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Reactive attachment disorder of infancy or early childhood

Reactive attachment disorder is a problem with social interaction that occurs when a child's basic physical and emotional needs are neglected, particularly when the child is an infant.

Causes, incidence, and risk factors

Reactive attachment disorder is caused by abuse or neglect of an infant's needs for:

  • Emotional bonds with a primary or secondary caretaker
  • Food
  • Physical safety
  • Touching

The risk of neglect to the infant or child increases when the:

  • Caregiver is mentally retarded
  • Caregiver lacks parenting skills
  • Parents are isolated
  • Parents are teenagers

A frequent change in caregivers (for example, in orphanages or foster care) is another cause of reactive attachment disorder.

Children who are adopted from foreign orphanages are commonly affected, particularly if they were removed from their birth parents during the first weeks of life.

Symptoms

Child:

  • Avoids caregiver
  • Avoids physical contact
  • Is difficult to comfort
  • Does not make distinctions when socializing with strangers
  • Resists social interaction
  • Wants to be alone

Caregiver:

  • Disregard for child's basic emotional needs for comfort, stimulation, and affection
  • Disregard for child's basic physical needs like food, toileting, and play

Signs and tests

This disorder is diagnosed with a:

  • Complete history
  • Physical examination
  • Psychiatric evaluation

Treatment

Treatment has two parts. The first priority is to make sure the child is currently in a safe environment where emotional and physical needs are met.

Once that has been established, the next step is to change the relationship between the caregiver and the child, if the caregiver has caused the problem. Parenting skills classes can help with this. These skills give the caregiver the ability to meet the child's needs and help them bond with the child.

The caregiver should also have counseling to work on any current problems, such as drug abuse or family violence. Social Services should follow the family to make sure the child remains in a safe, stable environment.

Parents who adopt babies or young children from foreign orphanages should be aware that this condition may occur and be sensitive to the child's need for consistency, physical affection, and love.

These children may be frightened of people and find physical affection overwhelming at first, and parents should try not to see this as rejection. It is a normal response in someone who has been abused to avoid contact. Hugs should be offered frequently, but not forced.

A mental health evaluation should be completed. This evaluation will be helpful in developing a treatment plan.

Expectations (prognosis)

The right intervention can improve the outcome.

Complications

If not treated, this condition can permanently affect the child's social interactions. It can be connected with:

Calling your health care provider

This disorder is usually identified when a parent (or prospective parent) is at high risk for neglect or when an adoptive parent has difficulty coping with a newly adopted child.

If you have recently adopted a child from a foreign orphanage or another situation where neglect may have occurred and your child shows these symptoms, see your health care provider.

Prevention

Early recognition is very important for the child. Parents who are at high risk for neglect should be taught parenting skills. The family should be followed by either a social worker or doctor to make sure the child's needs are being met.

References

Milosavljevic N, Brendel RW. Child abuse and neglect. In: Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 1st ed. Philadelphia, Pa: Mosby Elsevier; 2008:chap 8.

Schechter DS. Disturbances of attachment and parental psychopathology in early childhood. Child Adolesc Psychiatr Clin N Am.  2009 Jul 01; 18(3): 665-86.

Updated: 5/16/2012

Neil K. Kaneshiro, MD, MHA, Clinical Assistant Professor of Pediatrics, University of Washington School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.


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