Chapter 45. Developmental Disorders of Attachment, Feeding, Elimination, & Sleeping

Normal infants are born with the capacity to attach to their parents and to elicit care from them. Defects in the infant's capacity to attach or elicit care, and deficiencies or disruption in the response of the caregiver, can be associated with a number of conditions such as reactive attachment disorder, rumination disorder of infancy, nonorganic failure to thrive, and psychosocial dwarfism. These conditions commence in infancy and, if not corrected, distort later social and intellectual development. Sleep problems often commence in the first 2 years of age. Pica and elimination disorders are usually first diagnosed between 2 and 5 years of age.

Essentials of Diagnosis

DSM-IV-TR Diagnostic Criteria

Reactive Attachment Disorder

1. Markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5 years, as evidenced 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 contradictory 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 familiarity with relative strangers or lack of selectivity in choice of attachment figures)

2. 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.

3. 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)

4. There is a presumption that the care in Criterion C is responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C).

(Reprinted, with permission, from Diagnostic and Statistical Manual of Mental Disorders, 4th edn., Text Revision. Copyright 2000, Washington, DC: American Psychiatric Association.)

General Considerations

Epidemiology

Although this condition is believed to be rare, it has not been included in any population-based studies and its prevalence is unknown.

Etiology

Bowlby conceptualized attachment as the biologically based tendency for infants to elicit care from and maintain proximity to their mothers. Babies elicit care by crying, vocalizing, reaching, sucking, making eye contact, and smiling. They maintain proximity first by clinging and following and later by using their mother as a secure base from which to explore the world. The mother, in turn, ministers to the infant's physical, emotional, and social needs and protects the infant from danger. Both mother and infant monitor proximity in the second year, so that the child's exploration is curtailed ...