44.1 REACTIVE ATTACHMENT DISORDER OF INFANCY AND EARLY CHILDHOOD

44.1 REACTIVE ATTACHMENT DISORDER OF INFANCY AND EARLY CHILDHOODReactive attachment disorder of infancy and early childhood is one of the few disorders in the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) applicable to children under the age of 5. Since this disorder first appeared in the third edition of DSM (DSM-III), the criteria have been substantially revised. The rationale for DSM-IV and the 10th revision of International Statistical Classification of Diseases and Related Health Problems (ICD-10) criteria for the disorder clearly arises from converging lines of research on institutionalized and maltreated infants and young children. However, no systematic research validates these criteria, and reactive attachment disorder of infancy and early childhood is rarely cited in the literature.The normal development of the infant and young child's attachment system, first elucidated in John Bowlby's theory of attachment, is the marker against which behavior indicating disordered attachment is compared (Table 44.1-1). Two general patterns of deviant social responses have been described in published case studies and reviews of the literature on disturbances of attachment in institutionalized or maltreated infants and young children are reflected in current criteria for the disorder. Other less well studied or more subtle patterns also appear to exist. While the development of primary attachment relationships in early childhood is reciprocal, criteria clearly specify that this disorder occurs “as a result of grossly pathogenic care.”A number of important issues regarding reactive attachment disorder remain unresolved. First, can the disorder be reliably diagnosed? Does the disorder exist within the child or within the relationship? Can the disorder exist when grossly pathogenic care cannot be documented? What other abnormal attachment patterns are disturbed enough to be considered disordered? What is the prevalence and natural history of the disorder? How is the disorder related to other disorders, particularly pervasive developmental disorders?DEFINITIONReactive attachment disorder of infancy and early childhood as described in DSM-IV is characterized by “markedly disturbed and developmentally inappropriate social relatedness in most contexts.” These findings must occur in the context of “grossly pathogenic care.” The disorder must begin before 5 years of age to meet criteria and cannot be “accounted for solely by developmental delay.” Children who are mentally retarded are thus difficult to diagnose; those who meet criteria for pervasive development disorder are explicitly excluded from consideration for reactive attachment disorder.Two subtypes are spelled out in the DSM-IV criteria. The first pattern, generally linked in the literature to early childhood maltreatment, is characterized by inhibition of the normal developmental tendency to seek comfort from a select group of caregivers. Responses to social interactions are “excessively inhibited, hypervigilant, or highly ambivalent,” reflecting the overall inhibition of the attachment system in affected children. The second pattern, linked to institutionalization or exposure to multiple caregivers before age 5, is characterized by a relative hyperactivation of the attachment system, resulting in “diffuse” and unselective attachments, and patterned behavior labeled “indiscriminate sociability.”

