated with Reading Disorder, and it is relatively rare for either of these disorders to be found in the absence of Reading Disorder

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.

Diagnostic criteria summarized from:

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.