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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.
EPIDEMIOLOGY
Virtually 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.
ETIOLOGY
While 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 FEATURES
The 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.
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 DIAGNOSIS
Children 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 PROGNOSIS
Because 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.
TREATMENT
The 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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Textbook of Psychiatry