Attachment and Development Attachment, as described by Bowlby in his influential trilogy, refers to a biobehavioral system whose goal is to coordinate the balance between the need for safety in proximity to a caregiver or set of caregivers with the tendency for exploration and autonomy in infancy and early childhood. Bowlby argued that human infants were motivated by this heritable attachment system to seek an external goal of safety in proximity to a small number of identified caregivers (usually with the infant's mother) and an internal goal of “felt security.” This internal subjective sense of security is influenced heavily by the experience of the caregiver's emotional and physical availability in times of need and modified by the infant's own temperamental makeup. From the usual biobehavioral shift at age 7 to 9 months through the first 3 years, infants are thought to begin to form internal representations of their relationships with important caregivers. These representations (Bowlby called them “internal working models”) form the basis for both the intense emotional bond between infants and their primary caregivers and behavior in later relationships. This link provides evidence that attachment is salient throughout the course of development. Although these representations are relatively stable, they may be modified by significant experiences or relationships later in life.Bowlby's theoretical framework, refined from the early 1950s to the 1970s, has evoked much research in the last two decades on the development of patterns of secure and insecure attachment in early childhood. The normal developmental progression of attachment, captured in attachment-related behaviors, is summarized in Table 44.1-1. Though little of this research has been directed toward defining clinical disorders of attachment, much of it is germane to clinical medicine; assessment of attachment has become necessary for infant mental health professionals.Deviant patterns of attachment like those reflected in criteria for reactive attachment disorder have been recognized in populations raised in environments marked by extreme deprivation. The normative tendency to seek comfort actively from a restricted number of familiar caregivers in times of distress, a hallmark of secure attachment, is commonly not apparent in many of these children. Moreover, a series of anomalous behaviors in these relationships are evident and are reflected in the criteria for reactive attachment disorder.These anomalous behaviors are also the hallmark for a pattern of attachment labeled disorganized/disoriented. This pattern of attachment has been identified using standardized laboratory assessments. Recent longitudinal research suggests that disorganized/disoriented attachment in infancy is a risk factor for the development of psychopathology. Further, the antecedents of this pattern of attachment are primarily environmental factors that impact early relationship formation.These findings suggest that subsyndromal disturbances of attachment such as disorganized/disoriented attachment exist on a continuum. The findings also suggest that clinicians should be familiar with risk factors impacting early caregiver–infant interactions that are related to the development of disorganized/disoriented attachment. Maternal psychopathology, child maltreatment, family violence, and poor parental sensitivity to infant cues have been linked to the development of disorganized/disoriented attachment.HISTORYThe importance of early experience on infant development was recognized as far back as the thirteenth century when the Holy Roman Emperor Frederick II ordered that no one

should speak to, or interact with, a group of infants. His experiment, designed to see what language the children would learn to speak, ended with the premature death of all its subjects. Notes inscribed at the time by a Franciscan monk document the devastating social and emotional effects this lack of social interaction had on the infants.This crude experiment was one of the first designed to test the relative importance of nature versus nurture in influencing development. The nature-versus-nurture theme is as evident in the history of philosophy as it is today in the field of experimental developmental psychology. The work of Aristotle and Plato includes reflection on the relative importance of biology and environment in influencing development. The Enlightenment in the seventeenth and eighteenth centuries brought more interest in the origins of personality; the eminent English philosopher John Locke argued that the mind of the infant was a tabula rasa on which layers of experience were imprinted to create a person with a unique personality. This view was countered by Jean-Jacques Rousseau, among others, who viewed infants as being endowed at birth with inherent goodness that would naturally develop except in circumstances marked by parenting deficiency. By the nineteenth century, Charles Darwin had suggested that complex individual traits, including intelligence, could be largely accounted for by hereditary factors.The continued interest in the relative importance of nature and nurture has shaped much of the research in early childhood development in this century. The relatively common practice of institutionalization of infants in orphanages in the first half of the century unwittingly provided more evidence of the detrimental effects of what has been called “maternal deprivation.” Pediatricians had long argued against the practice of institutionalization, particularly because of the high mortality rates related to failure to thrive, but health care providers did not take notice of the effects of institutionalization on social and emotional development until René Spitz in the 1940s and James and Joyce Robertson in the 1950s conducted more rigorous studies (including control groups). Films that showed the effects of prolonged separations from caregivers and of institutionalization heightened interest in this social problem. These studies also led Spitz to propose a diagnostic entity he called “anaclitic depression,” which foreshadowed the DSM-III criteria for reactive attachment disorder and is consistent with some of the features of the DSM-IV inhibited subtype. Anaclitic depression seemed to follow prolonged separation of infants from their caregivers and was most severe if the infants were old enough to have developed a preference for that caregiver. The eventual recognition of the clinically meaningful consequences of institutionalization led to a marked decrease in state-run orphanages in many industrialized countries. However, the recent influx of young children from Romania and some Russian states has renewed interest in studying this population of children.Recognition of the scope of the problem of child maltreatment, on the other hand, did not begin until relatively recently, spurred initially by C. Henry Kempe's classic 1962 article on the “battered child syndrome.” Since the early 1960s, there has been a great deal of research on the development effects of maltreatment on children. Though this research is confounded by the number of competing variables influencing observed outcome, disturbed attachment patterns have been consistently documented in a range of samples of young children. On the other hand, it is not yet clear what percentage of these children might meet criteria for an attachment disorder at any given developmental stage.COMPARATIVE NOSOLOGY

