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DISORDERS OF ATTACHMENT

Human infants are born with the propensity to attach to their parents and to elicit care from them. Extremes of caregiving deficiencies—such as social and/or instrumental neglect, institutional rearing, or frequent changes in foster parents—increase the risk for a number of conditions such as reactive attachment disorder, disinhibited attachment disorder, rumination disorder of infancy, nonorganic failure to thrive, and psychosocial dwarfism. These conditions appear in infancy or early childhood and often are associated with cognitive, language, and social delays or deviancies and later functional impairment. Sleep problems usually appear in the first 2 years of life. Pica and elimination disorders are usually first diagnosed between 2 and 5 years of age.

REACTIVE ATTACHMENT DISORDER OF CHILDHOOD (F94.1)

ICD-10 Criteria

Starts in the first five years of life and is characterized by persistent abnormalities in the child's pattern of social relationships that are associated with emotional disturbance and are reactive to changes in environmental circumstances (e.g. fearfulness and hypervigilance, poor social interaction with peers, aggression toward self and others, misery, and growth failure in some cases). The syndrome probably occurs as a direct result of severe parental neglect, abuse, or serious mishandling.

Use additional code, if desired, to identify any associated failure to thrive or growth retardation.

Excl.:

Asperger syndrome (F84.5)

disinhibited attachment disorder of childhood (F94.2)

maltreatment syndromes (T74.-)

normal variation in pattern of selective attachment

sexual or physical abuse in childhood, resulting in psychosocial problems (Z61.4-Z61.6)

General Considerations
A. Epidemiology

Although this condition is believed to be rare, it has not been included in any population-based studies and its prevalence is unknown. Two studies of community samples of 2- to 5-year-old children recruited from pediatric clinics found no cases.

B. Etiology

Bowlby conceptualized attachment as the biologically based tendency for infants to seek comfort, support, nurturance, and protection from caregiving adults. The tendency for selective seeking of comfort is not apparent at birth, however. Following a period of interaction and comfort with adult caregivers during the first 6 months, two new infant behaviors become obvious: stranger wariness and separation protest, both at about 7–9 months of age. Stranger wariness describes an apparent discomfort with unfamiliar adults and selectively turning to those the child knows and trusts. Separation protest refers to the infant's tendency to protest separation from familiar caregivers. Although individual differences in the intensity and expression of these behaviors are clear, they may be considered universal. When these behaviors appear, the infant is said to be attached to one or more caregivers.

Infant behaviors that promote physical proximity to caregivers—such as crawling to, smiling at, clinging on—are known as attachment behaviors. Under species-typical rearing conditions, human infants gradually form attachments to a relatively small number of caregiving adults during the first year of life. Attachments form by 7–9 months of ...

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