Reactive Attachment Disorder of Infancy or Early Childhood

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Attachment is a central component of social and emotional development, and disordered attachment is defined by specific patterns of abnormal behavior in the context of pathogenic care beginning before age 5 years (American Academy of Child and Adolescent Psychiatry 2005; see Chapter 7 in this volume, "Normal Child and Adolescent Development," by Gemelli). Reactive attachment disorder (RAD) describes two outcomes of prolonged neglect or physical or emotional abuse: children who are hypervigilant and aloof (inhibited subtype) or children who are indiscriminant in their attachments (disinhibited subtype) (Table 21–34). Inhibited children maintain a degree of wariness and may appear hypoactive or lethargic. As infants, they have little interaction with their environment and often resist being held. Conversely, the disinhibited child demonstrates exaggerated, although emotionally empty, attachments and may show inappropriate clinging or hugging. These children fail to discriminate between attachment figures and often seek and are apparently willing to accept comfort from anyone, even strangers. In both types of RAD, disturbances in relatedness, emotional reactivity, and cognition are thought to arise from disordered development of early interpersonal attachment.

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Table Reference Number
TABLE 21–34. DSM-IV-TR diagnostic criteria for reactive attachment disorder


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