The criteria for reactive attachment disorder have evolved markedly since the diagnosis was first introduced in DSM-III. This early version of the disorder included growth failure and lack of social responsivity as central features. The diagnosis had to start by 8 months of age (the age at which preferred attachment to a restricted set of caregivers is usually just beginning to be evident) and could not result from a diagnosable medical condition. Gross neglect of the infant's physical and emotional needs had to be evident, and, as with later criteria, presence of autism or mental retardation precluded the diagnosis. Pertinent behaviors cited in the criteria included poor tone, weak cry, excessive sleep, lack of interest in the environment, and weak rooting and grasping when feeding.Though so-called nonorganic failure to thrive remains an important diagnostic entity in infant mental health, the restrictive age range of this set of criteria and the requirement for growth failure made the DSM-III definition difficult to apply in many cases. Further, it is rarely possible to rule out autistic disorder or mental retardation in severely malnourished infants under 1 year of age. The link between failure to thrive and reactive attachment disorder was dropped in the revised third edition of DSM (DSM-III-R), and the age of onset was changed to the first 5 years. The two subtypes of the disorder, inhibited and disinhibited, were introduced with DSM-III-R and have persisted in DSM-IV. The etiological link between the disorder and evidence of “pathogenic care” at the hands of the young child's primary caregivers and the exclusion of children whose symptoms might be accounted for by cognitive delay or one of the pervasive developmental disorders remained an emphasis of the criteria.Though reactive attachment disorder was not included in the ninth revision of International Statistical Classification of Diseases (ICD-9), it does appear in ICD-10—in a form largely consonant with DSM-IV criteria. The ICD-10 criteria do not explicitly link the disorder to pathogenic care, but a warning against making the diagnosis without evidence of abuse or neglect is included in the clinical description attached to the criteria. ICD-10 lists the two subtypes from DSM-IV as separate disorders (Table 44.1-2), and neither explicitly excludes children with mental retardation or pervasive developmental disorders. However, the clinician is required to document that the child shows “elements of normal social relatedness” with “non-deviant adults.”

DSM-IV and ICD-10 criteria for attachment disorders have been criticized in the literature on a number of fronts. First, the implication that the disorder is reactive is problematic. A temporal association of factors like maltreatment and inhibition should not imply a causative link. From a practical perspective, one cannot always know what experiences children might have had with their caregivers, and the limits of what is or is not pathogenic care are unclear. Some children might meet criteria for reactive attachment disorder without having experienced extreme deprivation or abuse. Second, the exclusion of infants and children with pervasive developmental disorders and mental retardation ostensibly on grounds that each has a different cause suggests that these disorders cannot coexist. Certainly, children with a mental age below 8 months are

unlikely to develop a focused set of attachments with caregivers. However, in children with milder cognitive impairment, the clinical distinction between these disorders is occasionally difficult, particularly when caregiving deficiencies are notable.The criteria emphasize the general social behavior of affected children across relationships rather than more specific attachment-related behaviors. These latter behaviors might include comfort seeking, compliance with caregiver requests, exploratory behavior, and attempts to control the caregiver either by acting in a caregiving role or by being bossy and punitive. Responses to reunion, used successfully to classify patterns of attachment, may also reveal extreme affective responses (e.g., ignoring, fearful, angry, or affectless reunions) that are clinically meaningful.A final concern is raised by the clear evidence that children act differently in different relationships. Both DSM-IV and ICD-10 criteria require that the aberrant behavior be evident across relationships, which excludes children whose behavior is clearly compromised in the presence of their primary caregivers but not in the few other relationships they might have. Changing this focus would compel the clinician to identify a relationship disorder rather than a pervasive pattern of abnormal social behavior, which might identify more children and families requiring intervention. This approach, however, flies in the face of current conceptualizations of psychiatric disorders—namely that they exist within individuals, not between them.These concerns about DSM-IV and ICD-10 criteria have led a group of researchers and clinicians to propose a series of alternate criteria designed to redress most of these concerns. Criteria have been proposed for six separate attachment disorders, beginning with disorders of nonattachment that can be diagnosed in any child with a mental age of 10 months or above (i.e., the age at which children typically show preferred attachments). These disorders follow DSM-IV criteria in including inhibited and disinhibited subtypes. However, the link to pathogenic care is dropped and evidence of less extreme social behavior in relationships with caregivers other than the primary caregiver does not disqualify the child for the diagnosis. A second general type of disorder is also proposed, disrupted attachment disorder, which applies when a child experiences the sudden loss of the caregiver; it includes behaviorally anchored criteria consistent with the descriptions Bowlby and others originally documented. The third general type of disorder, so-called secure base distortions, arises from clinical work with young children. Three types have been identified: attachment disorder with self-endangerment, attachment disorder with inhibition, and attachment disorder with role reversal. In each of these disorders, the child has a preferred attachment figure, but the relationship with this figure is markedly distorted in one of these three ways.Unfortunately, none of the available criteria, including those from DSM-IV and ICD-10, have been subjected to research aimed at validation and reactive attachment disorder remains a little-used and poorly studied phenomenon.EPIDEMIOLOGYVirtually no data exist on the prevalence and clinical course of reactive attachment disorder. Retrospective chart reviews of consecutive patients suggest that the diagnosis can be made reliably in a clinic-referred population. Because pathogenic care is often associated with broad-risk factors like poverty, family disruption and low social support, in clinical samples, these may be considered frequent conditions associated with the

diagnosis. However, reactive attachment disorder appears to exist across socioeconomic strata.ETIOLOGYWhile reactive attachment disorder typically occurs in the context of grossly neglectful or overtly abusive care, the critical elements of this care and their relation to the onset of the disorder are unclear. Certainly children institutionalized in the same facility or siblings raised together in a markedly disturbed family may have divergent outcomes. Individual temperamental or personality factors may combine with corrective experiences to yield a nonpathological outcome in some children who experience extremes of care. The individual fit between neglectful or abusive adults and their infants or children may be critical in determining which children develop symptoms consistent with an attachment disorder.Though research on what causes caregivers to be abusive or neglectful is limited, caregiver characteristics from severe personality disturbance to psychopathology appear to be important. Parental mental retardation and poor basic parenting skills, particularly in the context of little social support, may also lead to pathogenic care. Infants who are cared for by multiple caregivers in succession, as is common in the foster care system in the United States, are also at increased risk for attachment disorders. The traumatic experience of prolonged separation from a caregiver in early childhood, documented by Spitz, the Robertsons and Bowlby, is itself enough to cause attachment disturbance. Repeated prolonged separations typically cause more severe symptoms, and when these separations are accompanied by abuse, neglect, or both, attachment disorders appear to be particularly likely.DIAGNOSIS AND CLINICAL FEATURESThe diagnosis of reactive attachment disorder is contingent upon documenting clear evidence of pervasive disturbance in social relatedness that began prior to age 5 (Table 44.1-3). The pattern of behavior should fit one of the two different subtypes described in the criteria. The inhibited subtype is characterized by hypervigilant and fearful behavior (often recognized as a pattern of compulsive compliance with the abusive caregiver) or extreme ambivalence and contradictory behavior in relationships. Mixtures of approach and avoidance may be apparent, and frozen watchfulness may be noted. The disinhibited subtype is marked by a lack of selectivity in choosing social partners, resulting in diffuse attachments and a peculiar overfriendliness that has been labeled indiscriminate sociability. Caregivers may remark on their own subjective sense that the child is not truly attached to them.

It is difficult to make the diagnosis of reactive attachment disorder without a multisession evaluation, particularly when the caregiver's behavior is not known to be abusive or the child's history does not include multiple placements. Ascertaining whether the child has less-deviant behavior in the presence of the clinician or another trusted adult is important and may take time. The child's relationship with the primary caregiver can be adequately assessed with a combination of free play, structured teaching tasks that stress the dyad, and a brief separation and reunion. Videotaping the assessment is a useful way to document social responses, and the introduction of a clinically trained person whom neither partner has met is often informative. Children who meet criteria for this disorder may look quite different depending on their developmental stage.

A 26-month-old girl, recently placed in foster care, was referred by state child protective services with her biological and foster families to assist with long-term case management. Her history included two admissions for failure to thrive in the first year of life and a third admission at 13 months that revealed retinal hemorrhage and a subdural hematoma from suspected shaken baby syndrome. No perpetrator was conclusively identified. When seen with her biological mother in a comfortable, toy-filled room, she stood completely still and maintained little facial expression. She complied completely and in rote fashion with her mother's often angry instructions, maintaining no sustained eye contact with either her mother or the examiner. When briefly separated from her mother, she showed little reaction, looking up briefly with an odd grimace when her mother returned to the room. Her mother confirmed that her behavior had been similar when she had lived in her home; the child spoke infrequently and rarely sought comfort when distressed. When seen with her foster mother of 3 months, she was markedly more animated, though frequently irritable. She engaged in play freely and referenced both her foster mother and the examiner during play. She stopped playing and stared blankly when separated from her foster mother, though she actively reengaged her foster mother upon her return. The biological mother's parental rights were eventually terminated and though the child was placed in two more homes, she showed the capacity to engage with her new caregivers each time. The girl was diagnosed with reactive attachment disorder, inhibited type.

A 6-year-old boy was referred by his adoptive parents because of hyperactivity and disruptive behavior at school. He had been adopted at age 5, after living most of his life in a Romanian orphanage where he received care from a rotating shift of caregivers. Though he had been below the fifth percentile for height and weight upon arrival, he quickly approached the tenth percentile in his new home. However, both his adoptive parents were frustrated by their inability to “reach him.” They had initially worried about a hearing disturbance, though 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, though he had an extremely high tolerance for pain. Intensive intervention focused on problem behaviors at home decreased his self-endangering behavior, though he remained oddly overfriendly and unempathic both at home and in school. The boy was diagnosed with reactive attachment disorder, disinhibited type.

DIFFERENTIAL DIAGNOSISChildren with marked disinterest in social interaction altogether may require cognitive testing for developmental delay or a neurological workup. Evidence of stereotypies, grossly restricted range of interests, and poor response to changes in routines suggest the spectrum of pervasive developmental disorders; cognitive impairment is frequently moderate to severe in these children. Interviews with the caregivers of these children usually yield little evidence of inappropriate care, and consistent blunting of social interactions outside the family unit is common. However, many children with pervasive

developmental disorders or mental retardation form secure attachments with their primary caregivers despite an overall restriction in the range of attachment-related behaviors.Children with severe receptive and expressive language delays may present linically with difficulty in social relatedness. Often the clinical picture includes externalizing behavior that heightens as unsuccessful attempts to communicate are made; rarely does this behavior fit the reactive attachment disorder subtypes, and grossly inappropriate care is uncommon in this population. As communication improves, social interactions improve.Temporary or permanent loss of a primary caregiver to whom a young child is already attached is associated with significant disturbance. Bowlby described a common progression of reactions in this instance: protest, despair, and detachment. The clinical picture may mimic the inhibited form of reactive attachment disorder, though pathogenic care is not apparent in these cases. These children may quickly form new attachments to sensitive caregivers, particularly if they had some familiarity with the replacement caregiver before the loss. The clinician may diagnose depression in these cases, though the criteria for depression in infancy are not fully consonant with DSM-IV criteria for major depressive disorder.The relationship between failure to thrive and reactive attachment disorder has not been well studied. If failure to thrive is not caused by a medical condition, then investigation of the child's relationships with the caregivers is necessary. In severe cases of neglect, reactive attachment disorder and failure to thrive may coexist. Prolonged lack of stimulation may lead to psychosocial dwarfism and many of these children would be expected to meet criteria for reactive attachment disorder. Worldwide, the interplay of kwashiorkor, lack of appropriate caregiving, and attachment disorders may be significant.Comorbid psychiatric conditions appear common in older children whose history is consistent with reactive attachment disorder. Disorganized patterns of attachment behavior in the first 6 years appear to be associated with disruptive behavior disorders in later childhood; this may also be true for children with reactive attachment disorder.COURSE AND PROGNOSISBecause a sizable cohort of patients with reactive attachment disorder has never been followed, the typical course and prognosis for this disorder are not clear. It is likely that associated conditions from the nutritional and neurological sequelae of psychosocial deprivation to the stability of later relationships are critical in influencing the outcome. The possible range of outcomes include death in the most severe cases to relatively normal functioning with intervention leading to the establishment of healthy relationships. There have been several recent controlled studies of children adopted from international orphanages to Canada, England, and the United States. Despite the absence of a gold standard for diagnosing reactive attachment disorder and significant variation across samples (from age at adoption to conditions prior to adoption), these studies provide evidence that a subsample of adopted orphans have symptoms of indiscriminate sociability which continue for months or years after adoption. A smaller subsample appears to be at risk for externalizing disorders, and a handful of children from different samples have been reported to have chronic quasiautism. On the other hand, despite their histories of severe privation, it appears that a majority of these international adoptees rapidly assimilate after stable placement and have few ongoing psychiatric symptoms. Factors that are consistently related to these disparate outcomes have yet to be identified.

There are few long-term, controlled follow-up studies of children and adults who were raised primarily in institutional settings. The few available studies also suggest that indiscriminate sociability may persist and that the choice of marital partners in later life strongly influences eventual adult psychological functioning. The link between early disturbances of attachment and antisocial tendencies, particularly a lack of empathy, was first made by Bowlby; longitudinal studies of this association are needed to firmly establish this pathway.TREATMENTThe first consideration in the assessment of children exposed to grossly inadequate care is the child's safety. Child maltreatment is associated with significant morbidity, and mortality is not uncommon, particularly in children under 24 months of age. Early involvement of child protective services is often warranted, and assessment of parental fitness may be a necessary part of the evaluation. In some cases placement of the child may be necessary, and reunification of parent and child may not be warranted. Children in this situation have often not had appropriate medical care, and medical referral is almost always indicated. Unfortunately, the foster care system and the family court system may lead to multiple placements in the first years of life and thus increase the likelihood of an attachment disorder. The clinician may play a crucial role in staying involved with the child who is placed in foster care, providing expert testimony in court and individual or family treatment.Once the child is in a relatively stable placement and is medically healthy, full attention can be paid to psychosocial intervention, which must often be tailored to the individual. Possible interventions include individual psychotherapy for the child or caregiver; parent training with emphasis on developmental expectations; family therapy; or caregiver-child dyadic therapy, which is perhaps most specifically directed toward disturbances of attachment and in many instances is the treatment of choice. As described by Alicia Lieberman, this approach weaves together developmental training and guidance with an active attempt to address pressing instrumental issues (e.g., poor housing, inadequate medical care) and insight-oriented psychotherapy with the child present. The complexity of this approach reflects the complexity of the clinical problem. Long-term interventions are necessary in these cases, and psychiatric treatment should be bolstered by early intervention programs and ongoing medical care for the child.

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